Most cases of sporadic primary hyperparathyroidism present disturbances in a single parathyroid gland and the surgery of choice is adenomectomy.Conversely, hyperparathyroidism associated with multiple endocrine neoplasia type 1 (hyperparathyroidism/multiple endocrine neoplasia type 1) is an asynchronic, asymmetrical multiglandular disease and it is surgically approached by either subtotal parathyroidectomy or total parathyroidectomy followed by parathyroid auto-implant to the forearm.In skilful hands, the efficacy of both approaches is similar and both should be complemented by prophylactic thymectomy.In a single academic center, 83 cases of hyperparathyroidism/ multiple endocrine neoplasia type 1 were operated on from 1987 to 2010 and our first surgical choice was total parathyroidectomy followed by parathyroid auto-implant to the non-dominant forearm and, since 1997, associated transcervical thymectomy to prevent thymic carcinoid.Overall, 40% of patients were given calcium replacement (mean intake 1.6 g/day) during the first months after surgery, and this fell to 28% in patients with longer follow-up.These findings indicate that several months may be needed in order to achieve a proper secretion by the parathyroid auto-implant.Hyperparathyroidism recurrence was observed in up to 15% of cases several years after the initial surgery.Thus, long-term follow-up is recommended for such cases.We conclude that, despite a tendency to subtotal parathyroidectomy worldwide, total parathyroidectomy followed by parathyroid auto-implant is a valid surgical option to treat hyperparathyroidism/multiple endocrine neoplasia type 1. Larger comparative systematic studies are needed to define the best surgical approach to hyperparathyroidism/multiple endocrine neoplasia type 1.

OBJECTIVETo evaluate frequency, anatomic presentation, and quantities of supernumerary parathyroids glands in patients with primary hyperparathyroidism (HPT1) associated with multiple endocrine neoplasia type 1 (MEN1), as well as the importance of thymectomy, and the benefits of localizing examinations for those glands.METHODSForty-one patients with hyperparathyroidism associated with MEN1 who underwent parathyroidectomy between 1997 and 2007 were retrospectively studied. The location and number of supernumerary parathyroids were reviewed, as well as whether cervical ultrasound and parathyroid SESTAMIBI scan (MIBI) were useful diagnostic tools.RESULTSIn five patients (12.2%) a supernumerary gland was identified. In three of these cases (40%), the glands were near the thyroid gland and were found during the procedure. None of the imaging examinations were able to detect supernumerary parathyroids. In one case, only the pathologic examination could find a microscopic fifth gland in the thymus. In the last case, the supernumerary gland was resected through a sternotomy after a recurrence of hyperparathyroidism, ten years after the initial four-gland parathyroidectomy without thymectomy. MIBI was capable of detecting this gland, but only in the recurrent setting. Cervical ultrasound did not detect any supernumerary glands.CONCLUSIONThe frequency of supernumerary parathyroid gland in the HPT1/MEN1 patients studied (12.2%) was significant. Surgeons should be aware of the need to search for supernumerary glands during neck exploration, besides the thymus. Imaging examinations were not useful in the pre-surgical location of these glands, and one case presented a recurrence of hyperparathyroidism.

OBJECTIVE Little information is available on glomerular function changes after surgical treatment of primary hyperparathyroidism. The acute effects of some head and neck operations on renal function were studied. MATERIAL AND METHODS Retrospective analysis of changes in creatinine levels and estimated glomerular filtration rate (eGFR) after surgery. Preoperative values were compared with values available until 72 hours after the operation. RESULTS In tertiary hyperparathyroidism, mean preoperative and postoperative eGFR values were 57.7 mL/min and 40.8 mL/min (p < 0.0001), respectively. A similar decrease was observed after parathyroidectomy for primary hyperparathyroidism, from 85.4 mL/min to 64.3 mL/min (p < 0.0001). After major head and neck procedures, there was a slight increase in eGFR (from 94.3 mL/min to 105.4 mL/min, p = 0.002). CONCLUSION Parathyroidectomy may be followed by a transient decrease in eGFR that is not often observed in other head and neck operations.

Introducao: Os nodulos da glândula tireoide podem ser tratados durante a exploracao cervical por afeccao da paratireoide. Objetivo: A frequencia de doencas da tireoide em pacientes com hiperparatireoidismo primario e secundario foi revista. Metodos: Foram avaliados os dados disponiveis de 199 pacientes operados consecutivamente por hiperparatireoidismo primario (95 casos) ou secundario (104 casos). Os achados na glândula tireoide desses casos foram pesquisados. A glândula tireoide foi considerada normal quando nenhuma resseccao dela fora realizada ou quando o exame histopatologico relatava tecido tireoideo normal. A doenca da tireoide foi avaliada em relacao ao tipo de hiperparatireoidismo. Resultados: A glândula tireoide foi ressecada parcialmente ou totalmente em 126 situacoes (63,3%). Em 44 casos, a tireoide foi considerada normal pelo anatomopatologico e foi presumidamente normal em 117 pacientes ao todo (58,8%). Diferentes doencas da tireoide foram demonstradas com comprovacao histopatologica em 41,2% de todos os casos tratados por hiperparatireoidismo (bocio em 28,1%, tireoidite em 6,5%, carcinoma papilifero em 6% e outros em 0,5%). Nao houve diferenca entre as doencas da tireoide no hiperparatireoidismo primario e o secundario, embora o carcinoma papilifero tenha sido mais frequente no hiperparatireoidismo primario do que no secundario (9,5% no primario e 2,8% no secundario, p=0,07; Teste exato de Fisher). Conclusao: Doencas da tireoide sao frequentes nos pacientes operados por hiperparatireoidismo. A avaliacao pre-operatoria bem como atencao durante a operacao sao recomendaveis nesses doentes. Descritores: Hiperparatireoidismo. Glândula Paratireoide. Glândula Tireoide. Paratireoidectomia. Tireoidectomia.

1) Médico Assistente da Disciplina de Cirurgia de Cabeça e Pescoço (DCCP), Departamento de Cirurgia, Faculdade de Medicina, Universidade de São Paulo (FMUSP), Laboratório de Investigação Médica (LIM) 28 – Doutor pela FMUSP. 2) Médico Assistente da DCCP. Professor Livre-Docente pela FMUSP. 3) Médico Pós-graduando da DCCP-FMUSP. 4) Médico Colaborador da DCCP-FMUSP. 5) Professor Titular da DCCP-FMUSP. Instituição: Disciplina de Cirurgia de Cabeça e Pescoço e Laboratório de Investigação Médica 28 Hospital das Clínicas Faculdade de Medicina, Universidade de São Paulo – USP, São Paulo/SP, Brasil. o Correspondência: Fábio Luiz de Menezes Montenegro, Avenida Dr. Enéas de Carvalho Aguiar, 255, Instituto Central – 8 andar Sala 8174 – 05403-000 São Paulo/SP, Brasil. E-mail: fabiomonte@uol.com.br Recebido em: 03/10/2008; aceito para publicação em: 03/01/2009; publicado online em: 10/03/2009. Conflito de interesse: nenhum. Fonte de fomento: nenhuma. Artigo Original

Introduction: Hyperparathyroidism was considered a rare disease in Brazil, but the increment in diagnosis has increased the need for treatment. Although new drugs have been developed, surgery is still considered an important therapy. Albeit the improvement in parathyroid localizing imaging studies, results of the operation are still affected by the experience of the surgeon. Thus, evaluation of residents' skills in this of operation is mandatory to teaching institutions. The institution should develop instruments for this evaluation. Objective: To report the initial experience with a rating system for evaluating parathyroid surgery teaching. Methods: The results of evaluation forms applied to head and neck surgery residents in the year of 2007 were analyzed. The evaluation was performed by different supervising surgeons and it included cognitive, operative skills and behavioral aspects. There were two different forms, developed consecutively. Results: Nine forms were filled for each type of chart. Regarding the chart with three possible options (poor, regular and good) the results for operative skills were 82.5% of regular and 17.5% of good. In behavioral aspects there were 29.6% of regular and 70.4% of good. In the forms with five possibilities (very poor, poor, regular, good, very good) there were 22.2% of regular, 58.7% of good and 19.1% of very good for technical skills aspects. In behavioral aspects, there were 1.6% of very poor, 4.8% of poor, 14.3% of regular, 47.6% of good and 31.7% of very good. Conclusion: The modification of the evaluation chart apparently improved the analysis of the behavioral aspects.

BACKGROUND:Severe hypercalcemia is the leading cause of death in patients with parathyroid carcinoma. Non-curative resection and pharmacological measures may be useful for palliation in cases with recurrent and metastatic disease. Palliative treatment with intra-neoplastic ethanol injection has not been reported yet.METHODS:Ultrasound-guided percutaneous alcohol injection in one patient with unresectable parathyroid carcinoma is reported.RESULTS:One male patient with extensive recurrent parathyroid carcinoma suffering from severe hypercalcemia, refractory to all available medical measures has undergone two percutaneous ethanol injections. No major complications ensued and parathormone levels decreased from 2.990 pg/mL to 2.230 pg/ml after the first injection, and to 1.104 pg/mL after the second one. Calcium levels decreased from 19.8 mg/dL to 16.1 mg/dL and to 14.5 mg/dL, respectively. The patient died of metabolic hypercalcemia complications about two months later, probably due to mediastinal disease progression.CONCLUSION:Ultrasound-guided percutaneous ethanol injection may be employed to palliate parathyroid carcinoma in selected cases, with a transitory decrease in PTH and calcium levels.

Introducao: A existencia de doencas da tireoide em portadores de hiperparatireoidismo varia de 20 a 70%. Ha pouca referencia quanto ao uso da ultra-sonografia pre-operatoria para avaliacao da glândula tireoide nesses doentes. Objetivo: Avaliar os achados ultra-sonograficos pre-operatorios da glândula tireoide em operados por hiperparatireoidismo e sua correlacao com os achados a cirurgia e anatomo-patologico. Metodos: Foi realizada ultra-sonografia de tireoide pre-operatoria em doentes com hiperparatireoidismo operados em uma mesma instituicao no periodo de janeiro de 2001 a dezembro de 2002. Os resultados ultra-sonograficos foram comparados aos achados cirurgicos e anatomopatologicos da glândula tireoide. Resultados: A idade variou de 9 a 78 anos (media de 42,7 anos). Houve 31 mulheres e 19 homens. Em 18 casos, o HPT era primario e, em 32, secundario. Nessa serie, 19 pacientes (38%) apresentaram doenca nodular da tireoide. A ultra-sonografia foi determinante para a resseccao diagnostica da tireoide em tres casos, nos quais a palpacao nao apresentava anormalidades. Nesses casos, o exame anatomopatologico constatou microcarcinoma papilifero de 0,5 centimetro em um caso e bocio coloide nos demais. Dessa forma, em 6% dos doentes operados, a ultra-sonografia foi decisiva para evitar a preocupacao de um nodulo no pos-operatorio e, em 2% dos operados, permitiu a realizacao de tireoidectomia total no mesmo ato. Ao comparar-se o achado cirurgico com a ultra-sonografia preoperatoria, observou-se que a sensibilidade foi de 62,5%, com uma especificidade de 84,6%. Conclusao: A ultra-sonografia constitui metodo auxiliar util na avaliacao pre-operatoria da glândula tireoide nos doentes com hiperparatireoidismo e permitir tratamento simultâneo das doencas. Descritores: Hiperparatireoidismo. Paratireoidectomia. UltraSonografia. Tireoidectomia. Bocio. Câncer da Tireoide.

BACKGROUND:Parathyroid cryopreservation is essential in some cases of parathyroid surgery. The fate of autografted tissue after long-term cryopreservation is not fully discussed in the literature. METHODS:The successful experience with the use of parathyroid tissues preserved for 21 months and 30 months is reported. RESULTS:Both patients were women with renal hyperparathyroidism who underwent total parathyroidectomy without autotransplantation. Patient 1 was a 40-year-old woman. At 21 months of follow-up, her parathyroid hormone (PTH) level was undetectable, and despite oral calcium supplements, she was hypocalcemic. Forty-five cryopreserved fragments were thawed and implanted in her forearm. Calcium levels improved, and PTH steadily increased in both arms. PTH levels at 18 months after the autograft were 37.0 pg/mL in the contralateral arm and 1150.0 pg/mL in the implant arm. Patient 2 was a 44-year-old woman. After 30 months, her PTH was undetectable, and she underwent cryopreserved tissue implantation. CONCLUSION:These cases show that parathyroid tissue may remain viable even after long-term storage.

Eplerenone relieves spironolactone-induced painful gynaecomastia in a patient with primary aldosteronism Sir, Eplerenone is the second oral aldosterone antagonist available for the treatment of essential hypertension and congestive heart failure.Spironolactone, the first aldosterone antagonist, although effective for the above conditions, has progestational and antiandrogenic adverse effects due to its non-specific binding to various steroid receptors.We report the case of a 54-year-old Caucasian man, who was admitted to hospital because of severe hypertension and hypokalaemia.The plasma aldosterone/plasma renin activity ratio was well above the cut-off level of 30 ng/dl/ng ml À1 h À1 .The acute intravascular volume expansion with the intravenous administration of isotonic saline showed autonomous aldosterone production.The aforementioned results were considered diagnostic of primary aldosteronism.A computerized tomography scan with fine cuts (2.5-3 mm) showed bilateral adrenal gland hyperplasia.Therefore, the patient was started on spironolactone 100 mg t.d.s., and in the following days normokalaemia was restored and blood pressure was well-controlled.Two months later, the patient presented with bilateral painful gynaecomastia.We switched spironolactone to eplerenone 25 mg t.d.s., and the patient was completely relieved within 1 month, while his blood pressure remained well-controlled and serum potassium was normal.Spironolactone is the drug of choice for the treatment of primary aldosteronism, but presents sexual side effects, such as impotence, painful gynaecomastia and menstrual disturbances in pre-menopausal women.Several mechanisms have been proposed for these side effects, such as a dosedependent reduction of microsomal cytochrome P-450, alterations of the testosterone-estrogen ratio, a fall in plasma testosterone or a significant increase in its metabolic clearance, and the peripheral conversion of testosterone to estradiol or increased serum levels of estrone and estradiol [1].Gynaecomastia may be quite remarkable and its occurrence is dose-and time-dependent.Eplerenone is a highly selective aldosterone antagonist.Spironolactone is approximately 40-fold more potent than eplerenone in blocking aldosterone activation of mineralocorticoid receptor.However, the selectivity of eplerenone is significantly greater than spironolactone at androgen, progesterone and glucocorticoid receptors.Eplerenone is 370-fold less potent at blocking dihydrotestosteroneactivation of androgen receptors compared with spironolactone [2].Two large clinical studies have evaluated the efficacy and tolerability of these aldosterone antagonists.The Randomized Aldactone Evaluation Study (RALES) found that the administration of spironolactone 12.5-50 mg/day,

CONTEXT AND OBJECTIVEAdequate management of parathyroid carcinoma apparently relates to the surgeons ability to identify it at the first operation. The objective of this paper was to evaluate the role of clinical suspicion in the management of parathyroid carcinoma.DESIGN AND SETTINGRetrospective analysis of parathyroid carcinoma patients treated in Department of Head and Neck Surgery, Faculdade de Medicina da Universidade de São Paulo.METHODSCross-sectional study of 143 patients who underwent surgery from 1995 to 2000, due to hyperparathyroidism. These cases were reviewed to ascertain whether preoperative and intraoperative suspicion of parathyroid carcinoma were helpful during the operation, and which factors demonstrated the suspicion of cancer best.RESULTSAmong 66 patients with primary hyperparathyroidism there were four cases of parathyroid carcinoma (6.1%), and one case was found in secondary hyperparathyroidism (1.3%). Palpable nodules were found in five patients with primary hyperparathyroidism, four of them with parathyroid carcinoma. Preoperative levels of calcium in primary hyperparathyroidism with cancer patients varied from 12.0 mg/dl to 18.2 mg/dl. Two patients had gross macroscopic spread of the tumor to adjacent structures. Except for one patient, with extensive disease, tumors were resected en bloc. In secondary hyperparathyroidism, parathyroid carcinoma was found in a fifth mediastinal gland. One atypical adenoma was observed.CONCLUSIONSHigh levels of calcium, palpable tumors and adherence to close structures are more common in parathyroid carcinoma. These clinical signs may be helpful for decision-making during parathyroid surgery.

OBJETIVO: A ocorrência de carcinoma papilífero da tireóide (CPT) em doentes com hiperparatireoidismo (HPT) suscita dúvidas quanto a ser apenas coincidência ou apresentar relação causal. O objetivo deste trabalho é verificar se a incidência de CPT em diferentes formas de HPT é semelhante entre si e à incidência de CPT em achados de necropsias, assim como em doentes submetidos à tireoidectomia na mesma região. MÉTODO: Os dados de 222 pacientes consecutivos tratados por HPT foram revistos e foi analisada a incidência de CPT. Os pacientes foram estratificados em HPT primário (107) e HPT secundário (115). Os laudos anatomopatológicos foram revistos, a incidência de CPT foi pesquisada e suas características nesses indivíduos foram estudadas. Esses dados foram comparados a dados encontrados em casos de necrópsia e em 89 casos de bócio compressivo/mergulhante. Empregou-se o teste exato de Fisher e o teste t não pareado. RESULTADOS: Os laudos foram passíveis de análise em 103 casos de HPT primário, com 10 pacientes com CPT (9,7%) e em 111 portadores de HPT secundário, com três CPT associados (2,7%). Houve diferença entre o HPT primário e HPT secundário (p=0,04). Essa diferença também foi significativa em relação aos 1% de CPT achados em necrópsia na região (p=0,0001). Não houve diferença com relação à incidência de 11,2% de CPT no grupo operado por compressão e também em relação às características dos tumores, apesar de haver 80% de multicentricidade no CPT de doentes com HPT primário. CONCLUSÕES: A ocorrência de CPT em HPT primário é maior que em HPT secundário e que em achados de necropsia.