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History of Primary Hyperparathyroidism

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seth s

on 7 October 2015

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Transcript of History of Primary Hyperparathyroidism

History of Primary Hyperparathyroidism
And it all begins ... with a Med Student
Enter 25 year old Ivar Sandstrom
While working as a summer research assistant he discovers a new gland
Dissects dogs, cats, rabbits, an ox, and a horse, and 50 human cadavers that all have this gland
He submits his grand findings: "On a New Gland in Man and Fellow Animals"
Parathyroid gland. The great detoxifyer?
Patient #1
Captain Charles Martell
First US pt diagnosed with hyperparathyroidism
Presented to MGH with severe skeletal decalcification, renal calcifications, Ca 14.8 mg/dl Phos 3.3 mg/dl
Between 1927-1932 underwent 7 surgeries
Discovered a 3x3 mediastinal tumor
Lets try again... Patient #2
Elva Dawkins a 56-year-old farmer's wife
9 yr Hx of urinary frequency, weakness, and spontaneous fractures
A curious 4th year medical student at Washington University in St. Louis, Henry A Dixon, takes an interest in the case
Dixon found her Ca to be 17mg/dl and Phos to be 1.4mg/dl
Issac Y Olch excised a 3x3 adenoma on the inferior pole of the left thyroid at Barnes Hospital on August 1st 1928
First successful parathyroidectomy in the US

Quantum Leaps Forward
Berson and Yalow discover an immunoassay to measure parathyroid hormone levels
Welcome to Miami
Dr. Irvin, considered the father of minimally invasive parathyroidectomy
Developed the Miami Protocol
Intraoperative PTH sampling due to its short half life in tissues lets you localize hyperfunctioning glands
Protocol: check for 50% decline from preincisional or preexcisional PTH level at 5 and 10 minutes.

Today/Consult MM
In 19th and 20th century there was considerable debate about parathyroid gland function
Originally thought parathyroids detoxified the body
Removal of glands caused tetany and death
1927 MacCallum and Vallen at Hopkins discovered that parathyroidectomy could be reversed with calcium
1987 T.J. Martin isolates the hormone PTHrP, helping to explain a phemenom of hypercalcemia in cancer patients described as far back as 1941.
In 1968 the term MEN to describe familial cancers and hyperplaisa was coined. Not until 1993 were the responsible oncogenes found.
The History of Parathyroid Surgery by Claude H Organ Jr: American College of Surgeons Vol 191: September 2000 p284-299.

Assessment of Patient Outcomes after Operation for Primary Hyperparathyroidism by R.E. Burney et al. Surgery pg 120: 1996.

Operative Monitoring of Parathyroid Gland Hyperfunction by Irvin et al: American Journal of Surgery Volume 162: October 1991.

Dynamic Parathyroid Computed Tomography (4DCT) Facilitates Reoperative Parathyroidectomy and Enables Cure of Missed Hyperplasia. S. Cham et al. Ann of Surg Onc. October 2015.

4D-CT scan has a higher rate of surgical concordance to imaging and shorter operating time
However surgical outcomes are not improved
In Sestimibi-Negative patients, 4D-CT shows much more concordance to imaging and much shorter OR time
Lastly in patients who had diffuse parathyroid hyperplasia, 4D-CT identified multiple enlarged glands and correctly lateralized one or more glands.
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