Hyperparathyroid Crisis: Use of Bisphosphonates as a Bridge to Parathyroidectomy

• Published in: Journal of the American College of Surgeons Vol. 206; no. 6; pp. 1106 - 1115
• Main Authors: Phitayakorn, Roy, MD, McHenry, Christopher R., MD, FACS
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01.06.2008; Elsevier Science
• Subjects: Acute Disease; Biological and medical sciences; Diphosphonates - therapeutic use; Drug Utilization; Female; General aspects; Humans; Hypercalcemia - etiology; Hypercalcemia - prevention & control; Hyperparathyroidism - complications; Hyperparathyroidism - drug therapy; Hyperparathyroidism - mortality; Hyperparathyroidism - surgery; Medical sciences; Middle Aged; Parathyroidectomy; Pregnancy; Pregnancy Complications - drug therapy; Retrospective Studies; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of endocrine glands; Survival Rate; Treatment Outcome; Medicine; Bridges; Antiosteoporotic; Treatment; Antiosteoclastic agent; Surgery; Use; Parathyroidectomy; Bisphosphonates; Crisis
• ISSN: 1072-7515; 1879-1190
• DOI: 10.1016/j.jamcollsurg.2007.11.010

Background Hyperparathyroid crisis is an uncommon, potentially lethal condition for which emergent parathyroidectomy has been advocated. Study Design The manifestations of hyperparathyroid crisis and outcomes of bisphosphonate-based therapy and delayed parathyroidectomy were determined and compared with cases from a review of the literature. Laboratory indices and gland weights were compared with those from patients with primary hyperparathyroidism without crisis. Results Of the 292 patients operated on for hyperparathyroidism, 8 (2.8%) had hyperparathyroid crisis, consistent with rates of 1.6% to 6% reported in the literature. Hyperparathyroid crisis was manifested by vomiting, nausea, or both (n = 6); abdominal pain (n = 3); mental status changes (n = 3); pancreatitis (n = 2); bone pain, osteolytic lesions, or both (n = 2); electrocardiogram changes (n = 1); and an acute conversion disorder (n = 1). Isotonic sodium chloride and furosemide, in combination with a bisphosphonate drug in 7 of 8 patients, resulted in a calcium decline from 16.2 ± 1.6 mg/dL to 11.8 ± 1.6 mg/dL, with resolution of electrocardiogram and mental status changes, and pancreatitis before resection of an adenoma (n = 7) or carcinoma (n = 1). Patients with hyperparathyroid crisis had higher parathyroid hormone levels (691.7 ± 662.4 pg/mL versus 172.6 ± 147.5 pg/mL; p = 0.062), larger tumor weights (7.5 ± 8.4 g versus 1.6 ± 2.1 g; p = 0.085), and lower postoperative calcium levels (7.3 ± 1.6 mg/dL versus 8.7 ± 0.9 mg/dL; p = 0.035) than patients without crisis. Four (50%) of the 8 tumors were found in ectopic locations. There was no mortality from hyperparathyroid crisis, compared with a 7% mortality rate for cases reported in the literature since 1978. Conclusions Rehydration, calciuresis, and bisphosphonate therapy are effective in correcting life-threatening manifestations of hyperparathyroid crisis, providing an effective bridge to parathyroidectomy.