Parathyroid adenoma diagnostic study of choice: Difference between revisions

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__NOTOC__
__NOTOC__
{{Parathyroid adenoma}}
{{Parathyroid adenoma}}
{{CMG}}; {{AE}}
{{CMG}}; {{AE}} {{sali}}
== Overview ==
== Overview ==
* The diagnosis is usually first suspected because of the incidental finding of an elevated serum calcium concentration on biochemical screening tests.
* If hypercalcemia is confirmed, intact parathyroid hormone (PTH) should be measured concomitantly with the serum calcium.
* Parathyroid adenoma is diagnosed by finding a frankly elevated PTH concentration in a patient with hypercalcemia.
* When the PTH is only minimally elevated or within the normal range, Parathyroid adenoma remains the most likely diagnosis.
* Patients with Parathyroid adenoma typically come to medical attention in the setting of an evaluation for low bone mineral density (BMD), during which time PTH levels are drawn and found to be elevated in the absence of hypercalcemia.
* In particular, all secondary causes for Parathyroid adenoma, and ionized calcium levels should be normal.


== Diagnostic Study of Choice ==
== Diagnostic Study of Choice ==


=== Study of choice ===
==Serum calcium==  
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
* A single elevated serum calcium concentration should be repeated to confirm the presence of hypercalcemia.  
 
* The total serum calcium concentration should be used for both the initial and the repeat serum calcium measurements.  
OR
* If a laboratory known to measure ionized calcium reliably is available, some authorities prefer to measure the ionized calcium, although this usually adds little to the diagnosis of asymptomatic primary hyperparathyroidism (PHPT) in patients with normal serum albumin concentrations and no abnormalities in acid-base balance<ref name="pmid8964825">{{cite journal |vauthors=Silverberg SJ, Bilezikian JP |title=Evaluation and management of primary hyperparathyroidism |journal=J. Clin. Endocrinol. Metab. |volume=81 |issue=6 |pages=2036–40 |date=June 1996 |pmid=8964825 |doi=10.1210/jcem.81.6.8964825 |url=}}</ref>.
 
* Ionized calcium measurements are an important adjunct to diagnosis is in patients with presumed normocalcemic PHPT.  
The following result of [gold standard test] is confirmatory of [disease name]:
* Ionized calcium levels should be normal<ref name="pmid9612524">{{cite journal |vauthors=Glendenning P, Gutteridge DH, Retallack RW, Stuckey BG, Kermode DG, Kent GN |title=High prevalence of normal total calcium and intact PTH in 60 patients with proven primary hyperparathyroidism: a challenge to current diagnostic criteria |journal=Aust N Z J Med |volume=28 |issue=2 |pages=173–8 |date=April 1998 |pmid=9612524 |doi= |url=}}</ref>.
* [Result 1]
* [Result 2]
 
OR
 
[Name of the investigation] must be performed when:
* The patient presents with [symptom/sign 1], [symptom/sign 2], and [symptom/sign 3].
* A [name of test] is positive for [sign 1], [sign 2], and [sign 3] in the patient.
 
OR
 
[Name of the investigation] is the gold standard test for the diagnosis of [disease name].
 
OR
 
The diagnostic study of choice for [disease name] is [name of the investigation].
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name].  
 
OR
 
There is no single diagnostic study of choice for the diagnosis of [disease name], but [disease name] can be diagnosed based on [name of the investigation 1] and [name of the investigation 2].
 
OR
 
[Disease name] is primarily diagnosed based on the clinical presentation.
 
OR
 
Investigations:
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most specific test for the diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most sensitive test for diagnosis.
* Among the patients who present with clinical signs of [disease name], the [investigation name] is the most efficient test for diagnosis.
 
==== The comparison of various diagnostic studies for [disease name] ====
{|
|- style="background: #4479BA; color: #FFFFFF; text-align: center;"
! style="background: #4479BA; color: #FFFFFF; text-align: center;" | Test
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Sensitivity
! style="background: #4479BA; color: #FFFFFF; text-align: center;" |Specificity
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 1
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|-
! style="background: #696969; color: #FFFFFF; text-align: center;" |Test 2
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
| style="background: #DCDCDC; padding: 5px; text-align: center;" |...%
|}
<small> [Name of test with higher sensitivity and specificity] is the preferred investigation based on the sensitivity and specificity</small>
 
===== Diagnostic results =====
The following finding(s) on performing [investigation name] is(are) confirmatory for [disease name]:
* [Finding 1]
* [Finding 2]
 
===== Sequence of Diagnostic Studies =====
The [name of investigation] must be performed when:
* The patient presented with symptoms/signs 1, 2, and 3 as the first step of diagnosis.
* A positive [test] is detected in the patient, to confirm the diagnosis.
 
OR
 
The various investigations must be performed in the following order:
* [Initial investigation]
* [2nd investigation]
 
=== Name of Diagnostic Criteria ===
 
'''It is recommended that you include the criteria in a table. Make sure you always cite the source of the content and whether the table has been adapted from another source.'''
 
[Disease name] is primarily diagnosed based on clinical presentation. There are no established criteria for the diagnosis of [disease name].
 
OR
 
There is no single diagnostic study of choice for [disease name], though [disease name] may be diagnosed based on [name of criteria] established by [...].
 
OR
 
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
 
OR
 
The diagnosis of [disease name] is based on the [criteria name] criteria, which includes [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
[Disease name] may be diagnosed at any time if one or more of the following criteria are met:  
* Criteria 1
* Criteria 2
* Criteria 3
 
OR
 
'''IF there are clear, established diagnostic criteria'''
 
The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met: [criterion 1], [criterion 2], [criterion 3], and [criterion 4].
 
OR
 
The diagnosis of [disease name] is based on the [criteria name] criteria, which include [criterion 1], [criterion 2], and [criterion 3].
 
OR
 
The diagnosis of [disease name] is based on the [definition name] definition, which includes [criterion 1], [criterion 2], and [criterion 3].


OR
==Serum PTH==
* Parathyroid hormone (PTH) or PTH 1-84 assays (third-generation) should be measured concomitantly with the serum calcium level to diagnose hyperparathyroidism<ref name="pmid25162666">{{cite journal |vauthors=Eastell R, Brandi ML, Costa AG, D'Amour P, Shoback DM, Thakker RV |title=Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop |journal=J. Clin. Endocrinol. Metab. |volume=99 |issue=10 |pages=3570–9 |date=October 2014 |pmid=25162666 |doi=10.1210/jc.2014-1414 |url=}}</ref>.
* PTH is increased in a higher proportion of patients with PHPT using the PTH 1-84 assay, several other studies have found no increase in diagnostic utility<ref name="pmid14718396">{{cite journal |vauthors=Carnevale V, Dionisi S, Nofroni I, Romagnoli E, Paglia F, De Geronimo S, Pepe J, Clemente G, Tonnarini G, Minisola S |title=Potential clinical utility of a new IRMA for parathyroid hormone in postmenopausal patients with primary hyperparathyroidism |journal=Clin. Chem. |volume=50 |issue=3 |pages=626–31 |date=March 2004 |pmid=14718396 |doi=10.1373/clinchem.2003.026328 |url=}}</ref>.


'''IF there are no established diagnostic criteria'''
==24-hour urinary calcium==
* Measurement of 24-hour urinary calcium excretion is not always required for the diagnosis of Parathyroid adenoma.
* It is routinely measured in patients with asymptomatic Parathyroid adenoma in order to assess the risk of renal complications (when urine calcium is high) and thus determine subsequent management.
* Hypercalcemia and PTH that is only minimally elevated or inappropriately normal given the patient's hypercalcemia, the 24-hour urinary calcium also helps to distinguish PHPT from FHH<ref name="pmid2393037">{{cite journal |vauthors=Silverberg SJ, Shane E, Jacobs TP, Siris ES, Gartenberg F, Seldin D, Clemens TL, Bilezikian JP |title=Nephrolithiasis and bone involvement in primary hyperparathyroidism |journal=Am. J. Med. |volume=89 |issue=3 |pages=327–34 |date=September 1990 |pmid=2393037 |doi=10.1016/0002-9343(90)90346-f |url=}}</ref>.
* The data establishing the value of the Ca/Cr clearance ratio in differentiating FHH from PHPT are based primarily on 24-hour urine collections.
* There are insufficient data available to prove that Ca/Cr ratios calculated from spot urines are equivalent to those determined from 24-hour urines.


There are no established criteria for the diagnosis of [disease name].
==Serum 25-hydroxyvitamin D==


==References==
==References==

Latest revision as of 20:27, 3 October 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Musadiq Ali M.B.B.S.[2]

Overview

  • The diagnosis is usually first suspected because of the incidental finding of an elevated serum calcium concentration on biochemical screening tests.
  • If hypercalcemia is confirmed, intact parathyroid hormone (PTH) should be measured concomitantly with the serum calcium.
  • Parathyroid adenoma is diagnosed by finding a frankly elevated PTH concentration in a patient with hypercalcemia.
  • When the PTH is only minimally elevated or within the normal range, Parathyroid adenoma remains the most likely diagnosis.
  • Patients with Parathyroid adenoma typically come to medical attention in the setting of an evaluation for low bone mineral density (BMD), during which time PTH levels are drawn and found to be elevated in the absence of hypercalcemia.
  • In particular, all secondary causes for Parathyroid adenoma, and ionized calcium levels should be normal.

Diagnostic Study of Choice

Serum calcium

  • A single elevated serum calcium concentration should be repeated to confirm the presence of hypercalcemia.
  • The total serum calcium concentration should be used for both the initial and the repeat serum calcium measurements.
  • If a laboratory known to measure ionized calcium reliably is available, some authorities prefer to measure the ionized calcium, although this usually adds little to the diagnosis of asymptomatic primary hyperparathyroidism (PHPT) in patients with normal serum albumin concentrations and no abnormalities in acid-base balance[1].
  • Ionized calcium measurements are an important adjunct to diagnosis is in patients with presumed normocalcemic PHPT.
  • Ionized calcium levels should be normal[2].

Serum PTH

  • Parathyroid hormone (PTH) or PTH 1-84 assays (third-generation) should be measured concomitantly with the serum calcium level to diagnose hyperparathyroidism[3].
  • PTH is increased in a higher proportion of patients with PHPT using the PTH 1-84 assay, several other studies have found no increase in diagnostic utility[4].

24-hour urinary calcium

  • Measurement of 24-hour urinary calcium excretion is not always required for the diagnosis of Parathyroid adenoma.
  • It is routinely measured in patients with asymptomatic Parathyroid adenoma in order to assess the risk of renal complications (when urine calcium is high) and thus determine subsequent management.
  • Hypercalcemia and PTH that is only minimally elevated or inappropriately normal given the patient's hypercalcemia, the 24-hour urinary calcium also helps to distinguish PHPT from FHH[5].
  • The data establishing the value of the Ca/Cr clearance ratio in differentiating FHH from PHPT are based primarily on 24-hour urine collections.
  • There are insufficient data available to prove that Ca/Cr ratios calculated from spot urines are equivalent to those determined from 24-hour urines.

Serum 25-hydroxyvitamin D

References

  1. ↑ Silverberg SJ, Bilezikian JP (June 1996). "Evaluation and management of primary hyperparathyroidism". J. Clin. Endocrinol. Metab. 81 (6): 2036–40. doi:10.1210/jcem.81.6.8964825. PMID 8964825.
  2. ↑ Glendenning P, Gutteridge DH, Retallack RW, Stuckey BG, Kermode DG, Kent GN (April 1998). "High prevalence of normal total calcium and intact PTH in 60 patients with proven primary hyperparathyroidism: a challenge to current diagnostic criteria". Aust N Z J Med. 28 (2): 173–8. PMID 9612524.
  3. ↑ Eastell R, Brandi ML, Costa AG, D'Amour P, Shoback DM, Thakker RV (October 2014). "Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop". J. Clin. Endocrinol. Metab. 99 (10): 3570–9. doi:10.1210/jc.2014-1414. PMID 25162666.
  4. ↑ Carnevale V, Dionisi S, Nofroni I, Romagnoli E, Paglia F, De Geronimo S, Pepe J, Clemente G, Tonnarini G, Minisola S (March 2004). "Potential clinical utility of a new IRMA for parathyroid hormone in postmenopausal patients with primary hyperparathyroidism". Clin. Chem. 50 (3): 626–31. doi:10.1373/clinchem.2003.026328. PMID 14718396.
  5. ↑ Silverberg SJ, Shane E, Jacobs TP, Siris ES, Gartenberg F, Seldin D, Clemens TL, Bilezikian JP (September 1990). "Nephrolithiasis and bone involvement in primary hyperparathyroidism". Am. J. Med. 89 (3): 327–34. doi:10.1016/0002-9343(90)90346-f. PMID 2393037.

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