William C. McGarity

Carcinoma of the parathyroid gland: is it overdiagnosed?: A report of three cases

The true incidence of carcinoma of the parathyroid gland is probably about 1 percent of cases of primary hyperparathyroidism. Overreporting may occur if the diagnosis is based on histologic appearances alone because the histologic criteria are less than definitive. Carcinoma of the parathyroid gland, if diagnosed early and treated with adequate surgical excision, is associated with a satisfactory long-term prognosis. However, the possibility of distant metastases or locally recurrent disease is not necessarily excluded by a prolonged interval of disease-free status, and the physician should continue to follow the patient on a regular basis by physical examination and routine serum calcium analysis.

Surgical approach to insulinomas

Abstract The clinical findings and diagnosis of insulinomas are reviewed. The use of selective celiac and superior mesenteric angiography is an important adjunct in the diagnosis, localization, and treatment of islet cell tumors. Two cases illustrating enucleation and two cases illustrating two types of resection of the pancreas are presented. A blind distal resection is recommended for patients with organic hypoglycemia when no tumor can be located at operation. It may be necessary to resect up to 95 per cent of the distal pancreas. Distal resection is performed for palpable adenomas in the body and tail of the pancreas which are impossible to enucleate. Pancreatoduodenectomy is performed for palpable lesions in the pancreatic head which are impossible to enucleate.

Parathyroid Hormone Content Distinguishes True Normal Parathyroids from Parathyroids of Patients with Primary Hyperparathyroidism

Abstract. The purpose of this study was to clarify the pathophysiology of primary hyperparathyroidism by looking for differences between parathyroids from eucalcemic patients and patients with primary hyperparathyroidism (HPT) with respect to the following parameters: intracellular parathyroid content of parathyroid hormone (PTH) and parathyroid hormone messenger RNA (PTH mRNA); and serum PTH and calcium levels of patients and patient age. Coded samples of human parathyroid biopsies were assayed for PTH content with a C-terminal-specific radioimmunoassay. Total cellular RNA was extracted, and PTH mRNA was quantified by dot-blot analysis. These results were tabulated along with associated data on patient age, preoperative serum PTH, and preoperative calcium levels. The content of PTH was significantly higher in true normal (TN) parathyroids than in parathyroids from patients with hyperparathyroidism. PTH content of adenomas and hyperplasias were similar. PTH content of normal parathyroids biopsied from patients with parathyroid adenomas (NA) was statistically higher than that of adenomas but statistically lower than that of TN parathyroids. PTH mRNA and PTH content were correlated (p < 0.001) for TN parathyroid glands; however, it was not true for glands (grossly normal or otherwise) in patients with HPT. Patient groups were similar with regard to mean patient age and intracellular PTH mRNA levels. Hypercalcemic patients were similar with regard to preoperative serum calcium and PTH levels. NA parathyroids, adenomas, and hyperplasias are different from TN parathyroids with regard to their PTH content. PTH mRNA was similar across all groups. The relation between intracellular PTH mRNA and PTH was significantly absent in patients with HPT compared with TN glands. Furthermore, we have found that PTH content of normal parathyroid in patients with adenoma is similar to that of hyperplastic and adenoma tissues. These data suggest that the PTH content of parathyroid tissues may be of use in differentiating normal from abnormal parathyroids.

Surgical evaluation of parathyroid arteriography

Summary Preoperative parathyroid arteriography was carried out in a group of fourteen patients, each of whom underwent subsequent neck exploration. Preoperative angiographic demonstration of mediastinal adenomas was possible in two patients previously subjected to neck explorations, which proved to be nondiagnostic. Correct diagnosis and localization of hyperparathyroidism by arteriography were possible in only 43 per cent of patients despite the use of ancillary technics to differentiate thyroid from parathyroid staining. As a diagnostic procedure, parathyroid arteriography lacks the accuracy of the simple demonstration of persistent unexplained hypercalcemia. As a technic for localization of hyperparathyroidism, accuracy is limited by the frequent inability to differentiate thyroid from parathyroid staining. Considerations of uncertainty, risk, and expense of routine parathyroid arteriography seem likely to relegate the use of this procedure to patients with persistent postoperative hypercalcemia who are being considered for re-exploration.

Brucellosis: Indications for splenectomy

Abstract Brucellosis is discussed with special emphasis on splenic involvement and indications for surgical treatment. Two cases are presented. The first illustrates a chronic localized caseating focus of disease in the spleen with symptoms referable to the enlargement of that organ and intermittent febrile episodes. Complete recovery ensued with splenectomy. The second case is representative of the acute disease. The unusual occurrence of secondary hypersplenism probably resulted in thrombocytopenia and massive gastrointestinal bleeding. Splenectomy was a valuable adjunct in the treatment of this complication with brucellosis.

DNA index and ploidy distinguish normal human parathyroids from parathyroid adenomas and primary hyperplastic parathyroids

BACKGROUND The goal of this study was to identify factors that might aid in diagnosis and intraoperative management of hyperparathyroidism. METHODS We analyzed biopsy specimens of 242 parathyroids from 159 patients by use of flow cytometry and image cytometry (ICM) for DNA index (DI), defined as the content of nuclear DNA compared with that expected for a DNA diploid standard, for proliferative index (PI), and for ploidy (diploid versus aneuploid or tetraploid). RESULTS True normal and normal parathyroids from patients with solitary adenomas were uniformly diploid. Abnormal ploidy (aneuploidy or tetraploidy) was identified frequently in adenomas and occasionally in hyperplasias with the exception that multiple endocrine neoplasia (MEN) biopsy specimens were uniformly diploid. DI for adenomas was similar to that for hyperplasias, and DI of both was higher than for normal glands. ICM-DI correlated positively with flow cytometry-DI and patient age and inversely with serum parathyroid hormone. PI was relatively low in all groups but was higher for hyperplasias versus normal parathyroids from patients with solitary adenomas and MEN versus non-MEN. PI correlated inversely with patient age. CONCLUSIONS DI by ICM differentiates normal from abnormal parathyroids. DI might influence extent of resection in two- and three-gland hyperplasia and selection of the most appropriate gland for autografting and cryopreservation in patients with four-gland hyperplasia.

Pyoderma gangrenosum in Crohn's disease: Report of a case

SummaryA case of pyoderma gangrenosum of the abdominal wall occurring in a patient with histologically proven Crohns disease of the colon is described. An aggressive surgical approach (wide excision with delayed skin grafting) resulted in rapid healing of the abdominal wall. Subsequent colectomy through the previously involved abdominal site was accomplished without complication.