임상적으로 간과하기 쉬운 부갑상선암에 의한 부갑상선기능항진증 1예

이정훈,전숙,구자원,진상욱,이상열,최문찬,오승준,우정택,김성운,김진우,김영설 대한골대사학회 2012 대한골대사학회지 Vol.19 No.1

부갑상선암은 원발성 부갑상선기능항진증 원인의 약 1~2%로, 국내에서 증례 보고가 매우 드물다. 부갑상선암에 의해 발생한 부갑상선 기능항진증은 선종에 비하여 고칼슘혈증이 심하며, 신질환이 동반되는 경우가 흔하다. 부갑상선암의 경우일반적인 일차성 부갑상선기능항진증에 비하여 더 높은 혈중 칼슘 수치, 신기능이상, 뼈 대사의 이상 소견이 많이 나타나는 것으로 알려져 있다. 저자들은 6년 동안의 고칼슘혈증이 있었으나 특이한 임상 증상이 없어 진단하기 어려웠던 부갑상선암에 의한 부갑상선기능항진증을 진단하고 치료한 1예를 경험하여 보고하는 바이다. Parathyroid carcinoma is very rare in patients with primary hyperparathyroidism, only accounts for 1% to 2% of all cases. It is characterized by higher incidence of renal dysfunction, metabolic bone disease and gastrointestinal symptoms. Although the clinical manifestations of hyperparathyroidism are more severe in patients with parathyroid carcinoma when compared to those with those with parathyroid adenoma, it is difficult to differentiate carcinoma from adenoma without pathologic confirmation. To our knowledge, there have only been a few cases of hyperparathyroidism due to parathyroid carcinomas reported to date. Here, we report a case of 63-year-old woman developing osteoporosis,hypercalcemia and hypophosphatemia due to a parathyroid tumor and was diagnosed with parathyroid carcinoma postoperatively.

일차성, 이차성 그리고 삼차성 부갑상선 기능 항진증 환자의 수술 후 임상결과: 서울대학교 병원에서의 14년 경험

최윤석 ( Yun Suk Choi ),이규언 ( Kyu Eun Lee ),박귀원 ( Kwi Won Park ),노동영 ( Dong Young Noh ),오은미 ( Eun Mee Oh ),최준영 ( June Young Choi ),윤여규 ( Yeo Kyu Youn ),오승근 ( Seung Keun Oh ),구도훈 ( Do Hoon Koo ) 대한임상종양학회 2011 Korean Journal of Clinical Oncology Vol.7 No.1

목적: 일차성, 이차성, 삼차성 부갑상선 기능 항진증은 각각 원인과 치료방법 그리고 임상 경과가 서로 다르지만 부갑상선 절제술이 표준치료로 알려져 있다. 본 연구에서는 각각의 부갑상선 항진증의 수술 전후의 임상적 변화를 알아보고 부갑상선 절제술의 의미를 재고 해보고자 하였다. 방법: 1996년부터 2009년까지 총 126명이 서울대학교 병원에서 부갑상선 절제술을 시행 받았으며 각각 일차성 96명, 이차성 24명, 삼차성 6명이었다. 환자들의 나이, 성별, 생화학적 검사, 수술방법, 병리학적 검사 결과를 전자 의무기록을 통해 후향적으로 분석하였다. 결과: 모든 세 군의 환자에서 혈청 칼슘, 부갑상선 호르몬, 이온화 칼슘이 수술 전보다 호전을 보였다. 이차성 환자군은 다른 두 군에 비해 수술 전, 후의 부갑상선 호르몬이 높았으며(p<0.001, p=0.036), 수술 후 지속적인 부갑상선 기능 항진증(30.4%) 및 일과성 저칼슘혈증(87.5%)도 다른 두 군에 비해 많이 발생하였다.(p< 0.001) 일과성 저칼슘혈증의 대부분(90.4%) 은 6개월 이내 회복 되었다. 이차성 환자에서 부갑상선 아전 및 전 절제술을 시행 받은 경우 수술 후 일과성 저칼슘혈증이 많이 나타났으나(71.4%), 제한적 절제술을 시행 받은 경우 지속적 부갑상선 기능항진증이 더 많이 나타났다.(50%) 결론: 부갑상선 절제술은 생화학 검사상의 호전을 위한 치료 방법으로 추천될 수 있으며, 이차성에서는 제한적 절제를 하는 경우 지속적 부갑상선 항진증의 빈도가 더 높으므로 부갑상선 아전 및 전 절제술을 시행해야 한다. Purpose: Primary hyperparathyroidism(PHPT), secondary hyperparathyroidism(SHPT) and tertiary hyperparathyroidism(THPT) are different in the cause, treatment and prognosis. However the parathyroidectomy has been an efficient treatment in all hyperparathyroidism groups. A single institution`s 14 year experience of surgical treatment was analyzed to investigate perioperative changes of clinical characteristics and reconsider the value of parathyroidectomy as the treatment option. Materials and Methods: From 1996 to 2009, 126 patients underwent parathyroidectomy at single institute and the number of patients with PHPT, SHPT and THPT were 96, 24 and 6 retrospectively. The electronic medical records of age, sex, biochemical analysis, operative method, and pathologic results were reviewed retrospectively. Results: Postoperative calcium (Ca), parathyroid hormone (PTH), ionized calcium (iCa) levels were improved definitely than preoperative Ca, PTH, iCa level in all three groups. Pre and postoperative PTH level in SHPT was higher than in PHPT and THPT(p<0.001, p=0.036) and postoperative persistent PTH increased status were more common in SHPT.(30.4%, p<0.001) Postoperative temporary hypocalcemia was more common in SHPT(87.5%, p<0.001), almost of them (90.4%) were recovered in 6 month. In SHPT group, temporary hypocalcemia were more common in subtotal or total parathyroidectomy group than in limited resection group (94.1%) but persistent iPTH increase were more common in limited resection group (50%). . Conclusion: Parathyroidectomy is highly recommended to improve biochemical laboratory findings in patients with hyperparathyroidism. And in SHPT, subtotal or total parathyroidectomy is more appropriate surgical method for reducing the high incidence of persistent hyperparathyroidism.

갑상선 기능항진증 환자에서 나타난 간기능검사의 이상소견

채경훈 ( Kyung Hoon Chae ),권대순 ( Dae Soon Kwon ),남관우 ( Kwan Woo Nam ),강선형 ( Sun Hyung Kang ),김정일 ( Jeong Il Kim ),허원석 ( Won Seok Heo ),정재훈 ( Jae Hoon Jung ),강현모 ( Hyun Mo Kang ),강윤세 ( Yoon Sae Kang ),김연수 대한내과학회 2007 대한내과학회지 Vol.73 No.1

목적: 갑상선 기능항진증 환자에서 진단 당시에 나타나는 간기능검사치의 이상소견의 빈도와 항갑상선제를 이용한 치료 후에 평가된 갑상선 기능상태와 간기능검사치의 변화를 파악하고자 하였으며 아울러 연령과 성별 및 항갑상선제의 종류가 항갑상선제를 이용한 치료 후에 간기능검사의 정상화에 미치는 영향을 분석하고자 하였다. 방법: 2004년 6월부터 2005년 5월까지 충남대학교병원 내분비내과 외래에 내원한 갑상선 기능항진증 환자 중 간기능검사치의 이상소견을 동반할 수 있는 다른 원인의 감별이 가능하였으며 진단 당시에 간기능검사가 시행된 총 378명을 대상으로 하여 진단당시의 AST, ALT, Total bilirubin, AP 및 GGT치와 갑상선기능 검사치를 분석하였으며, 간기능검사치의 이상소견의 빈도를 구하였다. 간기능검사치에서 이상소견을 나타낸 272명 중 65명의 환자(Group 1)에서 항갑상선제 치료 후 간기능검사의 추적검사가 시행되었다. 이 65명의 환자군에서 연령, 성별, 진단 당시의 간기능 검사치(AST, ALT, Total bilirubin, AP 및 GGT), 진단 당시의 갑상선기능검사치(T3, T4, Free T4 및 TSH) 및 사용한 항갑상선제의 종류를 분석하였으며, 항갑상선제를 이용한 치료 후에 시행된 간기능검사치와 갑상선기능검사치를 분석하였다. 결과: 갑상선 기능항진증 환자에서 AST, ALT, Total bilirubin, AP 및 GGT의 증가는 각각 16.4%, 31.0%, 3.2%, 48.7% 및 26.9%에서 관찰되었으며 AP의 상승이 가장 흔한 이상소견이었다. 평균 6.1개월의 항갑상선제 복용 후에 65명의 환자 중 48명(73.8%)에서 간기능검사치가 정상화되었다. AST, ALT, Total bilirubin, AP 및 GGT치는 각각 92.2%, 74.2%, 60.1%, 34.6% 및 57.1%에서 정상화되었다. AST, ALT, AP 및 GGT의 정상화율은 항갑상선제 복용 후에도 여전히 갑상선 기능항진 상태로 지속되었던 군에 비해 정상 갑상선 기능상태로 회복된 군에서 더 높았다. 항갑상선제의 종류, 연령에 대한 간기능 이상소견의 정상화율은 통계학적으로 의미있는 차이가 없었으나 성별에 대한 분석에 있어서 여성의 ALT 정상화율이 남성의 ALT 정상화율에 비해 통계학적으로 의미있게 높았다. 결론: 갑상선 기능항진증 환자에서 간기능검사의 이상소견은 비교적 흔하며 이러한 이상소견은 갑상선 기능상태와 밀접하게 관련이 있다. Background: Abnormalities of liver function tests are common in patients with hyperthyroidism and may reflect thyroid hormone status. The aim of our study was to analyze the frequency of abnormal liver function tests in the patients with hyperthyroidism at diagnosis and the association with the thyroid function state after antithyroid therapy. Methods: Three hundred seventy eight patients with hyperthyroidism who visited Chungnam National University Hospital from June 2004 to May 2005 and had no other causes for abnormal liver function tests were examined. At diagnosis, 272 of 378 patients had various abnormalities seen on the liver function tests. Among 272 patients, 65 were followed up for liver function tests and were analyzed for sex, age, use of an antithyroid drug, and thyroid function tests after administration of an antithyroid drug. We analyzed the frequency of liver function abnormalities and the relevance between abnormalities of liver function and the thyroid function state. Results: Abnormalities in AST, ALT, total bilirubin, alkaline phosphatase and GGT were observed in 16.4%, 31.0%, 3.2%, 48.7% and 26.9% of the 378 patients with hyperthyroidism, respectively. The level of alkaline phosphatase was the most common abnormal parameter. After antithyroid therapy, 48 (73.8%) of 65 patients had normalization of their liver function abnormalities. The normalization rate for AST, ALT, alkaline phosphatase and GGT were higher in the euthyroid status group than the sustained hyperthyoid status group. The normalization rate for ALT was significantly higher in the female group than in the male group, but the effect of antithyroid drug use and age on the normalization rate was not statistically significant. Conclusions: These findings indicate that abnormalities of liver function tests are common in patients with hyperthyroidism and these abnormalities are strongly associated with thyroid hormone status.(Korean J Med 73:18-24, 2007)

甲狀腺機能亢進證에 有用한 韓方處方의 效果

田炳薰 圓光大學校 韓醫學硏究所 1997 원광한의학 Vol.7 No.1

영은 頸下에 發生하고 처음에는 영핵과 相以하며 皮寬不急하고 瘤는 皮肉中에서 홀연히 腫하여 처음에는 梅而大이나 점차 長大해지고 부통불양하고 不結强하는데 留結不散한다하여 瘤라 하였으며, 陳 等은 영은 陽으로 홍색을 띠고 高突하거나 或은 체소이하수하며 瘤는 陰으로 白色을 띠고 漫腫이며 ??양 瘀痛은 없으므로 감각하지 못한다 하였고 吳는 영은 纓絡之狀이고 瘤는 隧氣留住한다 하였다. 한편 중국내과학 등에서는 영병을 甲狀腺機能 亢進症, 單純性甲狀腺腫, 結節性甲狀腺腫, 甲狀腺腺瘤 혹 囊腫, 甲狀腺癌, 慢性甲狀腺炎등위 범주에 포함시켰으며 瘤는 頸淋巴結腫瘤, 甲狀腺腫痒의 범주에 포함시키고 있다. 갑상선 hormone의 量이 적어지는 갑상선기능저하증은 뇌과 골격의 성장 및 발육장애로 Certin이 되거나 체온이 하강하며 Anabolism보다 Catabolism의 저하가 더욱 현저하여 각 조직내에 대사산물이 축적되기 때문에 피로 및 근육쇠약, 체중증가, 무력감, 기억력 감퇴, 말이 느려짐, 근육통, 發汗感少, 식욕감퇴 등의 증상이 나타난다. 영병은 기영, 육영, 근영, 혈영, 석영의 오종으로 분류되기도 하는데 주요원인으로는 간물기체, 담어응결, 기체혈어, 음처양왕, 신음불족이며, 치법은 소간사회, 행어파적, 사심화호음액, 청심안신, 행신양음을 위주로 하고 있다. 이에 저자는 3,5,3^3-thriodothyronine을 투여시켜 갑상선기능항진증이 유발된 백서에 청간호회환을 투여하여 체중의 변화, 섭취량 측정, 심장의 중량, 혈압과 심전동수, 형청중 T_3, T_4 및 TSH함량을 관찰하여 유의한 결과를 얻었기에 보고하는 바이다. In this study, the effects of Cheongganhoheowhan on the hyperthyroidism induced by the intrapentoneal injection of 3,5,3-triiodothyranine was examined by the measurement of physical changes, body weight, the volume of food intake and rectal temperature, and heart weight, heart beat, blood pressure with contrast to propranolol, one of beta-blocking agents, the obtained results were as follows. 1. The Cheongganhoheowhan extract showed to inhibit the decrease of body weight and rectal temperature, and decrease th food intake, so the inhibitory effects of Cheongganhoheowhan extract on the experimental hyperthyaoidism were exhibited. 2. The Cheongganhoheowhan extract showed the inhibitory effects on the circulatory functions changed and enhanced by the experimental induced hyperthyroidism, the action of Cheongganhoheowhan extract was less effective than the propranolol of D-CONT group. 3. The Cheongganhoheowhan extract showed significant effects to inhibit the concentration of serum thyroid houmone, more effective than the propranolol, beta-blocking agents. 4. The Cheongganhoheowhan extract showed the effective inhibitory reaction on the biochemical changes in serum cholesterol, ketone bodies, free fatty acid, glucose in hyperthyroid rats induced by 3,5,3-triiodothyronine.

기능성 부갑상선암종 : A case report 1예 보고

송형근,이옥준,신향미,오태근,궁성수,윤효영 충북대학교 의과대학 충북대학교 의학연구소 1998 忠北醫大學術誌 Vol.8 No.1

부갑상선에 생기는 악성종양은 매우 드물며 이중 기능성 부갑상선암종이 대부분을 차지한다. 현재까지 270예가 보고 되었으며 국내에서는 5예뿐이다. 53세 여자의 부갑성선 기능항진증과 재발성 췌장염을 동반한 부갑상선암종 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Parathyroid carcinoma is a rare endocrine tumor, reported to be less than 1% of patients with primary hyperparathyroidism. Patients with parathyroid carcinomas are often symptomatic, have markedly elevated calcium levels. and have a palpable neck mass. They are equally distributed between the sexes. The diagnosis is suspected when the tumor is large, parathyroid hormone levels are high, and a palpable mass is present in the neck. Parathyroid carcinoma is often misdiagnosed preoperatively, suspected intraoperatively, and only confirmed postoperatively. We experienced a case of hyperfunctioning parathyroid carcinoma associated with recurrent pancreatitis in a 52 year old female, which was confirmed microscopically. The tumor showed : 1) blood vessel invasion ; 2) a trabecular pattern, and 3) intervening thick fibrous bands.

원발성 부갑상선 기능항진증

이기문,노동영,최국진,윤여규,오승근,Gee Mun Lee,Dong Young Noh,Kuk Jin Choe,Yeo Kyu Youn and Seung Keun Oh 대한갑상선-내분비외과학회 2003 The Koreran journal of Endocrine Surgery Vol.3 No.1

Purpose: Primary hyperparathyroidism is the most frequent cause of hypercalcemia and due to the routine examination of serum calcium levels, the number of patients with primary hyperparathyrodism has increased. Methods: We reviewed sixty patients treated by surgery over the 20-year period at the Department of Surgery, Seoul National University Hospital and retrospectively analyzed both the clinicopathologic and bio-chemcal features of the presented cases and the effective methods of treatment and diagnosis retrospectively. Results: The study group consists of 60 patients with primary hyperparathyroidism comprised of 18 males and 42 females. The most common presenting clinical manifestations were associated with bone pain in 38 (63%), and recurrent urinary stone in 27 (45%) patients; And 11 patients were asymptomatic. All patients showed hypercalcemia and the serum parathyroid hormone (PTH) level was elevated in all 49 patients after 1992. A preopeative localization study was performed with ultrasonography (USG), computed tomography (CT), Thallium-Technecium (Tl-Tc) substraction scan and Methoxylisobutyl isonitrile (MIBI) scan. Positive localization was made in 71%, 71%, 77% and 71% respectively. Histopathologic findings revealed solitary adenoma in 56 patients and carcinoma in 4 patients. Transient hypocalcemia following surgery occurred in 50 patients and they were treated with calcium. There were no recurrent cases with the exception of one who displayed carcinoma. Conclusion: In this study, most of the patients were discovered with an advanced clinical and biochemical status but the number of the asymptomatic patients is increasing. Through an accurate preoperative localization, they were successfully treated with parathyroidectomy without major complications. (Korean J Endocrine Surg 2003;3:7-14)

원발성 부갑상선 기능 항진증에 관한 임상적 고찰

한수진,김대겸,우상욱,김정한,남석진,양정현,Su-Jin Han,Dae-Kyum Kim,Sang-Uk Woo,Jeong-Han Kim,Seok-Jin Nam,and Jung-Hyun Yang 대한갑상선-내분비외과학회 2004 The Koreran journal of Endocrine Surgery Vol.4 No.1

원발성 부갑상선 기능항진증의 임상 경험

오승근,조항준,서경석,Seung Keun Oh,M,D,Hang Jun Cho,M,D,and Kyung Suk Suh,M,D 대한갑상선-내분비외과학회 2003 The Koreran journal of Endocrine Surgery Vol.3 No.1

Eighteen patients with primary hyperparathyroidism were treated by one of the authors (SKO) from 1981 through 1988 at the Department of Surgery, Seoul National University Hospital and the data were analyzed retrospectively. Eighteen patients comprised 6 males and 12 females, with the male to female ratio of 1 to 2. The age distribution was between 18 and 64 years. The chief complaints were associated with skeletal symptoms in 9 urinary symptoms in 5, and neurologic manifestation in 1 patient. There were 3 patients with asymptomatic hypercalcemia. All patients showed hypercalcemia and hypophosphatemia was found in 11 patients. Serum PTH level was elevated in 13 cases. performing preoperative localization with computed tomorgam, ultrasonogram and thallium-technetium subtraction scan, positive localization was made in 62.5% (10/16), 53.8% (7/13) and 85.7% (12/14), respectively. one patient, angiography and selective venous sampling were peformed and positive localization was made. All patients were treated by surgery. There were 17 patients with solitary adenoma and one with double tumors. Pathologic findings revealed adenoma of the parathyroid in all patients except one which was proved later to be carcinoma. There were no recurrent cases except one with carcinoma. There were no postoperative complications. primary hyperparathyroidism is a very rare disease in Korea. Causes of primary hyperparathyroidism in our study was confined to tumors of the parathyroid, such as adenoma and carcinoma.There was no hyperplasia causing primary hyperparathyroidism. Thallium-technetium subtraction scan was proved to be the best method for localization of the parathyroid tumors. Excision of the tumor with involved parathyroid followed by frozen-section biopsy of the univolved parathyroid was the best way to treat primary hyperparathyroidism in our study. (Korean J Endocrine Surg 2003;3:39-46)

이차성 부갑상선 기능항진증과 연관되어 발생한 상완골의 갈색종 1예

서지원,고태경,홍종철,박헌수,Ji Won Seo,Tae Kyung Koh,Jong Chul Hong,Heon Soo Park 대한갑상선-내분비외과학회 2013 The Koreran journal of Endocrine Surgery Vol.13 No.2

Brown tumor is a bone disease that arises in the setting of increased osteoclastic activity and fibroblastic proliferation in the involved bone. It is well recognized as serious complication of hyperparathyroidism. Brown tumor is uncommon, and brown tumor with secondary hyperparathyroidism resulting from chronic renal failure has rarely been reported. We recently experienced a case of a 28-year-old Korean woman with chronic renal failure caused by chronic glomerulonephritis, on hemodialysis for nine years. She has been hospitalized with left shoulder pain for two years. Image studies showed multiple cystic masses, and both suspicious marked thinning and partial destruction of the cortex on the head of the left humerus. Histopathologic analysis of the mass lesion showed a fibrotic capsule, hemosiderin pigmentation, and giant cell, all characteristic of brown tumor. A subtotal parathyroidectomy was done without surgery of the bony lesion (brown tumor), with successful results. We report this case with a brief review of the literature.

말기 신부전증에 의한 이차성 부갑상선 기능항진증 환자에서 부갑상선 조직의 세포자가사멸 연구

이유미,이재복<SUP>1<,SUP>,Yu Mi Lee,Ph,D and Jae Bok Lee,Ph,D,<SUP>1<,SUP> 대한갑상선-내분비외과학회 2008 The Koreran journal of Endocrine Surgery Vol.8 No.4

Purpose: The cause of renal hyperparathyroidism is unclear and the role of hyperphosphatamia is the only well established cause of renal osteodystrophy. The long life span of the parathyroid cells and the absence of a definite tissue marker for nodular parathyroid gland prohibit the timing of surgical intervention. The discrepancy between proliferation and apoptosis has been proposed as one possible cause of nodular development of the parathyroid gland in patients suffering with renal osteodystrophy. In the present study, we investigated the apoptotic labeling index of the parathyroid tissue in patients with renal hyperparathyroidism. Methods: The parathyroid tissues of 76 patients with renal hyperparathyroidism and those of 33 normal glands were used for determining the level of apoptosis by performing a Tdt-mediated dUTP nick end labeling (TUNEL) assay. The patients' information was collected by a review of the clinical charts. Statistical comparison was done via two tailed t-tests. Results: The averages of the TUNEL indices were 0.19 in the normal parathyroid glands and 1.84 in the hyperplastic parathyroid glands (P=0.00). The TUNEL index was higher in the oxyphil type of cells than in the chief cells and the water clear cell types (P=0.01). There was statistically significant correlation of the TUNEL index with the duration of the dialysis and less than 10 years dialysis showed a 2.23 index, which was higher than that of the longer term dialysis patients (P=0.00). The preoperative PTH level, recurrence, the Ki-67 labeling index and the pathologic type didn't show any statistical correlation with the TUNEL index (P>0.05). Conclusion: Our findings showed that the TUNEL index is useful for separating the cases of advanced renal hyperparathyroidism from the early ones and the TUNEL index is well correlated with hyperplastic types of cells. A decrease of apoptosis could be a probable cause of the progression of parathyroid hyperplasia in renal patients who are on dialysis support. (Korean J Endocrine Surg 2008; 8:250-255)