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Graphic Interpretation of Serum Parathyroid Hormone, Calcium, and Phosphorus Values in Primary Hyperparathyroidism
Letters Silicone Gel Breast Implants
The authors reply
Members of the Division of Plastic and Reconstructive Surgery at the Mayo Clinic in Rochester, Minnesota, are concerned with the case report entitled "Detection of Migratory Silicone Pseudotumor With Use of Magnetic Resonance Imaging," by Persellin and colleagues, which was published in the September 1992 issue of the Mayo Clinic Proceedings (pages 891 to 895). That article tended to exaggerate complications that have been reported in earlier literature. An 80% incidence of capsular contracture, which is based on the use of earlier implants, was cited. In fact, with use of current implants, the incidence is 26 to 38%, and such occurrences are often asymptomatic. Capsular contracture has not been shown to be a health hazard, although it may be a nuisance. The migration of silicone to distant parts, as described in the case report, is rare. Usually, if silicone gel escapes from the pocket, localized siliconomas, which are easily palpated and managed, occur. This complication is also uncommon. Silicone lymphadenopathy, far from being universal as indicated in the report, is rare indeed. In the Mayo Clinic experience with more than 4,000 patients with silicone implants, axillary adenopathy may occur in less than I % of patients and has not been associated with adverse symptoms; rather, it is noted as painless adenopathy. Although mammography may be helpful, we have encountered several false-positive and false-negative results because of intact capsules that contain free gel. Ruptured capsules with herniation of intact implants may falsely suggest extravasation of gel outside the pocket. Ultrasonography has been found to be more accurate for diagnosis than mammography. Although we are unaware of previous reports of magnetic resonance imaging for detecting ruptured implants, we are aware of other institutions that have been investigating the use of this modality in such situations. This is an expensive means (more than $1,000) of detecting rupture of breast implants when clinical examination, history, and ultrasonography can diagnose a problem (if one exists) in most instances. In our experience, when no clinical problems occur, ruptured implants have not been associated with untoward consequences.
We described a patient with a ruptured silicone gel breast implant and distant migration as an interesting, albeit rare, complication of breast implants. Magnetic resonance imaging vividly demonstrated the anatomic route of dissection, from the ruptured implant to the medial region of the elbow, and provided an unusual perspective of a perplexing clinical problem. We hoped to bring this unusual situation to the attention of physicians who see patients with breast implants. In our article, we stated that "as many as 80%" of implants develop capsular contracture. This figure is reiterated in a recent physician update published by the American Society for Aesthetic Plastic Surgery.' New implants may be associated with a lower incidence. We did not recommend routine use of magnetic resonance imaging to detect rupture of breast implants, although it may help identify gel that has extravasated into the regions of the brachial plexus and arm. These sites are difficult to assess with ultrasonography. Moreover, we did not intend to make a statement about the safety of silicone gel breast implants. We leave that decision to the Food and Drug Administration. Scott T. Persellin, M.D. James B. Vogler III, M.D. Paul W. Brazis, M.D. Owen J. Moy, M.D.
REFERENCE
1. Physician Update on Aesthetic Plastic Surgery. Long Beach (CA): American Society for Aesthetic Plastic Surgery, 1992 Summer
Graphic Interpretation of Serum Parathyroid Hormone, Calcium, and Phosphorus Values in Primary Hyperparathyroidism For years, the users of our parathyroid hormone (PTH) assay have wanted a graphic display of serum PTH, calcium, and phosphorus values in patients with primary hyperparathyroidism. We recently designed such a graphic. The distribution of serum calcium versus phosphorus was a mirror image of the distribution of calcium versus PTH. The graphic display was generated from our article on 361 patients with surgically proven primary hyperparathyroidism
John E. Woods, M.D. Phillip G. Arnold, M.D. N. Bradly Meland, M.D. Ricky P. Clay, M.D. Paul Petty, M.D. Uldis Bite, M.D. Division of Plastic Surgery Mayo Clin Proc 1993; 68:96-97
96
© 1993 Mayo Foundation for Medical Education and Research
LEITERS
Mayo Clin Proc, January 1993,Vol68
97
Ca, mg/dL 17
•
16 15
•
•
•
•
• •
:· I.
14
• I
13
•
11
...
10
9 1
2
3
4
Serum phosphorus, mg/dL
• •• ••
••
• •
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• ·':~~·.I~·:: ~ ..... .. ·. •
12
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.1 •• • • •
~t.I!I·
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• 10
20
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30
40
ICMA PTH, pmol/L
Fig. 1. Graphic display of serum phosphorus, calcium, and parathyroid hormone (PTH) values in 361 patients with surgically proven primary hyperparathyroidism. Correlation between serum calcium and PTH values is significant (r =0.434; P =0.0001), as shown in right half of diagram. Inverse correlation between serum calcium and phosphorus (r =-0.339; P = 0.0001) is shown in left half of diagram. Shaded boxes = normal ranges for serum phosphorus, calcium, and PTH; open triangles (on left and right halves of diagram) = a patient's phosphorus, calcium, and PTH values. leMA PTH = PTH values determined by immunochemiluminometric assay.
published in the July 1992 issue of the Mayo Clinic Proceedings (pages 637 to 645). Users can now apply our existing distribution data as a reference to interpret their own results. Pai C. Kao, Ph.D. Section of Clinical Biochemistry Edward G. Lufkin, M.D. Division of EndocrinologylMetabolism and Internal Medicine
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words, contain no more than 5 references, and be in a doublespaced, typewrittenformat. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion of the Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.
The authors reply
Members of the Division of Plastic and Reconstructive Surgery at the Mayo Clinic in Rochester, Minnesota, are concerned with the case report entitled "Detection of Migratory Silicone Pseudotumor With Use of Magnetic Resonance Imaging," by Persellin and colleagues, which was published in the September 1992 issue of the Mayo Clinic Proceedings (pages 891 to 895). That article tended to exaggerate complications that have been reported in earlier literature. An 80% incidence of capsular contracture, which is based on the use of earlier implants, was cited. In fact, with use of current implants, the incidence is 26 to 38%, and such occurrences are often asymptomatic. Capsular contracture has not been shown to be a health hazard, although it may be a nuisance. The migration of silicone to distant parts, as described in the case report, is rare. Usually, if silicone gel escapes from the pocket, localized siliconomas, which are easily palpated and managed, occur. This complication is also uncommon. Silicone lymphadenopathy, far from being universal as indicated in the report, is rare indeed. In the Mayo Clinic experience with more than 4,000 patients with silicone implants, axillary adenopathy may occur in less than I % of patients and has not been associated with adverse symptoms; rather, it is noted as painless adenopathy. Although mammography may be helpful, we have encountered several false-positive and false-negative results because of intact capsules that contain free gel. Ruptured capsules with herniation of intact implants may falsely suggest extravasation of gel outside the pocket. Ultrasonography has been found to be more accurate for diagnosis than mammography. Although we are unaware of previous reports of magnetic resonance imaging for detecting ruptured implants, we are aware of other institutions that have been investigating the use of this modality in such situations. This is an expensive means (more than $1,000) of detecting rupture of breast implants when clinical examination, history, and ultrasonography can diagnose a problem (if one exists) in most instances. In our experience, when no clinical problems occur, ruptured implants have not been associated with untoward consequences.
We described a patient with a ruptured silicone gel breast implant and distant migration as an interesting, albeit rare, complication of breast implants. Magnetic resonance imaging vividly demonstrated the anatomic route of dissection, from the ruptured implant to the medial region of the elbow, and provided an unusual perspective of a perplexing clinical problem. We hoped to bring this unusual situation to the attention of physicians who see patients with breast implants. In our article, we stated that "as many as 80%" of implants develop capsular contracture. This figure is reiterated in a recent physician update published by the American Society for Aesthetic Plastic Surgery.' New implants may be associated with a lower incidence. We did not recommend routine use of magnetic resonance imaging to detect rupture of breast implants, although it may help identify gel that has extravasated into the regions of the brachial plexus and arm. These sites are difficult to assess with ultrasonography. Moreover, we did not intend to make a statement about the safety of silicone gel breast implants. We leave that decision to the Food and Drug Administration. Scott T. Persellin, M.D. James B. Vogler III, M.D. Paul W. Brazis, M.D. Owen J. Moy, M.D.
REFERENCE
1. Physician Update on Aesthetic Plastic Surgery. Long Beach (CA): American Society for Aesthetic Plastic Surgery, 1992 Summer
Graphic Interpretation of Serum Parathyroid Hormone, Calcium, and Phosphorus Values in Primary Hyperparathyroidism For years, the users of our parathyroid hormone (PTH) assay have wanted a graphic display of serum PTH, calcium, and phosphorus values in patients with primary hyperparathyroidism. We recently designed such a graphic. The distribution of serum calcium versus phosphorus was a mirror image of the distribution of calcium versus PTH. The graphic display was generated from our article on 361 patients with surgically proven primary hyperparathyroidism
John E. Woods, M.D. Phillip G. Arnold, M.D. N. Bradly Meland, M.D. Ricky P. Clay, M.D. Paul Petty, M.D. Uldis Bite, M.D. Division of Plastic Surgery Mayo Clin Proc 1993; 68:96-97
96
© 1993 Mayo Foundation for Medical Education and Research
LEITERS
Mayo Clin Proc, January 1993,Vol68
97
Ca, mg/dL 17
•
16 15
•
•
•
•
• •
:· I.
14
• I
13
•
11
...
10
9 1
2
3
4
Serum phosphorus, mg/dL
• •• ••
••
• •
e. I -.
• ·':~~·.I~·:: ~ ..... .. ·. •
12
o
•
• •
0
I.!-
.• .•
.1 •• • • •
~t.I!I·
~i
~
• 10
20
•• •
•
30
40
ICMA PTH, pmol/L
Fig. 1. Graphic display of serum phosphorus, calcium, and parathyroid hormone (PTH) values in 361 patients with surgically proven primary hyperparathyroidism. Correlation between serum calcium and PTH values is significant (r =0.434; P =0.0001), as shown in right half of diagram. Inverse correlation between serum calcium and phosphorus (r =-0.339; P = 0.0001) is shown in left half of diagram. Shaded boxes = normal ranges for serum phosphorus, calcium, and PTH; open triangles (on left and right halves of diagram) = a patient's phosphorus, calcium, and PTH values. leMA PTH = PTH values determined by immunochemiluminometric assay.
published in the July 1992 issue of the Mayo Clinic Proceedings (pages 637 to 645). Users can now apply our existing distribution data as a reference to interpret their own results. Pai C. Kao, Ph.D. Section of Clinical Biochemistry Edward G. Lufkin, M.D. Division of EndocrinologylMetabolism and Internal Medicine
The Editor welcomes letters and comments, particularly pertaining to recently published articles in the Mayo Clinic Proceedings. A letter should be no longer than 500 words, contain no more than 5 references, and be in a doublespaced, typewrittenformat. The letter should be signed. It is assumed that appropriate letters may be published, at the discretion of the Editor, unless the writer indicates otherwise. The Editor reserves the right to edit letters in accordance with the Mayo Clinic Proceedings style and to abridge them if necessary.