Radioguided parathyroidectomy is equally effective for both adenomatous and hyperplastic glands

Radioguided parathyroidectomy effective in pediatric patients

BACKGROUND

Radioguided parathyroidectomy (RGP) has been shown to be effective in adult patients with hyperparathyroidism (HPT), but the utility of RGP in pediatric patients has not been systematically examined. It is not known if adult criteria for radioactive counts can accurately detect hyperfunctioning parathyroid glands in pediatric patients. The purpose of our study was to determine the utility of RGP in children with primary HPT.

MATERIALS AND METHODS

A retrospective review of our prospectively maintained single-institution database for patients who underwent a RGP for primary HPT identified 1694 adult and 19 pediatric patients aged 19 y or younger. From the adult population, we selected a control group matched three to one for gland weight and gender and compared pre- and postoperative laboratory values, surgical findings, pathology, and radioguidance values between the control and the pediatric groups.

RESULTS

Excised glands from pediatric patients were smaller than those in the total adult population (437 ± 60 mg versus 718 ± 31 mg, P = 0.0004). When controlled for gland weight, ex vivo counts as a percentage of background were lower in the pediatric group (51% ± 5% versus 91% ± 11%, P = 0.04). However, ex vivo radionuclide counts >20% of the background were found in 100% of pediatric patients and 95% of the adult-matched control group.

CONCLUSIONS

All pediatric patients met the adult detection criteria for parathyroid tissue removal when a RGP was performed, and 100% cure was achieved. We conclude that RGP is a useful treatment option for pediatric patients with primary HPT.

Use of (99m)Tc 2-methoxyisobutyl isonitrile in minimally invasive radioguided surgery in patients with primary hyperparathyroidism: A narrative review of the current literature

The use of technetium-99m 2-methoxyisobutyl isonitrile (^99mTc MIBI) for assistance in minimally invasive radioguided surgery (MIRS) is growing in popularity as a safe, effective, and proficient technique used for parathyroidectomy in primary hyperparathyroidism (PHPT) treatment. Previously, the preferred treatment for PHPT was bilateral neck exploration (BNE), a very invasive, costly, and lengthy procedure. However, as a large majority (80–85% of cases of PHPT) are attributed to a single parathyroid adenoma (PA), a simpler more direct technique such as MIRS is a far better option. The following article is an exploration of the current literature concerning varied protocols utilizing ^99mTc MIBI for assistance in MIRS for patients undergoing treatment of PHPT. This technique boasts many advantageous outcomes for patients suffering from PHPT. These include a reduction in cost, operating time, and patient recovery; less evidence of post-surgical hypocalcaemia, less pain, and complications; superior cosmetic results; same-day discharge; and the possibility of local anaesthesia which is particularly beneficial in elderly patients. Better outcomes for patients with deep or ectopic PAs, reduced intra-operative complications, and improved cosmetic outcomes for patients who have previously undergone thyroid and/or parathyroid surgery are also advantageous. Of the literature reviewed it was also found that no patients suffered any major surgical complications such as laryngeal nerve palsy or permanent hypoparathyroidism using ^99mTc MIBI for assistance in MIRS.

Significance of rebounding parathyroid hormone levels during parathyroidectomy

BACKGROUND

Using minimally invasive parathyroidectomy (MIP), most surgeons require a 50% decline in intraoperative parathyroid hormone (IoPTH) to determine cure, but the significance of IoPTH kinetics occurring after this drop remains unknown. The aim of this study was to determine the impact of IoPTH levels that first meet criteria for cure, but then increase again, or rebound, between 10 and 15 min postexcision.

METHODS

We conducted a retrospective review of patients undergoing initial parathyroidectomy for primary hyperparathyroidism at our institution from 2001 to 2011. Rebound IoPTH was defined as an increase in parathyroid hormone ≥5 pg/mL after achieving the 50% drop required for cure. Comparisons were evaluated with the Student t-test, chi-square test, or Fisher exact test where appropriate.

RESULTS

Of the 1386 patients who met selection criteria, 86 (6.2%) patients exhibited rebound IoPTH. The mean magnitude of rebound was 13.8 ± 3.6 pg/mL. Compared with those not displaying rebound, more patients with rebound IoPTH were treated with open parathyroidectomy rather than MIP (10.8% versus 4.5%, P < 0.01). The recurrence rate among those with rebound IoPTH was more than double that of the patients without rebound IoPTH (5.8% versus 2.2%, P = 0.03). Magnitude of rebound, however, did not correlate with recurrence. The rate of persistent disease was not different between those with and without rebound IoPTH. Rebound was a much better indicator of recurrence than patients whose final IoPTH levels were not within the normal range.

CONCLUSIONS

Rebound IoPTH is more common in patients who develop recurrent hyperparathyroidism. Therefore, surgeons should closely monitor patients with rebound IoPTH for disease recurrence.

Is minimally invasive parathyroidectomy associated with greater recurrence compared to bilateral exploration? Analysis of more than 1,000 cases

BACKGROUND

The durability of minimally invasive parathyroidectomy (MIP) has been questioned, and some advocate for routine open parathyroidectomy (OP). This study compared outcomes between patients treated with MIP compared with OP for primary hyperparathyroidism (PHPT).

METHODS

A retrospective review was performed to identify cases of PHPT with single adenomas (SA) between 2001 and 2011. Operations were classified as OP when both sides were explored. Kaplan-Meier estimates were plotted and compared by the log-rank test.

RESULTS

We analyzed 1,083 patients with PHPT with SA; 928 (85.7%) were MIP and 155 (14.3%) were OP. There was no difference in the rates of persistence (0.2% MIP vs 0% OP, P = .61) or recurrence (2.5% MIP vs 1.9% OP, P = .68) between the 2 groups. The Kaplan-Meier estimates did, however, began to separate beyond 8 years' follow-up. The OP group did experience a greater incidence of transient hypocalcemia postoperatively (1.9% vs 0.1%, P = .01).

CONCLUSION

MIP appears equivalent to OP in single-gland disease. Although patients undergoing OP experienced more transient hypocalcemia, patients undergoing MIP appear to have a greater long-term recurrence rate. Therefore, proper patient selection and counseling of these risks is necessary for either approach.

Sestamibi imaging for primary hyperparathyroidism: the impact of surgeon interpretation and radiologist volume

BACKGROUND

Preoperative localization is the first step towards minimally invasive targeted parathyroidectomy. While there are data emphasizing that surgeon experience optimizes operative outcomes, the role of the radiologist's experience in successful preoperative imaging is unclear. We hypothesized that the accuracy of sestamibi scanning for primary hyperparathyroidism is dependent upon surgeon interpretation and radiologist volume.

METHODS

Between January 2000 to August 2009, 1,255 patients underwent parathyroidectomy for hyperparathyroidism at our institution. Of these, 763 had sestamibi scans for primary hyperparathyroidism. All scans were reviewed by surgeons and radiologists blinded, and were correlated with the operative findings and pathological reports. Radiologists were grouped into high volume (>50 cases/year, HV-RAD) or low volume (<50 cases/year, LV-RAD) based upon a database of >6,000 parathyroid cases reported by 89 regional hospitals.

RESULTS

Of the 763 patients, 77 % were female and the mean age was 60 years. Mean baseline calcium and parathyroid hormone levels were 11.2 ± 0.03 mg/dl and 133 ± 3.27 pg/ml, respectively. The sensitivity of the surgeon (93 %) was higher than both HV (83 %) and LV (72 %) radiologists. Importantly, the positive predictive values were similar: 96 % for surgeon, 93 % for HV-RAD, and 98 % for LV-RAD. As a result, out of 99 scans which were correctly read by the surgeon but not by radiologist, 84 were read as negative by radiologist, 11 on the wrong side of the neck, and 4 on the same side but the wrong gland.

CONCLUSIONS

Surgeon interpretation and radiologist volume increase the likelihood of successful preoperative sestamibi parathyroid localization for primary hyperparathyroidism. We recommend that imaging be reviewed by experienced parathyroid surgeons rather than relying on radiological interpretation alone.

The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism

OBJECTIVE

To compare the results of minimally invasive parathyroidectomy (MIP) and conventional parathyroid surgery.

BACKGROUND

Primary hyperparathyroidism is a common endocrine disorder often treated by surgical intervention. Outpatient MIP, employing image-directed focused exploration under cervical block anesthesia, has replaced traditional surgical approaches for many patients with primary hyperparathyroidism. This retrospective review of a prospective database compared MIP with conventional parathyroid surgery.

METHODS

One thousand six hundred fifty consecutive patients underwent surgery for primary hyperparathyroidism by a single surgeon between 1990 and 2009 at 2 tertiary care academic hospitals. Conventional bilateral cervical exploration under general anesthesia was performed in 613 patients and MIP was performed in 1037 cases. Cure rates, complication rates, pathologic findings, length of hospital stay, and total hospital costs were compared.

RESULTS

Minimally invasive parathyroidectomy is associated with improvements in the cure rate (99.4%) and the complication rate (1.45%) compared to conventional exploration with a cure rate of 97.1% and a complication rate of 3.10%. In addition, the hospital length of stay and total hospital charges were also improved compared to conventional surgery.

CONCLUSIONS

Minimally invasive parathyroidectomy is a superior technique and should be adopted for the majority of patients with sporadic primary hyperparathyroidism.

Fluorescence-guided minimally invasive parathyroidectomy: clinical experience with a novel intraoperative detection technique for parathyroid glands

BACKGROUND

Detection of normal and pathologic parathyroid glands often is difficult due to their variability in number and location. We have implemented photosensitizer-induced fluorescence for the routine intraoperative identification of parathyroids for the surgical treatment of hyperparathyroidism.

METHODS

From 2004 to 2007, 25 patients suffering from primary and secondary hyperparathyroidism underwent minimally invasive videoscopic-assisted parathyroidectomy after oral photosensitization with aminolevulinic acid (ALA).

RESULTS

Fluorescence was sufficiently strong in 48% of patients to aid faster detection of the glands in situ. In an additional 44%, the fluorescence behavior supported the identification of the glands in situ and after excision, yielding a total of 92% of glands whose identity could be confirmed by the fluorescence technique.

CONCLUSIONS

Fluorescence-guided minimally invasive parathyroidectomy is technically feasible and may support the surgeon in detecting and confirming the parathyroid glands. As the fluorescence method requires only moderate additional technical efforts and clinical expenditure, it is a valuable add-on component in parathyroid surgery to facilitate the operation.

Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume

OBJECTIVE

To determine whether surgical volume influences the cause of operative failures after parathyroidectomy for hyperparathyroidism.

SUMMARY AND BACKGROUND DATA

The surgical success rate for hyperparathyroidism from high-volume centers exceeds 95%, but some patients have unsuccessful parathyroidectomies. Although operative failure can be due to hyperfunctioning parathyroid glands in ectopic locations, less experienced surgeons may be more likely to miss an abnormal parathyroid in normal anatomic locations, which we describe as "preventable operative failure."

METHODS

We used 2 prospective databases containing over 2000 consecutive patients who underwent parathyroidectomy. We identified 159 patients with persistent/recurrent hyperparathyroidism subsequently cured with additional surgery. The initially failed operations were classified as being performed at high- (>50 cases/yr) or low-volume (<50 cases/yr) hospitals. Hospital volume was obtained from a Wisconsin state database of 89 hospitals, which reported 6336 parathyroid operations during the same decade.

RESULTS

Patients who initially failed their operation performed at the high- or low-volume centers were similar with regard to age, laboratory values, gender, and parathyroid weights. Despite a higher incidence of multigland disease (which increases the likelihood of operative failure) in the high-volume group, patients in the low-volume group were more likely to have a missed parathyroid gland in a normal anatomic location (89% vs. 13%, P < 0.0001), and thus a higher proportion of preventable operative failures.

CONCLUSIONS

Surgical volume influences the failure pattern after parathyroidectomy for hyperparathyroidism. Preventable operative failures are more common in low-volume centers.

Imaging of parathyroid glands

Preoperative imaging studies have an important role in facilitating successful localization of adenomas for surgeons. Their use has increased and parallels the recent growth of minimally invasive parathyroidectomy. Based on findings that scintigraphy is reported to have the highest accuracy for localization of adenomas when compared with anatomic imaging techniques, this article discusses the current role and limitations of imaging, with a focus on scintigraphy, in the evaluation of patients before surgery for hyperparathyroidism.

Secondary and tertiary hyperparathyroidism: the utility of ioPTH monitoring

BACKGROUND

The aim of the present study was to examine the utility of intraoperative parathyroid hormone (ioPTH) monitoring in patients with secondary (2) and tertiary (3) hyperparathyroidism (HPT).

MATERIALS AND METHODS

We identified 105 patients with 2HPT (n = 33) and 3HPT (n = 72) who underwent ioPTH monitoring during parathyroidectomy. Data are reported as mean +/- SEM.

RESULTS

The 2HPT patients underwent 17 subtotal, 10 total, and 6 re-exploratory parathyroidectomies, whereas the 3HPT patients underwent 54 subtotal, 15 limited, and 3 re-exploratory parathyroidectomies. The percent decrease from the baseline ioPTH level at 5, 10, and 15 min after parathyroid resection, respectively, were 72% +/- 3%, 76% +/- 3%, and 76% +/- 3% in patients with 2HPT, and 52% +/- 6%, 60% +/- 4%, and 69% +/- 4% in patients with 3HPT. IoPTH levels failed to drop >50% from baseline in 5 patients (2HPT: n = 2, 3HPT: n = 3) who were normocalcemic at last follow-up. IoPTH did not alter the surgical approach in any 2HPT patients, but did alter management in 25% of 3HPT patients (15 limited resections and 3 supernumerary glands). Normocalcemia was achieved in 97% of 2HPT patients and 99% of 3HPT patients; 2 patients developed recurrent disease.

CONCLUSIONS

Intraoperative PTH levels fell by >50% in nearly 95% of patients with 2HPT and 3HPT, and the PTH level reliably predicted postoperative cure. Although the use of ioPTH did not alter surgical management in any patient with 2HPT, this rapid PTH assay affected the surgical care of a quarter of the patients with 3HPT, and it may prove to be a useful adjunct in this group of patients.

A rising ioPTH level immediately after parathyroid resection: are additional hyperfunctioning glands always present? An application of the Wisconsin Criteria

OBJECTIVE

This study was designed to determine if a rising intraoperative parathyroid hormone (ioPTH) level following parathyroid resection indicates multiple hyperfunctioning glands and to determine the appropriate intraoperative management.

SUMMARY BACKGROUND DATA

IoPTH monitoring is commonly used to guide parathyroid surgery. A significant rise in the ioPTH immediately after resection of a single parathyroid is often perceived to be indicative of the presence of additional hyperfunctioning glands.

METHODS

A total of 797 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism with ioPTH monitoring. Patients with an elevated 5 minute ioPTH were extensively studied. Operative success was defined as normocalcemia 6 months after surgery.

RESULTS

Of the 797 patients, 108 (14%) had a rising ioPTH 5 minutes after resection of a single parathyroid. Of these 108 patients, 36 (33%) continued to have elevated ioPTH levels and further exploration revealed additional hyperfunctioning glands. Importantly, in the majority of patients (n = 72 or 67%), the ioPTH started to fall after an additional 5 minutes (10 minutes after resection). The ioPTH declined by more than 50% from the 5 minute elevated value in 30%, 89%, and 99% of patients at 10, 15, and 20 minutes after resection, respectively. Importantly, this fall correctly predicted operative success in 100% of patients after removal of a single abnormal gland.

CONCLUSIONS

A rising ioPTH level immediately after parathyroidectomy is observed in 14% of patients. The majority of these patients do not have additional hyperfunctioning glands. Most of patients fell below 50% of the 5 minute elevated value within 20 minutes of gland resection and in all cases this fall correctly predicted operative success.

Surgical management of primary hyperparathyroidism: state of the art

This article reviews the current state of the art regarding therapy for primary hyperparathyroidism. Clinical evaluation and indications for parathyroidectomy are described, followed by a review of surgical techniques currently being practiced and possible outcomes involved. Focused parathyroidectomy has become a successful alternative to conventional bilateral cervical exploration.

Secondary and tertiary hyperparathyroidism, state of the art surgical management

This article reviews the current surgical management of patients with secondary and tertiary hyperparathyroidism. The focus is on innovative surgical strategies that have improved the care of these patients over the past 10 to 15 years. Modalities such as intraoperative parathyroid hormone monitoring and radioguided probe utilization are discussed.

Utility of intraoperative PTH for primary hyperparathyroidism due to multigland disease

BACKGROUND

Surgical resection is the only curative therapy for patients with primary hyperparathyroidism (1HPT). Although cure rates of parathyroidectomy are generally high, failure is most often due to unrecognized multigland disease (MGD), which compromises 15-20% of patients with 1HPT. The use of intraoperative PTH (ioPTH) monitoring is well established for single-gland disease. Controversy remains over the utility of ioPTH in MGD, with concern for false-positive results leading to prematurely concluding the operation and leaving behind abnormal parathyroid tissue, risking future recurrence. The aim of this study was to determine the utility of ioPTH monitoring for MGD.

METHODS

Between November 2000 and March 2008, data were prospectively collected on 755 patients with 1HPT who underwent parathyroidectomy. PTH samples were collected pre-incision, and then at 5, 10, and 15 min after excision of suspected abnormal parathyroid gland(s). Surgical cure was defined as a drop of greater than 50% in PTH level. Patients were clinically cured if they became normocalcemic postoperatively and remained so for 6 months. The data were analyzed to determine how accurately ioPTH predicted success or failure of parathyroidectomy.

RESULTS

Of the 755 patients, 163 (21.5%) were found to have MGD on pathology. Intraoperative PTH monitoring was used in 161 of these cases. In 146/161 cases (90.7%), the ioPTH level fell by at least 50% after removal of all suspected abnormal glands. All of these patients (100%) remained normocalcemic postoperatively. In 15/161 cases (9.3%), the PTH level did not fall by >50%. For 11/15 cases (73%), patients remained hypercalcemic postoperatively or had recurrence. However, in the remaining four cases, the patients became normocalcemic postoperatively despite failure of the PTH to fall by >50%. In each of these patients, PTH levels fell by 40-50%.

CONCLUSIONS

ioPTH monitoring accurately predicted success or failure of parathyroidectomy in 97.5% (157/161) of patients with MGD. A fall of ioPTH by >50% can be used as a highly accurate predictor of cure in patients with MGD. Therefore, ioPTH monitoring is a very useful tool in patients with 1HPT and MGD.

Intraoperative adjuncts in surgery for primary hyperparathyroidism

PURPOSE

This paper is a review of the evidence base to produce recommendations for the use of intraoperative parathyroid hormone (PTH), radioguided parathyroidectomy (RGP), methylene blue (MB), frozen section, and intraoperative neuromonitoring during surgery for primary hyperparathyroidism (PHPT).

MATERIALS AND METHODS

A Medline keyword search of English-language articles led to the production of a draft document, subsequently revised by committee, containing levels of evidence and the grading of recommendations as proposed by the Agency for Healthcare Research and Quality.

RESULTS

Literature review provides the basis for clear recommendations on the use of intraoperative PTH at surgery for PHPT. There is little evidence to support the use of RGP, MB, routine frozen section, and intraoperative neuromonitoring.

Preserving function and quality of life after thyroid and parathyroid surgery

Endocrine disease has been recognised for thousands of years, but surgical treatment of endocrine disorders has only been widely used in the past century. Surgery is an effective treatment for hyperfunctioning glands and benign and malignant tumours. Advances in surgical technique have led to the development of short and safe operations with a high cure rate, and recent studies have not only assessed the success of the operations but also have focused on how these diseases affect patient-reported quality of life before and after surgery. In this Review, we summarise current approaches to surgical treatment of thyroid and parathyroid disease, focusing on how these approaches both preserve function and improve quality of life after surgery.

Utility of an intraoperative gamma probe in the surgical management of secondary or tertiary hyperparathyroidism

BACKGROUND

In primary hyperparathyroidism the gamma probe is effective, but its role in secondary hyperparathyroidism is unclear. We investigated the utility of the probe in the surgical management of secondary and tertiary hyperparathyroidism.

METHODS

The value of the probe in guiding resection of parathyroids was determined prospectively in 29 patients with secondary or tertiary hyperparathyroidism. Resected tissues with radioactivity of greater than 20% as compared with the wound bed was considered hyperfunctional parathyroid and was confirmed histologically.

RESULTS

The probe was helpful in guiding resection in 13% of the hyperplastic glands, including ectopic glands and those not detected preoperatively. The gamma probe confirmed the presence of hyperfunctional parathyroid after resection with a sensitivity and specificity of 97% and 92%, respectively.

CONCLUSIONS

The probe is particularly useful in confirming the presence of hyperfunctional parathyroids after resection. It also is useful in identifying ectopic localizations, but its value is limited in guiding surgery for secondary or tertiary disease.

Usefulness of intraoperative 99m Tc-MIBI-guided detection for recurrent sites in secondary hyperparathyroidism: a case-controlled study

PURPOSE

(99m)Tc-Methoxyisobutylisonitrile ((99m)Tc-MIBI)-guided surgery for the detection of abnormal parathyroid glands in primary hyperparathyroidism (1-HPT) has gained popularity as an effective technique. However, in secondary hyperparathyroidism (2-HPT), the efficacy of this method remains controversial, especially for the recurrence sites of 2-HPT.

METHODS

(99m)Tc-MIBI-guided surgery was performed for 28 recurrent sites of transplanted parathyroid tissue in 4 patients, and the detection rates of this method were compared with the results of preoperative ultrasound (US) examination and computed tomography (CT) scanning.

RESULTS

The results of (99m)Tc-MIBI-guided surgery for regions of recurrence were a sensitivity of 100% (28/28) and an accuracy of 100% (29/29), compared with preoperative US and CT which had a sensitivity of 92.9% (26/28) and 0% (0/28), and an accuracy of 89.7% (26/29) and 0% (0/28), respectively.

CONCLUSIONS

Intraoperative (99m)Tc-MIBI-guided surgery can identify recurrent parathyroid tissues of 2-HPT more precisely than preoperative US examination or CT scanning, and makes the surgery easier to perform.

The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing

OBJECTIVE

To determine the utility of routine perioperative bilateral internal jugular venous sampling of parathyroid hormone (BIJ PTH) for localization during parathyroid surgery.

SUMMARY BACKGROUND DATA

Venous sampling for PTH is a useful tool for parathyroid localization in patients undergoing reoperative surgery for hyperparathyroidism (HPT). With the development of intraoperative rapid PTH (ioPTH) testing, internal jugular PTH sampling with ioPTH testing to guide operative localization has been shown to be possible in select, difficult cases. However, the value of BIJ PTH for patients with HPT is unclear.

METHODS

Between May 2004 and February 2006, 216 consecutive patients underwent neck exploration for HPT by one surgeon. Of these, 168 patients had BIJ PTH. Internal jugular venous blood was drawn from both left and right sides and analyzed for PTH using a rapid PTH assay. BIJ PTH levels were defined as lateralizing if >5% differences were observed between the right and left internal jugular vein samples.

RESULTS

Of the 168 patients, 120 (71.4%) had a single parathyroid adenoma, 15 (8.9%) had double adenoma, and 33 (19.6%) had hyperplasia. The cure rate after parathyroidectomy was 98.2%. There were no complications related to BIJ PTH sampling. Sensitivity and positive predictive value of BIJ PTH for primary hyperparathyroidism were 80% and 71%, respectively. BIJ PTH was diagnostic in 95 cases (62.9%) in primary HPT. BIJ PTH successfully localized an abnormal gland in 26 of 45 (57.8%) in patients with negative sestamibi scanning. BIJ PTH was especially helpful in 18 of 168 (10.7%) cases when intraoperative peripheral parathyroid hormone did not fall by 50% and BIJ PTH successfully localized the hyperfunctioning glands.

CONCLUSIONS

In patients with HPT, BIJ PTH is safe and effective, providing additional localization information in the majority of cases. BIJ PTH is particularly useful in the setting of negative sestamibi scanning and in complex multigland disease cases.

Radioguided parathyroidectomy for recurrent parathyroid cancer

We report a case of radioguided parathyroidectomy in a patient with parathyroid carcinoma. A 61-year-old woman presented to our center with persistent hypercalcemia (17.2 mg/dL) and hyperparathyroidism (PTH=324 pg/mL) following her second neck resection for recurrent parathyroid carcinoma at an outside facility. Her elevated serum calcium had not responded to treatment with intravenous bisphosphonates, furosemide, or calcitonin. Calcimemetic therapy (Cinacalcet) was effective but had to be discontinued due to GI intolerance. She requested a second opinion at our center after being referred for palliative radiation therapy for presumed inoperable disease. On presentation, she remained symptomatic with bone and joint pain, diffuse abdominal pain and fatigue. Repeat technetium-99m sestamibi (Tc-99m sestamibi) scintigraphy showed a faint area of uptake near the right clavicular head, adjacent to the site of her previous resections. With the intraoperative guidance of a hand-held gamma probe, a 2 cm recurrent parathyroid carcinoma was located and successfully excised. Intraoperative PTH levels confirmed surgical cure of this previously undetected foci of disease. The use of radioguidance and intraoperative PTH monitoring were the keys to a successful resection, and our patient remains disease free with 17 months of follow-up.

Parathyroidectomy for Primary Hyperparathyroidism in Octogenarians and Nonagenarians: A Risk–Benefit Analysis

BACKGROUND

The only cure for primary hyperparathyroidism (1 degrees HPT) is parathyroidectomy. However, many elderly patients are not referred for surgery due to medical comorbidities and/or advanced age. The purpose of this study was to evaluate benefits against risks of parathyroidectomy in this patient population.

MATERIALS AND METHODS

From March 2001 to June 2006, 50 patients aged 80 years or older with 1 degrees HPT underwent parathyroidectomy by a single surgeon. Clinical presentation and surgical outcomes of all patients were evaluated. The standard form of the SF-36 Health Survey, designed to measure patient quality of life (QOL), was completed by a subset of patients.

RESULTS

There were 45 females and 5 males with a mean age of 83 +/- 2 y. Patient comorbidities included hypertension (72%), coronary artery disease (22%), diabetes mellitus (16%), chronic obstructive pulmonary disease (10%), and congestive heart failure (10%). Bone pain was the most common primary presenting symptom (44%), followed by fatigue (12%), confusion (6%), and joint pain (6%). Eleven patients (22%) had ectopic glands. The cure rate postsurgery was 98% (49/50). There were 2 postoperative complications (4%): one patient with transient hypocalcemia and another with cellulitus at an i.v. site. Of patients who completed QOL surveys, greater than 60% reported improved physical functioning, social functioning, and/or mental health, and reduction of bodily pain.

CONCLUSION

Parathyroidectomy is safe and curative for octogenarians and nonagenarians with 1 degrees HPT, and maintains or improves quality of life. The surgical benefits outweigh operative risks, making parathyroid surgery an excellent option for patients over 80 years of age.

Ex Vivo Radioactive Counts and Decay Rates of Tissues Resected During Radioguided Parathyroidectomy

BACKGROUND

Radioguided parathyroidectomy using TC-99m-sestamibi injection and the handheld gamma probe allows more precise and rapid intraoperative localization of abnormal parathyroid glands. This technique is based on the principle that hypercellular parathyroid tissues have markedly higher in vivo radiotracer counts than surrounding tissue including thyroid and lymph nodes. While in vivo radioactivity after TC-99m-sestamibi administration in various tissues has been documented, there is a lack of data regarding ex vivo radioactive properties after surgical resection.

METHODS

During a 6-week period in June/July 2005, 21 patients underwent radioguided parathyroidectomy by a single surgeon. Fifty-four tissue samples (39 parathyroid, 15 nonparathyroid) from these patients were collected and analyzed for ex vivo radioactive counts over a 30-min period. These data were then compared with the pathologic results.

RESULTS

There is a significant difference in ex vivo counts between parathyroid adenomas, hyperplastic glands, and nonparathyroid tissue immediately after resection. However, radioactive decay/slope rates do not differ between the tissues. Importantly, an ex vivo count of >20% of background is 100% specific for parathyroid tissue. These differences persisted for up to 30 min.

CONCLUSIONS

This is the first comprehensive study of ex vivo radioactive properties after TC-99m-sestamibi injection during radioguided parathyroidectomy. Parathyroids have a greater rate of uptake compared to nonparathyroid tissue, allowing ex vivo counts to predict tissue type. These tissues have similar decay rates, allowing these predictions to be made anytime up to 30 min after gland resection.

Valor de la cirugía radioguiada con 99mTc-MIBI sensibilizada con dobutamina en el hiperparatiroidismo secundario persistente

99mTc-MIBI is a radiopharmaceutical that has been successfully used for the detection of hyperfunctioning parathyroid glands and for radioguided surgery techniques. We report on the case of a 55 year old woman in hemodialysis, with secondary persistent hyperparathyroidism after total parathyroidectomy. The conventional double-phase 99mTc-MIBI parathyroid scintigraphy was negative. The study was repeated after sensibilization with intravenous low-dose dobutamine showing an area of increased focal uptake in the lower cervical region. With this finding, radioguided 99mTc-MIBI surgery was performed after dobutamine administration, using a hand held gamma probe. The technique was considered successful with the resection of parathyroid cervical tissue which was further confirmed as nodular hyperplasia. We conclude that this methodology has the potential of being a an useful tool for the intraoperative localization of remanent tissue in patients with secondary persistent/recurrent hyperparathyroidism.

Radioguided thoracoscopic mediastinal parathyroidectomy with intraoperative parathyroid hormone testing

BACKGROUND

Primary hyperparathyroidism is the leading cause of hypercalcemia in the United States. The goal of this study was to evaluate the feasibility of radioguided thoracoscopic mediastinal parathyroidectomy and intraoperative immunoreactive parathyroid hormone (iPTH) level testing to guide completeness of resection.

METHODS

Mediastinal parathyroidectomy was performed thoracoscopically with intraoperative radioguidance using a hand-held gamma probe after injection of 10 mci of TC-99m sestamibi. Parathyroid excision was confirmed by ex vivo measurement of specimen radioactivity greater than 20% of background. Complete resection was confirmed by a greater than 50% decrease in serum iPTH level at 5 minutes postresection.

RESULTS

Four patients had mediastinal parathyroid glands successfully localized and resected thoracoscopically. Mean weight of the excised parathyroid adenoma was 1,714 mg (range, 425 to 4,400 mg). Baseline iPTH levels decreased from a mean of 202 to 39 pg/dL 5 minutes postresection. One patient underwent radioguided resection of a second enlarged cervical parathyroid adenoma at the same setting when his intraoperative iPTH levels failed to fall below 50% of baseline, despite resection of a 440 mg mediastinal parathyroid gland. Median hospital stay was one day. All mediastinal parathyroid glands resected were confirmed adenomas on final histologic examination. All patients were normocalcemic at follow-up (mean, 25 months), indicating cure.

CONCLUSIONS

Thoracoscopic mediastinal parathyroidectomy with intraoperative iPTH level monitoring is safe and effective. Radioguidance facilitates parathyroid localization. Ex vivo specimen radioactivity of greater than 20% of background confirms parathyroid resection and obviates the need for costly, time-consuming frozen section analysis. A 50% decrease in baseline iPTH level 5 minutes postresection confirms complete resection of parathyroid adenomas.

Fluorescence-guided minimally invasive parathyroidectomy: a novel surgical therapy for secondary hyperparathyroidism

Secondary hyperparathyroidism (SHPT) is a severe and frequent complication in patients with advanced chronic kidney disease, characterized by hyperplasia of all parathyroid glands and elevated serum parathyroid hormone levels. When surgery is required to prevent cardiovascular consequences, bone pain, osteoporosis, or even soft-tissue calcifications, detection of the enlarged glands often can be difficult because of their variability in number and location. A novel surgical technique, fluorescence-guided minimally invasive parathyroidectomy, may facilitate intraoperative localization of parathyroid glands. A 52-year-old woman with SHPT underwent minimally invasive videoscopic-assisted parathyroidectomy after photosensitization with aminolevulinic acid (ALA): Under special fluorescence illumination by D-Light (Karl Storz Co, Tuttlingen, Germany), bilateral neck exploration was performed. All enlarged parathyroid glands were identified because of their ALA-induced intense red fluorescence. Such surrounding structures as thyroid, lymph nodes, and soft tissue remained nonfluorescent and could be distinguished easily from parathyroid glands. Total parathyroidectomy with autotransplantation into the sternocleidoid muscle was performed. In patients with SHPT, exploration of all parathyroid glands during surgery is mandatory. However, to date, there is no convincing technical aid for the surgeon to facilitate this procedure. The ALA-induced fluorescence technique represents an innovative visual detection method for intraoperative identification of parathyroid glands. The technique serves as an additional tool requiring only moderate technical and clinical expenditure.

In vivo characterisation of parathyroid lesions by use of gamma probe: comparison with ex vivo count method and frozen section results

OBJECTIVE

In this study we hypothesized that if timing of gamma probe-guided parathyroidectomy were individualized according to an optimal-time-to-surgery technique, in vivo characterization of parathyroid lesions would be possible. We compared our findings with an ex vivo counting method ("20% rule") and frozen section results.

STUDY DESIGN AND SETTINGS

Thirty-five patients who were referred for surgical treatment of hyperparathyroidism were studied. Maximum parathyroid to thyroid sestamibi uptake ratio (UR(max)) was measured by use of preoperative dynamic scintigraphy. The interval between sestamibi injection and UR(max) was defined as the optimal time to surgery. On the day of surgery, the patients received the same dose of sestamibi and were taken to the operating room at UR(max) as determined by preoperative scintigraphy. Intraoperative in vivo gamma probe counts from parathyroid lesions were compared with in vivo contralateral background thyroid counts (in vivo/Bkg) and to ex vivo parathyroid counts relative to postexcision background of the adjacent normal tissue (ex vivo/Bkg).

RESULTS

A total of 70 excised lesions were evaluated. In vivo/Bkg counts obtained from parathyroid adenoma were significantly different from parathyroid hyperplasia (z = -3.093, P = 0.002) and other lesions (z = -3.958, P = 0.0001). By receiver operating characteristic curve (ROC) analysis, we found the cutoff value for the in vivo/Bkg counts ratio to be 103% to differentiate parathyroid adenoma from hyperplasia with a sensitivity, specificity, and accuracy of 82.5, 65, and 74.4%, respectively. On the other hand, sensitivity, specificity, and accuracy of the ex vivo/Bkg method to differentiate parathyroid adenoma from hyperplasia with a cutoff value of 34.7 was found to be 70.8%, 60%, and 65.9%, respectively. The difference between the accuracy of these 2 tests was not significant statistically (P = 0.137). Sensitivity of frozen section to differentiate parathyroid adenoma and hyperplasia was 76.2% and 33.3%, respectively.

CONCLUSIONS

Patient-specific optimal protocol for timing of sestamibi injection together with in vivo/Bkg method is a useful alternative method in guiding the surgeon to differentiate parathyroid adenoma from parathyroid hyperplasia and other tissues and may help surgeons' decisions during the operation. Combined use of in vivo/Bkg and ex vivo/Bkg methods may give more accurate results than frozen section.

Radioguided neck dissection in recurrent metastatic papillary thyroid carcinoma

Although radioguided surgery has been used for the excision of sentinel nodes in breast cancer and melanoma, sparse literature exists describing its use in thyroid cancer. We report a 69-year-old patient with a previous total thyroidectomy and lymph node dissection for papillary carcinoma who was subsequently found to have recurrent metastatic disease. After a therapeutic dose of radioactive iodine, a hand-held gamma-probe was used to selectively dissect the neck. The patient was offered radioguided revision neck dissection to remove the disease using residual radioactivity of the original therapeutic iodine 131 dose. Our case report seeks to demonstrate a recent example of our use of the gamma-probe in radioguided surgical excision of recurrent metastatic papillary thyroid carcinoma.

L'imagerie préopératoire des hyperparathyroïdies des insuffisants rénaux a-t-elle un intérêt en pratique clinique ?

AIM OF THE STUDY

To evaluate the efficiency of preoperative parathyroid ultrasonography and scintigraphy in the management of renal hyperparathyroidism.

PATIENTS AND METHODS

The charts of the last consecutive 200 patients who underwent surgery for renal hyperparathyroidism from 1998 to 2003 were retrospectively reviewed to collect data concerning parathyroid gland function, results of preoperative ultrasonography and scintigraphy, as well as modalities and results of surgical exploration.

RESULTS

Ultrasonography and scintigraphy sensibilities were 36.4% and 49.3%, respectively. Efficiency of both examinations was improved when they were combined (sensibility of 64.7%) and in those patients managed for recurrent hyperparathyroidism. Were more often detected by preoperative examinations glands with high weight and/or greatest diameter, orthotopic and inferior glands as well as glands exhibiting nodular hyperplasia content upon pathological examination.

CONCLUSION

Parathyroid ultrasonography and scintigraphy are of poor interest in the management of renal hyperparathyroidism. In a preoperative setting, they should be performed only in patients with recurrent disease.

The role of intraoperative parathyroid hormone testing in patients with tertiary hyperparathyroidism after renal transplantation

BACKGROUND

Intraoperative parathyroid hormone (PTH) testing has been shown to accurately define adequacy of parathyroid resection in patients with primary hyperparathyroidism (HPT) and alters the operative management in 10% to 15% of cases. However, the benefit of this technique in patients with tertiary HPT after renal transplantation undergoing parathyroidectomy is unclear.

METHODS

Intraoperative PTH was measured in 32 consecutive patients undergoing parathyroidectomy for tertiary HPT after renal transplantation between March 2001 and November 2004 by using the Elecsys assay at baseline and, subsequently, 5, 10, and 15 minutes after curative resection. The outcomes of these patients were evaluated.

RESULTS

All patients were cured after surgery. Of the 32 patients, 29 were found to have parathyroid hyperplasia, while 1 had a single adenoma and 2 had double adenomas. The average drop in intraoperative PTH levels after curative resection was 69 +/- 3.5% at 5 min., 77 +/- 2.3% at 10 minutes, and 83 +/- 3.4% at 15 minutes. PTH testing changed the intraoperative management in 5 (16%) patients. One patient with a single adenoma and 2 patients with double adenomas had a >50% drop at 10 minutes. after excision; therefore, the operation was terminated without further resection. Two patients did not have a >50% drop at 10 minutes after 3.5 gland resection. These patients were explored further, and additional supernumerary parathyroid glands were identified and resected. After resection of these additional glands, the PTH fell by >50%, indicating cure.

CONCLUSIONS

In patients undergoing parathyroidectomy for tertiary HPT after renal transplantation, a decrease in intraoperative PTH levels >50% at 10 minutes after completion of the operation indicated adequate resection. Furthermore, intraoperative PTH testing altered the operative management in 16% of patients. Therefore, similar to its role in patients with primary HPT, intraoperative PTH testing appears to play an equally important role in the management of patients with tertiary HPT undergoing parathyroidectomy.

Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy

BACKGROUND

Intraoperative parathyroid hormone (iPTH) testing often is used during minimally invasive parathyroidectomy for primary hyperparathyroidism (1 degrees HPT). However, several investigators report that these assays are not cost effective and do not improve outcomes significantly.

METHODS

To determine the impact of iPTH testing on the outcomes of patients with 1 degrees HPT, we reviewed our experience. From January 1990 to June 2004, there were 345 consecutive patients with 1 degrees HPT and positive localization studies for a single parathyroid adenoma who were candidates for minimally invasive parathyroidectomy. Group 1 patients (n = 157) underwent parathyroid exploration without iPTH testing and group 2 patients (n = 188) had an operation with iPTH testing.

RESULTS

Of the group 1 patients, 15 (10%) still were hypercalcemic postoperatively owing to additional unidentified hyperfunctioning parathyroid glands. In contrast, among 188 group 2 patients, 170 (90%) had resection of a single parathyroid adenoma, a greater than 50% decrease in iPTH levels, and were cured. The remaining 18 (10%) patients did not have an adequate reduction in iPTH levels and underwent bilateral neck exploration with resection of additional parathyroids. Of these 18 patients, 9 had double adenomas and 9 had 3- or 4-gland hyperplasia. Importantly, all patients in group 2 were cured.

CONCLUSIONS

iPTH testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. iPTH testing allowed intraoperative recognition and resection of additional hyperfunctioning parathyroids missed by preoperative imaging studies. Consequently, we strongly advocate the routine use of iPTH testing in patients who undergo minimally invasive parathyroidectomy for 1 degrees HPT.

A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable?

OBJECTIVE

To determine the utility of several perioperative adjuncts for parathyroid localization during parathyroid surgery, we prospectively compared the accuracy of sestamibi-single photon emission computed tomography (SPECT) scanning, radioguided surgery, and intraoperative parathyroid hormone (ioPTH) testing.

SUMMARY AND BACKGROUND DATA

Minimally invasive parathyroidectomy (MIP) is rapidly becoming the procedure of choice in patients with primary hyperparathyroidism (HPT). Several perioperative adjuncts can be used to localize parathyroid adenomas, including sestamibi-SPECT scanning, radioguided surgery, and ioPTH testing. However, the relative value of each of these technologies is unclear.

METHODS

Between March 2001 through September 2004, 254 patients with primary HPT underwent parathyroidectomy. All patients had preoperative imaging studies and underwent radioguided surgery with a gamma probe and ioPTH testing. The use of each perioperative adjunct was determined based on the intraoperative findings.

RESULTS

The mean age of patients was 61 +/- 1 year. The mean calcium and parathyroid hormone levels were 11.4 +/- 0.1 mg/dL and 136 +/- 6 pg/mL, respectively. Of the 254 patients, 206 (81%) had a single parathyroid adenoma, 28 (11%) had double adenomas, 19 (8%) had hyperplasia, and one had parathyroid cancer. All resected parathyroid glands were hypercellular (mean weight = 895 +/- 86 mg). The cure rate after parathyroidectomy was 98%. The positive predictive values for sestamibi scanning, radioguided surgery, and ioPTH testing were 81%, 88%, and 99.5%, respectively.

CONCLUSIONS

This series is one of the largest to date that prospectively compares the use of sestamibi scanning, radioguided surgery, and ioPTH testing. Of all the perioperative adjuncts used during parathyroid surgery, ioPTH testing has the highest sensitivity, positive predictive value, and accuracy. Thus, the inherent variability of sestamibi scanning and radioguided techniques emphasizes the critical role of ioPTH testing during parathyroid surgery.

Changing Trends for Surgery in Elderly Patients with Hyperparathyroidism at a Single Institution1

BACKGROUND

Many elderly patients with primary hyperparathyroidism (1HPT), which increases in incidence with age and is frequently asymptomatic, are often not referred for surgery. However, the development of minimally invasive techniques has facilitated complex operations even in the elderly. Therefore, we sought to delineate the changes in the trends for surgical referral at our institution for patients over 70 years of age with 1HPT.

METHODS

From January 1990 to March 2004, 422 patients underwent surgery for 1HPT at our institution. Of these, 98 were 70 years or older. In 2001, we introduced minimally invasive radioguided parathyroidectomy (MIRP). Patients were then analyzed based upon the availability of this technology (pre-MIRP era 1990-2000, and MIRP era 2001-2004).

RESULTS

In the MIRP era, more elderly patients were referred for surgery when compared to the pre-MIRP era (30% versus 18%, P = 0.001). On average, 18 elderly patients/year had parathyroid surgery in the MIRP era compared to only 4 elderly patients/year pre-MIRP, representing a 4.5-fold increase. Furthermore, there were significantly more patients undergoing parathyroidectomy who were asymptomatic from 1HPT during the MIRP era (14% versus 2%, P < 0.001). Importantly, patients who underwent surgery in the MIRP era had a higher cure rate, lower complication rate, and shorter hospital stay.

CONCLUSIONS

Since the introduction of MIRP at our institution, there has been an increase in the number of elderly patients with 1HPT referred for surgery as well as the proportion with only mild disease. Furthermore, there have been improvements in elderly patient outcomes during this time. MIRP is one of several factors that have led to an increase in elderly patients undergoing surgery for 1HPT.

Best practice no 183. Examination of parathyroid gland specimens

The pathological examination of parathyroid glands is an essential component of the evaluation of hyperparathyroidism. Traditionally, this has involved intraoperative frozen sections during bilateral surgical exploration of the neck, to confirm removal of parathyroid tissue. With recent developments in imaging, some diseased glands can be localised preoperatively, enabling removal by minimally invasive, targetted surgery, with or without additional non-histological intraoperative procedures to confirm the removal of all hyperfunctioning parathyroid tissue. This article reviews these developments and describes the ideal approach to reporting parathyroid specimens.

Historical perspective of parathyroid disease

This article highlights key historical developments in the understanding of parathyroid function and disease, a story that involves many clinical investigators and classic scientific debate. The current medical community is certainly indebted to the innate curiosity and perseverance of these historical figures.