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Güneş E, Koca N, Tufanoğlu FH. Tissue Parathyroid Hormone Washout: A Reliable Method for the Localization and Exclusion of Parathyroid Adenomas. Cureus 2023; 15:e45814. [PMID: 37745742 PMCID: PMC10517582 DOI: 10.7759/cureus.45814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/23/2023] [Indexed: 09/26/2023] Open
Abstract
Background and objective Accurate identification of parathyroid adenoma (PA) is essential for minimally invasive treatment of primary hyperparathyroidism (PHPT). The aim of this study is to evaluate the results of parathyroid hormone (PTH) assay in aspirates of suspicious neck lesions and to clarify its reliability in determining whether the lesion is of parathyroid origin. Methods A total of 134 lesions (104 imaging-suspected PA and 30 concomitant thyroid nodules as a control group) of 101 patients were retrospectively analyzed. Patients with positive, negative, or never scintigraphy were included in our study. Ultrasound (US) was performed again and US-guided tissue fine needle aspiration with PTH washout (PTH-WO) was performed from suspicious lesions. A PTH-WO level higher than the patient's serum PTH levels is proposed for a positive test, and a PTH-WO level lower than the upper limit of the laboratory PTH level is proposed for a negative test. A definitive diagnosis was made postoperatively histopathologically. Results PTH-WO levels (median (IQR)) were significantly higher in the positive group (n = 93, 5000 (1600) ng/L) compared to the negative group (n = 11, 17 (13.1) ng/L) and thyroid nodule aspirate group (n = 30, 14 (4.3) ng/L) (p < 0.001). Among 93 PTH-WO-positive lesions, 42 lesions (45.1%) were not identified by parathyroid scintigraphy (PS), 20 (21.5%) lesions were suspiciously PS, and 33 lesions (35.4%) were negative or suspicious by first US findings. Of the 93 patients localized with PTH-WO, two were cystic PAs ablated by aspiration. The final pathology result of 91 operated patients proved PA. The sensitivity, specificity, negative predictive value, and positive predictive value of the PTH-WO were observed as 1.00, 0.82, 0.09, and 0.91, respectively. Conclusion Comprehensive repeated US and PTH-WO from the lesion increase the accurate localization of PAs. PTH-WO is a highly reliable method for differentiating parathyroid lesions from other cervical lesions.
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Affiliation(s)
- Elif Güneş
- Department of Endocrinology, Metabolism and Diabetes, Health Sciences University, Bursa State Hospital, Bursa, TUR
| | - Nizameddin Koca
- Department of Internal Medicine, Health Sciences University, Bursa State Hospital, Bursa, TUR
| | - Fatih Hakan Tufanoğlu
- Department of Radiology, Health Sciences University, Bursa State Hospital, Bursa, TUR
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2
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Vultaggio F, Martino B, Nitro L, Fuccillo E, Felisati G, De Pasquale L. A parathyroid cancer with soporous state, depression, and severe cognitive decline in acute renal failure. Clin Case Rep 2023; 11:e7627. [PMID: 37397577 PMCID: PMC10310898 DOI: 10.1002/ccr3.7627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 05/29/2023] [Indexed: 07/04/2023] Open
Abstract
Key Clinical Message Soporous state in acute renal failure represent an atypical presentation of parathyroid cancer. Complete prompt investigations and diagnosis have a fundamental role in the management of this disease. Abstract This report describes a case of parathyroid carcinoma (PC) with an uncommon first clinical presentation: soporous state, depression, and severe cognitive decline in association with acute renal failure. After discovering extremely high serum calcium and parathyroid hormone (PTH) levels, the diagnosis of primary hyperparathyroidism (pHPT) was made and a surgical en bloc resection was performed. After the surgical intervention, the histological examination revealed the presence of a malignant parathyroid disease, thus confirming our first preoperative suspicion.
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Affiliation(s)
- Federica Vultaggio
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Barbara Martino
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Letizia Nitro
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Emanuela Fuccillo
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Giovanni Felisati
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
- Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
| | - Loredana De Pasquale
- Otolaryngology Unit, Santi Paolo e Carlo Hospital, Department of Health SciencesUniversità degli Studi di MilanoMilanItaly
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3
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Neves MCD, Santos RO, Ohe MN. Surgery for primary hyperparathyroidism. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2022; 66:678-688. [PMID: 36382757 PMCID: PMC10118824 DOI: 10.20945/2359-3997000000557] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Primary hyperparathyroidism (PHPT) is a hypercalcemic disorder that occurs when one or more parathyroid glands produces excessive parathyroid hormone (PTH). PHPT is typically treated with surgery, and it remains the only definitive therapy, whose techniques have evolved over previous decades. Advances in preoperative localization exams and the intraoperative PTH monitoring have become the cornerstones of recent parathyroidectomy techniques, as minimally invasive techniques are appropriate for most patients. Nevertheless, these techniques, are not suitable for PHPT patients who are at risk for multiglandular disease, especially in those who present with familial forms of PHPT that require bilateral neck exploration. This manuscript also explores other conditions that warrant special consideration during surgical treatment for PHPT: normocalcemic primary hyperparathyroidism, pregnancy, reoperation for persistent or recurrent PHPT, parathyroid carcinoma, and familial and genetic forms of hyperparathyroidism.
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Perrier N, Lang BH, Farias LCB, Poch LL, Sywak M, Almquist M, Vriens MR, Yeh MW, Shariq O, Duh QY, Yeh R, Vu T, LiVolsi V, Sitges-Serra A. Surgical Aspects of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2373-2390. [PMID: 36054175 DOI: 10.1002/jbmr.4689] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022]
Abstract
Parathyroidectomy (PTX) is the treatment of choice for symptomatic primary hyperparathyroidism (PHPT). It is also the treatment of choice in asymptomatic PHPT with evidence for target organ involvement. This review updates surgical aspects of PHPT and proposes the following definitions based on international expert consensus: selective PTX (and reasons for conversion to an extended procedure), bilateral neck exploration for non-localized or multigland disease, subtotal PTX, total PTX with immediate or delayed autotransplantation, and transcervical thymectomy and extended en bloc PTX for parathyroid carcinoma. The systematic literature reviews discussed covered (i) the use of intraoperative PTH (ioPTH) for localized single-gland disease and (ii) the management of low BMD after PTX. Updates based on prospective observational studies are presented concerning PTX for multigland disease and hereditary PHPT syndromes, histopathology, intraoperative adjuncts, localization techniques, perioperative management, "reoperative" surgery and volume/outcome data. Postoperative complications are few and uncommon (<3%) in centers performing over 40 PTXs per year. This review is the first global consensus about surgery in PHPT and reflects the current practice in leading endocrine surgery units worldwide. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Nancy Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Brian H Lang
- Department of Surgery, Queen Mary Hospital, Pokfulam, Hong Kong
| | | | - Leyre Lorente Poch
- Endocrine Surgery Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mark Sywak
- Endocrine Surgery Unit, University of Sydney, Sydney, Australia
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Menno R Vriens
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center, Utrecht, The Netherlands
| | - Michael W Yeh
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Omair Shariq
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, UK
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Randy Yeh
- Memorial Sloan Kettering Cancer Center, Molecular Imaging and Therapy Service, New York, NY, USA
| | - Thinh Vu
- Neuroradiology Department, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Virginia LiVolsi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Akgün IE, Ünlü MT, Aygun N, Kostek M, Uludag M. Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy. Front Surg 2022; 9:1024350. [PMID: 36211265 PMCID: PMC9532520 DOI: 10.3389/fsurg.2022.1024350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients. Methods The data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2). Results There were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%–97.6% according to the 20 min intraoperative parathyroid hormone value. Conclusion The cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.
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6
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Adler Y, Tzelnick S, Shopen Y, Reifen E, Bachar G, Shpitzer T, Mizrachi A. Retrospective analysis of the role of intra-operative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism: a single center experience over 2 decades. Eur Arch Otorhinolaryngol 2022; 279:5375-5380. [PMID: 35767063 DOI: 10.1007/s00405-022-07440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 05/09/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Role of intra-operative parathyroid hormone (IOPTH) monitoring during parathyroidectomy for primary hyperparathyroidism (PHPT) has long been debated. Our main goal was to investigate the cure rates of parathyroidectomy for primary hyperparathyroidism with and without IOPTH monitoring. Our secondary goal was to investigate if operating room time can be saved when IOPTH monitoring is not used. METHODS A retrospective analysis of patients who underwent parathyroidectomy for PHPT due to a single adenoma between 2004 and 2019 was performed. Cure rates and operating room time were compared. RESULTS 423 patients were included. IOPTH was used in 248 patients (59%). Four patients were not cured, two from each group, with no significant difference between the groups (98.8% vs. 99.1%, p = 0.725). Surgery time was significantly longer in the IOPTH group, p < 0.001. CONCLUSIONS There is no advantage for using IOPTH during parathyroidectomy in suitable clinical settings. The procedure may be safely performed without IOPTH while achieving non-inferior success rates and reducing operative time.
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Affiliation(s)
- Yehonatan Adler
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sharon Tzelnick
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoni Shopen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ella Reifen
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Bachar
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Shpitzer
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Mizrachi
- Department of Otorhinolaryngology-Head and Neck Surgery, Rabin Medical Center, Petah Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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7
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Shah SA. Is it Time to Obviate Intraoperative Parathyroid Hormone Monitoring in Localized Large Adenomas? World J Surg 2022; 46:1915-1916. [PMID: 35562541 DOI: 10.1007/s00268-022-06583-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Syed Ammer Shah
- Hunter Holmes McGuire VA Medical Center, Virginia Commonwealth University, Richmond, USA.
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8
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Intraoperative assessment of parathyroid pathology in sporadic primary hyperparathyroidism: An institutional experience. Hum Pathol 2022; 123:40-45. [PMID: 35196527 PMCID: PMC9050927 DOI: 10.1016/j.humpath.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2022] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/21/2022]
Abstract
Intraoperative consultation for assessment of parathyroid tissue is a controversial area of endocrine pathology. This assessment often follows historical institutional and individual surgical practitioner practices rather than documented utility data and adjuvant intraoperative testing data, including intraoperative parathyroid hormone level testing by clinical pathologists and the use of Oil Red O vital stain on frozen tissue sections by anatomic pathologists, as a means of conferring etiology of parathyroid disease. The American Association of Endocrine Surgeons (AAES), in 2016, proposed guidelines for the management of primary hyperparathyroidism, including recommendations for intraoperative consultation, recommending against the use of intraoperative frozen section to determine parathyroid functional status but in support for its use for parathyroid identification. In this series, we review a one-year, retrospective cohort of consecutive parathyroid surgeries at Massachusetts General Hospital, including over 200 cases meeting inclusion criteria for which primary hyperparathyroidism was the indication for surgery, discussing outcomes, compliance with AAES guidelines, and overall utility of intraoperative consultation and adjuvant testing.
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9
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Miller JA, Gundara J, Harper S, Herath M, Ramchand SK, Farrell S, Serpell J, Taubman K, Christie J, Girgis CM, Schneider HG, Clifton-Bligh R, Gill AJ, De Sousa SMC, Carroll RW, Milat F, Grossmann M. Primary hyperparathyroidism in adults-(Part II) surgical management and postoperative follow-up: Position statement of the Endocrine Society of Australia, The Australian & New Zealand Endocrine Surgeons, and The Australian & New Zealand Bone and Mineral Society. Clin Endocrinol (Oxf) 2021. [PMID: 34927274 DOI: 10.1111/cen.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations to guide the surgical management and postoperative follow-up of adults with primary hyperparathyroidism. METHODS Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing eight key questions. RESULTS Diagnostic imaging does not determine suitability for surgery but can guide the planning of surgery in suitable candidates. First-line imaging includes ultrasound and either parathyroid 4DCT or scintigraphy, depending on local availability and expertise. Minimally invasive parathyroidectomy is appropriate in most patients with concordant imaging. Bilateral neck exploration should be considered in those with discordant/negative imaging findings, multi-gland disease and genetic/familial risk factors. Parathyroid surgery, especially re-operative surgery, has better outcomes in the hands of higher volume surgeons. Neuromonitoring is generally not required for initial surgery but should be considered for re-operative surgery. Following parathyroidectomy, calcium and parathyroid hormone levels should be re-checked in the first 24 h and repeated early if there are risk factors for hypocalcaemia. Eucalcaemia at 6 months is consistent with surgical cure; parathyroid hormone levels do not need to be re-checked in the absence of other clinical indications. Longer-term surveillance of skeletal health is recommended. CONCLUSIONS This position statement provides up-to-date guidance on evidence-based best practice surgical and postoperative management of adults with primary hyperparathyroidism.
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Affiliation(s)
- Julie A Miller
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Endocrine Surgical Centre, Epworth Hospital Network, Richmond, Victoria, Australia
| | - Justin Gundara
- Department of Surgery, Redland Hospital, Metro South and Faculty of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
- Department of Surgery, Logan Hospital, Metro South and School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
| | - Simon Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Department of Surgery, University of Otago, Wellington, New Zealand
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Farrell
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jonathan Serpell
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Endocrine Surgery, Monash University, Victoria, Clayton, Australia
| | - Kim Taubman
- Department of Medical Imaging, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Endocrinology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - James Christie
- PRP Diagnostic Imaging, Sydney, New South Wales, Australia
| | - Christian M Girgis
- Department of Diabetes and Endocrinology, Westmead Hospital, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Clayton, Victoria, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Sunita M C De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Richard W Carroll
- Endocrine, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Frances Milat
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
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10
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The role of Rapid Intraoperative Parathyroid Hormone (ioPTH) assay in determining outcome of parathyroidectomy in primary hyperparathyroidism: A systematic review and meta-analysis. Int J Surg 2021; 92:106042. [PMID: 34339883 DOI: 10.1016/j.ijsu.2021.106042] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/27/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a common endocrine disorder. In the last few decades, the introduction of Rapid Intraoperative Parathyroid Hormone (ioPTH) monitoring has allowed to ensurance of the excision of all hyperfunctioning parathyroid tissues, reducing the risks of persistent and recurrent PHPT. However, the use of ioPTH is still debated among endocrine surgeons. MATERIAL AND METHODS The objective of this systematic review and meta-analysis was to assess if ioPTH monitoring is able to reduce the incidence of persistent or recurrent PHPT. A systematic literature search was performed using PubMed, Scopus, ISI-Web of Science and Cochrane Library Database. Prospective and retrospective studies addressing the efficacy of ioPTH monitoring were included in the systematic review and meta-analysis. The random-effects model was assumed to account for different sources of variation among studies. The overall effect size was computed through the inverse variance method. Heterogeneity across studies, possible outlier studies, and publication bias were evaluated. RESULTS A total of 28 studies with 13,323 patients were included in the quantitative analysis. The incidence of operative failure was 3.2% in the case group and 5.8% in the control group. After excluding three outlier studies, the quantitative analysis revealed that ioPTH reduced significantly the incidence of postoperative persistent or recurrent PHPT. (Risk Difference = -0.02; CI = -0.03, -0.01; p < 0.001). There was no evidence of heterogeneity among the studies (Q = 19.92, p = 0.70; I2 = 0%). The analysis of several continuous moderators revealed that the effectiveness of ioPTH was larger in studies with lower preoperative serum calcium values and higher incidences of multiple gland disease. CONCLUSION ioPTH monitoring is effective in reducing the incidence of persistent and recurrent PHPT. Its routine use should be suggested in the next guidelines regarding management of PHPT.
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Minimally invasive video-assisted parathyroidectomy (MIVAP) without intraoperative PTH determination. Eur Arch Otorhinolaryngol 2021; 278:4997-5001. [PMID: 33713193 DOI: 10.1007/s00405-021-06740-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/05/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Minimally invasive video-assisted parathyroidectomy (MIVAP) has become a standard approach to primary hyperparathyroidism (pHPT) since described. Although intraoperative parathyroid hormone assay (IOPTH) has been generalized as a complementary technique to MIVAP, its actual impact on the surgical success of this technique is not without controversy. The aim of this study was to describe our results in the management of pHPT with successful preoperative localization, by MIVAP technique, without IOPTH determination, confirming in a larger series our preliminary results. METHODS A retrospective descriptive study was conducted in pHPT patients treated by MIVAP with no IOPTH determination in a tertiary hospital between 2007 and 2019. RESULTS A total of 167 patients were included in the study. Biochemical cure was achieved in 96.4%, and 94.1% did not present any surgical complication. The mean duration of surgery was 61 min, and the mean length of hospital stay was 1.8 days CONCLUSIONS: In case of positive preoperative localization studies, MIVAP is a safe and effective technique for the surgical treatment of pHPT due to a parathyroid adenoma, regardless of IOPTH determination, with a success rate > 95% and a low complication rate.
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12
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Quinn AJ, Ryan ÉJ, Garry S, James DL, Boland MR, Young O, Kerin MJ, Lowery AJ. Use of Intraoperative Parathyroid Hormone in Minimally Invasive Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:135-143. [PMID: 33211086 DOI: 10.1001/jamaoto.2020.4021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Importance Intraoperative parathyroid hormone (ioPTH) is a surgical adjunct that has been increasingly used during minimally invasive parathyroidectomy (MIP). Despite its growing popularity, to our knowledge a meta-analysis comparing MIP with ioPTH vs MIP without ioPTH has not yet been conducted. Objective To evaluate the safety and efficacy of MIP with ioPTH for treatment of primary hyperparathyroidism. Data Sources A systematic search of the databases PubMed, Embase, Scopus, Web of Science, and Cochrane Collaboration was performed to identify studies that compared MIP with and without ioPTH. Data were analyzed between August and September 2019. Study Selection Inclusion criteria consisted of randomized clinical trials and observational studies with a retrospective/prospective design, comparing MIP using ioPTH vs MIP not using ioPTH for treatment of primary hyperparathyroidism. Eligible studies had to present odds ratio (OR), risk ratio, or hazard ratio estimates (with 95% CI), standard errors, or number of events necessary to calculate these for the outcome of interest rate. Studies involving patients with secondary or tertiary hyperparathyroidism or those with multiple endocrine neoplasia syndrome were excluded. Data Extraction Two reviewers independently reviewed the literature according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Dichotomous variables were pooled as ORs while continuous variables were compared using weighted mean differences. Quality assessment was performed using the Newcastle-Ottawa Scale. Main Outcomes and Measures The primary outcome was rate of cure. Secondary outcomes included need for reoperation, need for bilateral neck exploration, morbidity, and length of surgery. Results A total of 12 studies, involving 2290 patients with primary hyperparathyroidism, were eligible for inclusion. The median (SD) age of participants was 60.1 (11.8) years and 77.3% of participants were women. The median Newcastle-Ottawa score was 7. Patients who underwent MIP with ioPTH had higher cure rates (OR, 3.88; 95% CI, 2.12-7.10; P < .001). There was a greater need for reoperation in the group of patients who had surgery without ioPTH (OR, 0.40; 95% CI, 0.19-0.86; P = .02). There was a trend toward longer operating times/increased duration of surgery in the ioPTH group; however, this did not reach statistical significance (weighted mean difference, 21.62 minutes; 95% CI, -0.93 to 44.17 minutes; P = .06). The use of ioPTH was associated with higher rates of bilateral neck exploration (OR, 3.55; 95% CI, 1.27-9.92; P = .02). Conclusions and Relevance Use of ioPTH is associated with higher cure rates for patients with primary hyperparathyroidism undergoing MIP. Minimally invasive parathyroidectomy performed without ioPTH is associated with less conversion to bilateral neck exploration at initial surgery but with lower cure rates and an increased risk for reoperation. Trial Registration PROSPERO identifier: CRD42020148588.
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Affiliation(s)
| | - Éanna J Ryan
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Stephen Garry
- Department of Otorhinolaryngology, Head & Neck Surgery, Galway University Hospitals, Galway, Ireland
| | - Danielle L James
- Department of Surgery, Galway University Hospitals, Galway, Ireland
| | - Michael R Boland
- Department of Surgery, The Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Young
- Department of Otorhinolaryngology, Head & Neck Surgery, Galway University Hospitals, Galway, Ireland
| | - Michael J Kerin
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, Ireland
| | - Aoife J Lowery
- Department of Surgery, Galway University Hospitals, Galway, Ireland.,The Lambe Institute for Translational Research, National University of Ireland, Galway, Galway, Ireland
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De Pasquale L, Lori E, Bulfamante AM, Felisati G, Castellani L, Saibene AM. Evaluation of Wisconsin and CaPTHUS Indices Usefulness for Predicting Monoglandular and Multiglandular Disease in Patients with Primary Hyperparathyroidism through the Analysis of a Single-Center Experience. Int J Endocrinol 2021; 2021:2040284. [PMID: 34671396 PMCID: PMC8523259 DOI: 10.1155/2021/2040284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The main challenge for treating primary hyperparathyroidism (PHPT) is to understand if it is caused by a single adenoma (80-85% of the cases) or by a multiglandular disease (15-20%), both preoperatively and intraoperatively. For this reason, some preoperative scores were proposed in the literature, to perform focused parathyroidectomy, avoiding intraoperative parathormone assay (ioPTH). The most known are the CaPTHUS test and the Wisconsin index. We applied them to our experience. METHODS A retrospective cohort study on 462 patients referred for parathyroidectomy to Thyroid and Parathyroid Unit at Santi Paolo e Carlo Hospital, Milan, Italy, from 2011 to 2021. Only patients affected with benign PHPT and neck ultrasound performed at our institution were included. Both patients for whom preoperative imaging agreed with the localization of a single diseased parathyroid and those with only ultrasound or scintigraphy positive for parathyroid localization underwent Mini-Invasive Video-assisted parathyroidectomy. In all cases, ioPTH assay was performed. The conversion to bilateral neck exploration was decided based on the drop in ioPTH. CaPTHUS score and the Wisconsin index (Win) were applied to the series. CaPTHUS score ≥3 and Win index >1600, according to the original studies of the literature, were considered at high probability of monoglandular disease. Outcomes in these two groups were examined. RESULTS 236 patients were eligible for the study. The pathology resulted in multiglandular disease in 24 patients (10.2%). Among these, 18 (75.0%) obtained a CaPTHUS score ≥3, and 20 (83.3%) had a Win index>1600. Intraoperative PTH allowed to identify multiglandular disease in 16 of 18 cases with CaPTHUS ≥3 and in 18 of 20 cases with win >1600, who could have been lost, based only on the results of these 2 tests. CONCLUSION Based on our experience, CaPTHUS test and Wisconsin index were not so useful in predicting multiglandular disease as ioPTH.
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Affiliation(s)
- Loredana De Pasquale
- Thyroid and Parathyroid Surgery Service (Head Dott. Loredana De Pasquale)-Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Eleonora Lori
- Department of Surgical Science, “Sapienza” University of Rome, Rome 00161, Italy
| | - Antonio Mario Bulfamante
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Giovanni Felisati
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
| | - Luca Castellani
- Otolaryngology Unit (Head: Professor Giovanni Felisati), ASST Santi Paolo e Carlo, Department of Health Sciences, Università Degli Studi di Milano, Via A. di Rudinì, 8, Milan 20142, Italy
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14
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Lorenz K, Schneider R, Elwerr M. [Intraoperative measurement of parathyroid hormone in hyperparathyroidism]. Chirurg 2020; 91:448-455. [PMID: 32052111 DOI: 10.1007/s00104-020-01123-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intraoperative parathyroid hormone (IOPTH) determination is based on the short half-life of parathyroid hormone (PTH) and the rapid analytical technology. The IOPTH provides functional information regarding correction of the overproductive state in hyperparathyroidism (HPT) and is superior to macroscopic evaluation of the parathyroid gland (PG) as well as any (intraoperative frozen section) form of histology (so-called biochemical frozen section). In this article the relevance and evaluation of IOPTH is defined for the most important forms of HPT, for primary HPT, renal secondary and tertiary HPT, multiple endocrine neoplasia type 1 (MEN1) and parathyroid carcinoma and clinical scenarios based on the currently available data. It becomes apparent that the additional benefits of IOPTH depend on diverse prerequisites of the specific type of HPT, the diagnostics as well as individual patient factors and strategic considerations for resection. Overall, the costs for IOPTH are comparably low and seem to be justified with respect to the gain in quality. In the hands of specialized endocrine surgeons IOPTH is an essential tool for intraoperative decision-making and quality assurance.
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Affiliation(s)
- K Lorenz
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland.
| | - R Schneider
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland
| | - M Elwerr
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland
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15
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Intraoperative Adjunct Methods for Localization in Primary Hyperparathyroidism. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2020; 53:84-95. [PMID: 32377064 PMCID: PMC7199831 DOI: 10.14744/semb.2019.37542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 04/09/2019] [Indexed: 12/16/2022]
Abstract
Primary hyperparathyroidism (pHPT) is a frequently seen endocrine disease, and its main treatment is surgery. In the majority of pHPT, the disease involves only a single gland, and the majority of the pathological glands can be determined by preoperative localization methods.In addition to preoperative localization studies in parathyroidectomy, the use of adjunct methods to improve intraoperative localization in order to increase success of surgery is becoming widespread. These methods include different approaches, mainly intraoperative parathyroid hormone (PTH) measurement, followed by intraoperative gamma probe application, intraoperative ultrasonography, parathyroid imaging with methylene blue, and frozen section examination. Recently, especially promising new imaging methods have been described in the literature with various optical technologies to increase the localization of the parathyroid glands and to evaluate their viability. These methods include parathyroid imaging with autofluorescence, indocyanine green imaging with autofluorescence, autofluorescence imaging with methylene blue, autofluorescence imaging with 5-aminolevulinic acid, optical coherence tomography, laser speckle contrast imaging, dynamic optical contrast imaging, and Raman spectroscopy. Currently, minimally invasive parathyroidectomy has become the standard treatment for selected pHPT patients with the aid of preoperative imaging and intraoperative auxiliary methods . The aim of the present study was to evaluate the routinely used new promising intraoperative adjunct methods in pHPT.
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16
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Mak NTJJ, Li J, Vasilyeva E, Hiebert J, Guo M, Lustig D, Holmes D, Wiseman SM. Intraoperative parathyroid hormone measurement during parathyroidectomy for treatment of primary hyperparathyroidism: When should you end the operation? Am J Surg 2020; 219:785-789. [PMID: 32169248 DOI: 10.1016/j.amjsurg.2020.02.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/23/2020] [Accepted: 02/24/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The study objective was to evaluate the intraoperative 50% decrease in PTH level ± PTH normalization for its accuracy and efficiency in predicting cure during parathyroidectomy (PTx) for the treatment of primary hyperparathyroidism (PHP). METHODS A retrospective review of patients undergoing PTx was conducted. The timepoints at which the 50% PTH decrease was reached were recorded. The accuracy of intraoperative PTH for predicting cure, defined as normocalcemia at 6 months postoperatively, was evaluated. RESULTS The study population was made up of 248 PHP patients, with 247 patients achieving normocalcemia at 6 months postoperatively. If a 50% PTH decrease was used to indicate operation conclusion, 1 patient would not be cured. Persistent PTH elevation above normal range at T10 had a PPV of 77%, NPV of 99.5%, sensitivity of 95.2% and specificity of 97.3% for predicting the presence of a contralateral pathological parathyroid gland. For the study cohort, 24.5 h of cumulative operating time would be saved if the 50% PTH decrease triggered operation conclusion. DISCUSSION A decrease in the pre-excision PTH level to 50% of the baseline level, or a decrease in the higher of the baseline or pre-excision PTH levels by 50% at 5 or 10 min post pathological parathyroid gland removal, regardless of whether the PTH level normalizes, reliably predicts cure from PHP and should be used to guide the surgeon during parathyroidectomy.
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Affiliation(s)
- Nicole T J J Mak
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Jennifer Li
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Elizaveta Vasilyeva
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Jake Hiebert
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Michael Guo
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Daniel Lustig
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada
| | - Daniel Holmes
- Department of Pathology & Laboratory Medicine, St. Paul's Hospital & University of British Columbia, Canada
| | - Sam M Wiseman
- Department of Surgery, St. Paul's Hospital & University of British Columbia, Canada.
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17
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Bhangu JS, Riss P. The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT). Best Pract Res Clin Endocrinol Metab 2019; 33:101310. [PMID: 31409538 DOI: 10.1016/j.beem.2019.101310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed - each with their particular advantages and disadvantages, but the "perfect" criterion is still missing. Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease.
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Affiliation(s)
- Jagdeep Singh Bhangu
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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