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Blanco Saiz I, Salvador Egea P, Anda Apiñániz E, Rudic Chipe N, Goñi Gironés E. Radio-guided procedure in minimally invasive surgery for primary hyperparathyroidism. Cir Esp 2023; 101:152-159. [PMID: 36067944 DOI: 10.1016/j.cireng.2022.09.001] [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: 04/08/2022] [Accepted: 07/03/2022] [Indexed: 11/16/2022]
Abstract
Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radioguided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radioguided parathyroid surgery procedures (MIBI and R.O.L.L.) are exposed.
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Blanco Saiz I, Salvador Egea P, Anda Apiñániz E, Rudic Chipe N, Goñi Gironés E. WITHDRAWN: Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Blanco Saiz I, Salvador Egea P, Anda Apiñániz E, Rudic Chipe N, Goñi Gironés E. Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario. Cir Esp 2022. [DOI: 10.1016/j.ciresp.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Primary hyperparathyroidism can be asymptomatic or symptomatic, as well as classic, normocalcemic, or normohormonal. It is important to rule out other causes of hypercalcemia or hyperparathyroidism. Preoperative localization with imaging is necessary for a minimally invasive approach and can be helpful even if planning 4-gland exploration. There are a variety of intraoperative techniques that can assist with localization as well as confirming success. Standard of care remains surgical resection of affected glands. However, there are less invasive management strategies that can be considered for poor surgical candidates.
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Affiliation(s)
- Lauren Slattery
- University of Utah, 50 N Medical Drive, Salt Lake City, UT 84132, USA
| | - Jason P Hunt
- University of Utah, Huntsman Cancer Institute, 50 N Medical Drive, 3C120SOM, Salt Lake City, UT 84132, USA.
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Individualised Timing of Radio-Guided Parathyroidectomy Using Multi-Phase SPECT/CT Increases In Vivo Sensitivity and Accuracy and Reduces Operating Time: A Randomised Clinical Trial. Diagnostics (Basel) 2021; 11:diagnostics11040677. [PMID: 33918800 PMCID: PMC8070050 DOI: 10.3390/diagnostics11040677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 04/04/2021] [Accepted: 04/07/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Minimally invasive parathyroidectomy is the preferred treatment for primary hyperparathyroidism. Despite relatively accurate preoperative information, minimally invasive parathyroidectomy can be challenging, especially in the case of small and ectopic adenomas. Radio guidance aids in both in vivo identification and ex vivo confirmation of adenoma. In vivo accuracy is currently not satisfactory. The present study evaluated whether a beneficial effect (increased sensitivity, specificity, accuracy) is obtained with individualised timing of minimally invasive radio-guided parathyroidectomy (MIRGP) using preoperative multi-phase 99mTc-MIBI single photon emission computed tomography (SPECT)/computed tomography (CT). Methods: This randomised clinical trial was conducted from May 2016 to January 2020 in a tertiary referral hospital. Adult patients with primary hyperparathyroidism sent for 99mTc-MIBI SPECT/CT were included consecutively and randomly assigned to conventional (dual-phase) SPECT/CT and conventional MIRGP (group I) or multi-phase SPECT/CT and individualised MIRGP (group II). One hundred of 106 eligible patients were included, and 83 patients underwent complete intervention. Results: A total of 47 patients in group I and 35 patients in group II were analysed. Group II had a shorter operating time (p = 0.003). The in vivo sensitivity and accuracy of radio guidance was 85.1% in group I and 100% in group II (p = 0.046), and 90.4% in group I and 100% in group II (p = 0.021), respectively. We found no difference in the in vivo specificity and ex vivo parameters between groups. Conclusion: Individualised timing increased the in vivo sensitivity and accuracy of radio guidance and reduced operating time, as some parathyroid adenomas rapidly wash out the radionuclide.
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Radioguided surgery in primary hyperparathyroidism: a review of the different techniques available. Rev Esp Med Nucl Imagen Mol 2021. [DOI: 10.1016/j.remnie.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Goñi-Gironés E, Fuertes-Cabero S, Blanco-Sáiz I, Casáns-Tormo I, García-Talavera San Miguel P, Martín-Gil J, Sampol-Bas C, Abreu-Sánchez P, Díaz-Expósito R, Vidal-Sicart S. Radioguided surgery in primary hyperparathyroidism: a review of the different available techniques. Rev Esp Med Nucl Imagen Mol 2020; 40:57-66. [PMID: 33386282 DOI: 10.1016/j.remn.2020.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 11/19/2020] [Accepted: 11/19/2020] [Indexed: 11/25/2022]
Abstract
Parathyroidectomy has evolved over the years from bilateral neck exploration to a single gland approach using minimally invasive surgery. The precise presurgical localization of the problem gland, using functional techniques, such as double-phase scintigraphy with [99mTc] Tc-MIBI including SPECT-CT and PET-CT with [18F]-Choline and morphological ones, such as ultrasound have played a crucial role in this paradigm's shift. Radioguided surgery techniques have also adapted and grown with new contributions known for their indication in other fields. Thus, we currently have a wide range of techniques that have been added to the minimally invasive radioguided parathyroidectomy with [99mTc] Tc-MIBI, which was the first on the stage and for which more experience exists. Among them, in this update, we will discuss parathyroidectomy using ultrasound-guided ROLL technique as well as with the use of 125I seeds and finally, hybrid techniques that use radiotracer and fluorescence.
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Affiliation(s)
- E Goñi-Gironés
- Servicio de Medicina Nuclear, Complejo Hospitalario de Navarra, Pamplona, Navarra, España.
| | - S Fuertes-Cabero
- Servicio de Medicina Nuclear, Hospital Universitario Quirónsalud Madrid, Madrid, España
| | - I Blanco-Sáiz
- Servicio de Medicina Nuclear, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - I Casáns-Tormo
- Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valencia, Valencia, España
| | | | - J Martín-Gil
- Servicio de Cirugía General, Hospital Quirónsalud San José, Madrid, España
| | - C Sampol-Bas
- Servicio de Medicina Nuclear, Hospital Universitari Son Espases, Mallorca, España
| | - P Abreu-Sánchez
- Servicio de Medicina Nuclear, Hospital Universitario Doctor Peset, Valencia, España
| | - R Díaz-Expósito
- Servicio de Medicina Nuclear, Fundación Instituto Valenciano de Oncología, Valencia, España
| | - S Vidal-Sicart
- Servicio de Medicina Nuclear, Hospital Clinic Barcelona, Barcelona, España
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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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Suárez JP, Domínguez ML, de Santos FJ, González JM, Fernández N, Enciso FJ. Radioguided Surgery in Primary Hyperparathyroidism: Results and Correlation With Intraoperative Histopathologic Diagnosis. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018. [DOI: 10.1016/j.otoeng.2017.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Suárez JP, Domínguez ML, de Santos FJ, González JM, Fernández N, Enciso FJ. Cirugía radioguiada en el hiperparatiroidismo primario: resultados y correlación con el diagnóstico anatomopatológico intraoperatorio. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2018; 69:86-94. [DOI: 10.1016/j.otorri.2017.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 03/27/2017] [Accepted: 04/02/2017] [Indexed: 10/19/2022]
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Hinson AM, Lawson BR, Franco AT, Stack BC. Association of Parathyroid Gland Biopsy Excision Technique With Ex Vivo Radiation Counts During Radioguided Parathyroid Surgery. JAMA Otolaryngol Head Neck Surg 2017; 143:595-600. [PMID: 28358958 DOI: 10.1001/jamaoto.2016.4635] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Parathyroid biopsy represents a means for normal and hyperfunctional glands to be distinguished intraoperatively. However, no data exist to guide surgeons regarding how much of a parathyroid gland must be biopsied to satisfy the 20% rule. Objective To quantify the relative proportion of a hyperfunctional parathyroid gland that must be evaluated with the gamma probe to satisfy the 20% rule. Design, Setting, and Participants A retrospective review of surgical data for 24 consecutive patients (16 women, 18 men; mean [SD] age, 66.6 [10] years; range, 51-83 years) who underwent surgery for primary hyperparathyroidism between May and October, 2015, in a tertieary academic medical center. Main Outcomes and Measures Extirpated parathyroid glands were sectioned into parallel or pie-shaped biopsies and evaluated ex vivo with a gamma probe to determine what percentage of a hyperfunctional gland must be sampled to meet the Norman 20% rule. The hypothesis was formulated during data collection. Results In total, 253 ex vivo biopsy specimens were obtained from 33 surgically removed parathyroid glands. Parathyroid biopsies satisfied the 20% rule with an accuracy that depended on the relative proportion of the parent gland represented: half or more (96.6%; 95% CI, 91.7%-100.0%), a quarter to one-half (87.0%; 95% CI, 79.3%-94.7%), less than a quarter (63.6%; 95% CI, 54.5%-72.8%). When less than a quarter of the gland was removed, pie-shaped biopsies were more likely to satisfy the 20% rule compared with parallel biopsies of the same weight (78.4% vs 56.2%; absolute difference, 22.2%; 95% CI, 4.7%-39.7%). Conclusions and Relevance Unless half of a parathyroid gland is biopsied during radioguided parathyroidectomy, the 20% rule cannot reliably rule out the presence of a hyperfunctional parathyroid lesion. Pie-shaped biopsies originating from the center of the gland are associated with a lower rate of false-negative results compared with peripheral biopsies of similar size. Pie-shaped biopsies and biopsy of half or more of each nonexcised parathyroid gland for ex vivo counts may increase the risk of remnant devascularization and resultant hypoparathyroidism.
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Affiliation(s)
- Andrew M Hinson
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
| | - Bradley R Lawson
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock2Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts
| | - Aime T Franco
- Department of Physiology and Biophysics, University of Arkansas for Medical Sciences, Little Rock
| | - Brendan C Stack
- Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock
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Sho S, Yilma M, Yeh MW, Livhits M, Wu JX, Hoang JK, Sepahdari AR. Prospective Validation of Two 4D-CT-Based Scoring Systems for Prediction of Multigland Disease in Primary Hyperparathyroidism. AJNR Am J Neuroradiol 2016; 37:2323-2327. [PMID: 27659191 DOI: 10.3174/ajnr.a4948] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/11/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Patients with multigland primary hyperparathyroidism are at higher risk for missed lesions on imaging and failed parathyroidectomy. The purpose of this study was to prospectively validate the ability of previously derived predictive score systems, the composite multigland disease score, and the multiphase multidetector contrast-enhanced CT (4D-CT) composite multigland disease score, to identify patients with a high likelihood of multigland disease. MATERIALS AND METHODS This was a prospective study of 71 patients with primary hyperparathyroidism who underwent 4D-CT and successful parathyroidectomy. The size and number of lesions identified on 4D-CT, serum calcium levels, and parathyroid hormone levels were collected. A composite multigland disease score was calculated from 4D-CT imaging findings and the Wisconsin Index (the product of the serum calcium and parathyroid hormone levels). A 4D-CT multigland disease score was obtained by using the CT data alone. RESULTS Twenty-eight patients with multigland disease were compared with 43 patients with single-gland disease. Patients with multigland disease had a significantly smaller lesion size (P < .01) and a higher likelihood of having either ≥2 or 0 lesions identified on 4D-CT (P < .01). Composite multigland disease scores of ≥4, ≥5, and 6 had specificities of 72%, 86%, and 100% for multigland disease, respectively. 4D-CT multigland disease scores of ≥3 and 4 had specificities of 74% and 88%. CONCLUSIONS Predictive scoring systems based on 4D-CT data, with or without laboratory data, were able to identify a subgroup of patients with a high likelihood of multigland disease in a prospectively accrued population of patients with primary hyperparathyroidism. These scoring systems can aid in surgical planning.
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Affiliation(s)
- S Sho
- From the Department of Surgery (S.S., M.Y., M.W.Y., M.L., J.X.W.), Section of Endocrine Surgery
| | - M Yilma
- From the Department of Surgery (S.S., M.Y., M.W.Y., M.L., J.X.W.), Section of Endocrine Surgery
| | - M W Yeh
- From the Department of Surgery (S.S., M.Y., M.W.Y., M.L., J.X.W.), Section of Endocrine Surgery
| | - M Livhits
- From the Department of Surgery (S.S., M.Y., M.W.Y., M.L., J.X.W.), Section of Endocrine Surgery
| | - J X Wu
- From the Department of Surgery (S.S., M.Y., M.W.Y., M.L., J.X.W.), Section of Endocrine Surgery
| | - J K Hoang
- Department of Radiology (J.K.H.), Duke University Medical Center, Durham, North Carolina
| | - A R Sepahdari
- Department of Radiological Sciences (A.R.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
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Desiato V, Melis M, Amato B, Bianco T, Rocca A, Amato M, Quarto G, Benassai G. Minimally invasive radioguided parathyroid surgery: A literature review. Int J Surg 2016; 28 Suppl 1:S84-93. [DOI: 10.1016/j.ijsu.2015.12.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 04/10/2015] [Accepted: 05/10/2015] [Indexed: 01/08/2023]
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Barber B, Moher C, Côté D, Fung E, O'Connell D, Dziegielewski P, Harris J. Comparison of single photon emission CT (SPECT) with SPECT/CT imaging in preoperative localization of parathyroid adenomas: A cost-effectiveness analysis. Head Neck 2016; 38 Suppl 1:E2062-5. [PMID: 26849426 DOI: 10.1002/hed.24379] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 12/04/2015] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Controversy exists regarding the superiority of single photon emission CT (SPECT)/CT over SPECT for preoperative localization of parathyroid adenomas in primary hyperparathyroidism (PHPT), as well as the cost-effectiveness. METHODS A retrospective review was undertaken of patients undergoing surgery for PHPT from January 2009 to August 2014. Ultrasound and SPECT (ultrasound-SPECT) or SPECT/CT (ultrasound-SPECT/CT) were performed for each patient. Sensitivity and positive predictive value (PPV) of each modality were calculated. Cost-effectiveness was determined by an incremental cost-effectiveness ratio (ICER) analysis. RESULTS Two hundred fifty-nine patients with 266 parathyroid adenomas were included in the study. Lateralization sensitivity and PPV of ultrasound-SPECT were 85.1% and 98.2%, respectively. The lateralization sensitivity and PPV of ultrasound-SPECT/CT were 86.9% and 99.4%, respectively. A cost of $2499.22 (CAD) per additional parathyroid adenoma detection by ultrasound-SPECT/CT was determined from the ICER analysis. CONCLUSION Similar sensitivities and PPVs were observed between ultrasound-SPECT and ultrasound-SPECT/CT in preoperatively lateralizing parathyroid adenomas, with relatively equivalent cost-effectiveness. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2062-E2065, 2016.
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Affiliation(s)
- Brittany Barber
- Division of Otolaryngology - Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Conrad Moher
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - David Côté
- Division of Otolaryngology - Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Elaine Fung
- Department of Otolaryngology, Queen's University, Kingston, Ontario, Canada
| | - Daniel O'Connell
- Division of Otolaryngology - Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Peter Dziegielewski
- Division of Head and Neck Oncologic Surgery, University of Florida, Gainesville, Florida
| | - Jeffrey Harris
- Division of Otolaryngology - Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada
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Marí Hualde A, Rotger Regí A, Orcajo Rincón J, Simal Badiola I, Cerdá Berrocal J, Alonso Farto J. Utility of radioguided surgery in splenosis. Rev Esp Med Nucl Imagen Mol 2014. [DOI: 10.1016/j.remnie.2014.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Schwarzlmüller T, Brauckhoff K, Løvås K, Biermann M, Brauckhoff M. High cardiac background activity limits 99mTc-MIBI radioguided surgery in aortopulmonary window parathyroid adenomas. BMC Surg 2014; 14:22. [PMID: 24758398 PMCID: PMC4003509 DOI: 10.1186/1471-2482-14-22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Accepted: 04/03/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Radioguided surgery using 99m-Technetium-methoxyisobutylisonitrile (99mTc-MIBI) has been recommended for the surgical treatment of mediastinal parathyroid adenomas. However, high myocardial 99mTc-MIBI uptake may limit the feasibility of radioguided surgery in aortopulmonary window parathyroid adenoma. CASE PRESENTATION Two female patients aged 72 (#1) and 79 years (#2) with primary hyperparathyroidism caused by parathyroid adenomas in the aortopulmonary window were operated by transsternal radioguided surgery. After intravenous injection of 370 MBq 99mTc-MIBI at start of surgery, the maximum radioactive intensity (as counts per second) was measured over several body regions using a gamma probe before and after removal of the parathyroid adenoma. Relative radioactivity was calculated in relation to the measured ex vivo radioactivity of the adenoma, which was set to 1.0. Both patients were cured by uneventful removal of aortopulmonary window parathyroid adenomas of 4400 (#1) and 985 mg (#2). Biochemical cure was documented by intraoperative measurement of parathyroid hormone as well as follow-up examination. Ex vivo radioactivity over the parathyroid adenomas was 196 (#1) and 855 counts per second (#2). Before parathyroidectomy, relative radioactivity over the aortopulmonary window versus the heart was found at 1.3 versus 2.6 (#1) and 1.8 versus 4.8 (#2). After removal of the adenomas, radioactivity within the aortopulmonary window was only slightly reduced. CONCLUSION High myocardial uptake of 99mTc-MIBI limits the feasibility of radioguided surgery in aortopulmonary parathyroid adenoma.
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Affiliation(s)
- Thomas Schwarzlmüller
- Department of Radiology, Centre for Nuclear Medicine/PET, Haukeland University Hospital, Jonas Liesvei 65, Bergen 5021, Norway.
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[Utility of radioguided surgery in splenosis]. Rev Esp Med Nucl Imagen Mol 2014; 33:180-2. [PMID: 24438912 DOI: 10.1016/j.remn.2013.10.012] [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: 09/22/2013] [Revised: 10/08/2013] [Accepted: 10/09/2013] [Indexed: 11/20/2022]
Abstract
Splenosis is a common finding after traumatic rupture of the spleen or therapeutic splenectomy, defined as a heterotopic autotransplantation of the spleen in peritoneal cavity and surface. In splenectomized patients due to hematologic disease, splenosis can lead to disease recurrence. We present a case of splenosis in a patient with idiopathic thrombocytopenic purpura who relapsed after splenectomy. For its localization, conventional imaging and scintigraphy with (99m)Tc-denatured red cells was performed, and at least five splenic foci were observed. Given the difficult intraoperative localization of these nodules, radioguided surgery was performed, with excellent localization and removal of all known nodules and multiple peritoneal implants of millimeter size that were not previously observed. We conclude that radioguided surgery is an excellent tool for locating foci of peritoneal splenosis, which have difficult access, thus avoiding early recurrence of the disease.
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Karyağar S, Karyağar SS, Yalçın O, Yüney E, Mülazımoğlu M, Ozpaçacı T, Karatepe O, Ozdenkaya Y. Gamma Probe Guided Minimally Invasive Parathyroidectomy without Quick Parathyroid Hormone Measurement in the Cases of Solitary Parathyroid Adenomas. Mol Imaging Radionucl Ther 2013; 22:3-7. [PMID: 23610724 PMCID: PMC3629789 DOI: 10.4274/mirt.69885] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2012] [Accepted: 12/28/2012] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE In this study, our aim was to study the efficiency of gamma probe guided minimally invasive parathyroidectomy (GP-MIP), conducted without the intra-operative quick parathyroid hormone (QPTH) measurement in the cases of solitary parathyroid adenomas (SPA) detected with USG and dual phase 99mTc-MIBI parathyroid scintigraphy (PS) in the preoperative period. MATERIAL AND METHODS This clinical study was performed in 31 SPA patients (27 female, 4 male; mean age 51±11years) between February 2006 and January 2009. All patients were operated within 30 days after the detection of the SPA with dual phase 99mTc-MIBI PS and USG. The GP-MIP was done 90-120 min after the iv injection of 740 MBq 99mTc-MIBI. In all cases, except 1 patient, the GP-MIP was performed under local anesthesia; due to the enormity of size of SPA, then general anesthesia is chosen. RESULTS The operation time was 30-60 min, mean 38,2±7 min. In the first postoperative day, there was a more than 50% decrease in PTH levels in all patients and all but one had normal serum calcium levels. Transient hypocalcemia was detected in one patient. CONCLUSION GP-MIP without intra-operative QPTH measurement is a suitable method in the surgical treatment of SPA detected by dual phase 99mTc-MIBI PS and USG. CONFLICT OF INTEREST None declared.
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Affiliation(s)
- Savaş Karyağar
- Trabzon Kanuni Training and Research Hospital, Department of Nuclear Medicine, Trabzon, Turkey
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Changing practices in the surgical management of hyperparathyroidism – A 10-year review. Surgeon 2012; 10:314-20. [DOI: 10.1016/j.surge.2011.10.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 10/25/2011] [Indexed: 11/20/2022]
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Sadik KW, Kell M, Gorey T. Minimally invasive parathyroidectomy using surgical sonography. Int J Med Sci 2011; 8:283-6. [PMID: 21537491 PMCID: PMC3085174 DOI: 10.7150/ijms.8.283] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2010] [Accepted: 04/12/2011] [Indexed: 11/05/2022] Open
Abstract
Minimally invasive parathyroidectomy is the procedure of choice for primary hyperparathyroidism due to parathyroid adenoma. Localization of the offending adenoma in minimally invasive parathyroidectomy (MIP) has been described in the literature aided by isotope, telescope or ultrasound guidance. We present a prospective study of two techniques based on surgeon experience. Thirty patients diagnosed with primary hyperparathyroidism at the Mater hospital in Dublin, Ireland were randomized to have a minimally invasive parathyroidectomy using surgical sonography (MIPUSS) or the conventional unilateral open procedure (OP) over a two year period. The age, sex and serum calcium/parathormone were comparable in both groups. There was no significant difference in complications between the two groups with temporary hypocalcemia occurring in 3 patients undergoing unilateral neck exploration and in 2 MIPUSS patients. There was one transient episode of recurrent laryngeal neuropraxia occurring in the OP group which resolved at 30 day follow-up. The incision size, operating time, hospital stay, and required post-operative analgesia were all markedly reduced in the MIPUSS group. In conclusion, MIPUSS is safe, effective and has advantages in terms of operating time, incision size and early discharge.
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Affiliation(s)
- Karim W Sadik
- Mater Misericordiae University Hospital, Dublin 2, Ireland
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Abstract
In recent years, parathyroid surgery has evolved from traditional bilateral neck exploration to minimal invasive parathyroidectomy. This trend became possible due to preoperative localization imaging that guides the surgeon in the search for a parathyroid adenoma. Intraoperative adjuncts are complementary to preoperative localization and assist in localizing parathyroid glands, confirming parathyroid tissue and establishing a cure. Institutions and surgeons utilize different intraoperative adjuncts in different protocols with varying results. The purpose of this article is to review the available intraoperative adjuncts to parathyroid surgery and critically evaluate their utility, accuracy and their added value to the surgeon.
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Affiliation(s)
- Haggi Mazeh
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
| | - Herbert Chen
- a Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, H4/722 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
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Intraoperative determination of PTH concentrations in fine needle tissue aspirates to identify parathyroid tissue during parathyroidectomy. World J Surg 2011; 34:538-43. [PMID: 20052470 DOI: 10.1007/s00268-009-0351-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Exact tissue identification during parathyroidectomy is essential to successfully cure hyperparathyroidism. PTH level determination from tissue aspirates has been advocated as a "biochemical frozen section" for parathyroid tissue identification. We investigated the sensitivity and specificity of this method in a large cohort of consecutive patients who underwent parathyroidectomy in a tertiary referral center. METHODS PTH levels of 359 tissue aspirates were measured intraoperatively in 223 consecutive patients from March 2006 to December 2008. Suspected parathyroid and control tissues were aspirated with a standardized technique immediately after their excision. Samples were processed for quick-PTH assay with peripheral blood samples before and after excision. PTH levels from tissue aspirates were correlated with pathological diagnosis. The Mann-Whitney test was used to determine statistical significance (P < 0.05). RESULTS A total of 255 parathyroid (196 adenoma, 30 hyperplasia, 4 carcinoma, 25 normal parathyroid) and 104 nonparathyroid tissue (88 thyroid, 16 lymph node, thymus, or fat) aspirates were compared. A highly significant difference was found between PTH levels of parathyroid (8,120 +/- 2,711 pg/ml; interquartile range (IQR): 4,949-9,075) and nonparathyroid (0.8 +/- 9.29 pg/ml; IQR: 0.4-1.4) tissue aspirates (P < 0.005). This test is 100% sensitive and 100% specific to identify parathyroid tissue for values >84 pg/ml. Furthermore, PTH levels of pathological parathyroid aspirates (8,169 +/- 2,597; IQR: 5,634-9,109) were higher than that of normal parathyroid aspirates (4,130 +/- 2,952; IQR: 2,569-8,284; P = 0.0011). CONCLUSIONS PTH level determination from tissue aspirates is a highly reliable, quick, and simple method to differentiate parathyroid and nonparathyroid tissues during parathyroidectomy. This method can obviate frozen sections in patients undergoing surgery for hyperparathyroidism.
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Abstract
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.
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Affiliation(s)
- David Chien
- Division of Nuclear Medicine, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
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Radioguided surgery of primary hyperparathyroidism in a population with a high prevalence of thyroid pathology. Eur J Nucl Med Mol Imaging 2010; 37:2060-7. [DOI: 10.1007/s00259-010-1462-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2010] [Accepted: 03/29/2010] [Indexed: 10/19/2022]
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Minimally invasive radioguided parathyroidectomy for hyperparathyroidism. Ann Nucl Med 2010; 24:233-40. [DOI: 10.1007/s12149-010-0366-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 02/18/2010] [Indexed: 11/26/2022]
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Singh VP, Mir R. Present Trends in Parathyroid Surgery. APOLLO MEDICINE 2009. [DOI: 10.1016/s0976-0016(11)60083-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Adil E, Adil T, Fedok F, Kauffman G, Goldenberg D. Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism. Otolaryngol Head Neck Surg 2009; 141:34-8. [PMID: 19559955 DOI: 10.1016/j.otohns.2009.03.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 03/12/2009] [Accepted: 03/25/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Parathyroid surgery is often challenging due to considerable variability in anatomy. Minimally invasive radioguided parathyroidectomy (MIRP) is a directed surgical approach that has been made possible by the advent of new imaging techniques, specifically sestamibi scanning. In this study, we review our experience and outcomes with MIRP in one of the largest case series reported in the literature. STUDY DESIGN Case series with chart review. SETTING Tertiary care center. SUBJECTS AND METHODS Subjects were 305 patients who underwent MIRP in our institution between 1997 and 2007. Data including symptoms, preoperative and postoperative calcium levels, and PTH levels were collected. Analyses were performed using Excel AnalysisPak. RESULTS MIRP in this series had a 100 percent rate of success in removing a hyperfunctional parathyroid gland. The mean preoperative calcium was 10.9 whereas the mean postoperative level was 9.8. There was a significant difference between preoperative and postoperative calcium levels (both ionized and total) (P<0.01). Mean preoperative and postoperative serum PTH levels were 138 and 50, respectively. PTH levels were therefore significantly lower postoperatively (P<0.01). Rapid PTH testing showed a similar pattern. There were no cases of recurrent laryngeal nerve palsy. CONCLUSION MIRP is an effective method for removal of image-localized hyperfunctional parathyroid glands.
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Affiliation(s)
- Eelam Adil
- Division of Otolaryngology-Head and Neck Surgery, Pennsylvania State College of Medicine, Pennsylvania State University, Hershey, PA 17033, USA
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Intraoperative adjuncts in surgery for primary hyperparathyroidism. Langenbecks Arch Surg 2009; 394:799-809. [PMID: 19590891 DOI: 10.1007/s00423-009-0532-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 06/18/2009] [Indexed: 10/20/2022]
Abstract
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.
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Povoski SP, Neff RL, Mojzisik CM, O'Malley DM, Hinkle GH, Hall NC, Murrey DA, Knopp MV, Martin EW. A comprehensive overview of radioguided surgery using gamma detection probe technology. World J Surg Oncol 2009; 7:11. [PMID: 19173715 PMCID: PMC2653072 DOI: 10.1186/1477-7819-7-11] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Accepted: 01/27/2009] [Indexed: 02/08/2023] Open
Abstract
The concept of radioguided surgery, which was first developed some 60 years ago, involves the use of a radiation detection probe system for the intraoperative detection of radionuclides. The use of gamma detection probe technology in radioguided surgery has tremendously expanded and has evolved into what is now considered an established discipline within the practice of surgery, revolutionizing the surgical management of many malignancies, including breast cancer, melanoma, and colorectal cancer, as well as the surgical management of parathyroid disease. The impact of radioguided surgery on the surgical management of cancer patients includes providing vital and real-time information to the surgeon regarding the location and extent of disease, as well as regarding the assessment of surgical resection margins. Additionally, it has allowed the surgeon to minimize the surgical invasiveness of many diagnostic and therapeutic procedures, while still maintaining maximum benefit to the cancer patient. In the current review, we have attempted to comprehensively evaluate the history, technical aspects, and clinical applications of radioguided surgery using gamma detection probe technology.
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Affiliation(s)
- Stephen P Povoski
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Ryan L Neff
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - Cathy M Mojzisik
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - David M O'Malley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
| | - George H Hinkle
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
- College of Pharmacy, The Ohio State University, Columbus, OH, 43210, USA
| | - Nathan C Hall
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Douglas A Murrey
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Michael V Knopp
- Department of Radiology, The Ohio State University, Columbus, OH, 43210, USA
| | - Edward W Martin
- Division of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA
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Harrell RM, Bimston DN. Optimization of minimally invasive radio-guided parathyroidectomy: the importance of neck ultrasonography and intraoperative parathyroid hormone assay. Endocr Pract 2008; 14:856-62. [PMID: 18996813 DOI: 10.4158/ep.14.7.856] [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] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine whether close collaboration between a neck ultrasound-certified endocrinologist and a skilled endocrine surgeon can optimize minimally invasive radio-guided parathyroidectomy (MIRP) surgical outcomes. METHODS Outcome data were collected on patients with primary hyperparathyroidism whom we intended to treat with MIRP at the induction of anesthesia between October 1, 2005, and December 31, 2007. Patients underwent preoperative gamma camera sestamibi scanning (GCSS), intraoperative gamma probe sestamibi scanning (IOSS), and preoperative neck ultrasonography. Intraoperative parathyroid hormone (PTH) monitoring was performed. Postoperative surgical success was defined as a serum calcium concentration between 8.0 and 10.4 mg/dL within 4 weeks of surgery. RESULTS During the study period, MIRP was planned for 46 patients. Of the 46 patients, 39 had preoperative neck ultrasonography; 7 underwent evaluation by an endocrinologist or internist who was not ultrasound certified and they therefore did not undergo preoperative ultrasonography. IOSS correctly identified 1 adenomatous gland in 38 of 46 patients (83%), while GCSS correctly localized 1 adenomatous gland in 30 of 46 patients (65%). In 11 GCSS-negative patients, IOSS identified the abnormal gland in 7 (64%), while ultrasonography identified the abnormal gland in 8 (73%). The surgical approach was converted to traditional parathyroidectomy in 3 patients. Every patient exhibited at least a 51% drop in intraoperative PTH levels with resection of the final adenoma; average decrement for the entire group was 79 +/- 8% from the highest baseline level. Forty-five patients (98%) demonstrated sustained normalization of serum calcium within several days of surgery. CONCLUSION A collaborative endocrinology and surgical endocrine oncology practice arrangement, emphasizing careful preoperative physician-supervised neck ultrasonography and the use of intraoperative PTH measurement, optimizes MIRP outcomes.
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Affiliation(s)
- R Mack Harrell
- Fort Lauderdale Endocrine Surgery, Imperial Point Medical Center, Fort Lauderdale, FL, USA.
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Exposure of surgical staff in surgical probe applications in radioguided parathyroidectomy. Eur Arch Otorhinolaryngol 2008; 265:1545-8. [DOI: 10.1007/s00405-008-0716-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 05/21/2008] [Indexed: 11/26/2022]
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Jorna FH, Jager PL, Lemstra C, Wiggers T, Stegeman CA, Plukker JTM. Utility of an intraoperative gamma probe in the surgical management of secondary or tertiary hyperparathyroidism. Am J Surg 2008; 196:13-8. [PMID: 18436177 DOI: 10.1016/j.amjsurg.2007.05.059] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 05/23/2007] [Accepted: 05/23/2007] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Francisca H Jorna
- Department of Surgery/Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Untch BR, Barfield ME, Bason J, Olson JA. Minimally invasive radio-guided surgery for primary hyperparathyroidism. Ann Surg Oncol 2007; 14:3401-2. [PMID: 17899291 DOI: 10.1245/s10434-007-9519-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 06/19/2007] [Accepted: 06/20/2007] [Indexed: 11/18/2022]
Abstract
BACKGROUND Minimally invasive parathyroidectomy can reduce operative morbidity and operative time. Radio-guided parathyroidectomy utilizing Tc-99m Sestamibi is one approach to minimally invasive parathyroidectomy. Here, we report a multimedia case study of minimally invasive radio-guided parathyroidectomy. METHODS A 60-year-old African American female was found to have total calcium of 11.1 mg/dl, intact parathyroid hormone (iPTH) of 175 pg/ml, and a 24-h urine calcium of 620 mg/24 h. A Tc-99 Sestamibi scan (23.5 mCi of Tc-99 Sestamibi injected i.v.) and ultrasound localized a candidate adenoma to the right upper position. The patient was injected with 5.3 mCi Tc-99m Sestamibi 3 h before incision. RESULTS A gamma probe (C-Trak Automatic System, Care Wise Medical Products) recorded in vivo counts of the right upper parathyroid (3,465) that were 160% of the background. Background counts were recorded from the resected tumor bed (2,224). A 1.4-g adenoma was identified in this location; ex vivo counts (3,226) were 150% of the background. Intra-operative iPTH baseline values were 176 pg/ml and 148 pg/ml, and 5- and 10-min post-resection levels were 17 pg/ml (90% drop) and 18 pg/ml (90% drop), respectively. The patient's recovery was uncomplicated. At 1 week postoperatively, total calcium was 8.9 mg/dl and iPTH was 16 pg/ml. At 1 year, the calcium and iPTH levels were 8.7 mg/dl and 53 pg/ml, respectively. CONCLUSIONS Radio-guided minimally invasive parathyroidectomy using Tc-99 Sestamibi localization is an effective approach to hyperparathyroidism. For patients without localization, exposure of all four parathyroid glands is preferable. Surgeons should be familiar with both techniques.
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Affiliation(s)
- Brian R Untch
- Department of Surgery, Duke University Medical Center, Box 3873, Durham, NC 27710, USA
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Parathyroidectomy: Overview of the Anatomic Basis and Surgical Strategies for Parathyroid Operations. Clin Rev Bone Miner Metab 2007. [DOI: 10.1007/s12018-007-0003-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Olson J, Repplinger D, Bianco J, Chen H. Ex Vivo Radioactive Counts and Decay Rates of Tissues Resected During Radioguided Parathyroidectomy. J Surg Res 2006; 136:187-91. [PMID: 17046791 DOI: 10.1016/j.jss.2006.04.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 03/27/2006] [Accepted: 04/24/2006] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Jordan Olson
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison Wisconsin 53792, USA
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Rubello D, Fig LM, Casara D, Piotto A, Boni G, Pelizzo MR, Shapiro B, Sandrucci S, Gross MD, Mariani G. Radioguided Surgery of Parathyroid Adenomas and Recurrent Thyroid Cancer Using the "Low Sestamibi Dose" Protocol. Cancer Biother Radiopharm 2006; 21:194-205. [PMID: 16918295 DOI: 10.1089/cbr.2006.21.194] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE The aim of this study was to establish the clinical efficacy of the "low sestamibi dose" (LSD) protocol to perform thyroid and parathyroid radioguided surgery in a large series of patients homogeneously studied and operated on by the same surgeon. The LSD protocol was initially developed in our center to cure primary hyperparathyroid (PHPT) patients with a high likelihood of a solitary parathyroid adenoma (PA) by minimally invasive radioguided surgery (MIRS). Since then, the same protocol has been applied to differentiated thyroid cancer (DTC) patients with 131I-negative, but sestamibi-positive, locoregional recurrent disease in order to obtain radical radioguided extirpation of tumoral lesions at reoperation. STUDY DESIGN We reviewed the clinical charts of 453 consecutive patients referred at the surgical department at Padova University (Padova, Italy) to investigate a PHPT or a DTC recurrence: 336 patients (74.2%) met the inclusion criteria for radioguided surgery, and these patients were analyzed for the aim of this study. There were 298 patients affected by PHPT with a high likelihood of a solitary sestamibipositive PA and 38 DTC patients affected by 131I-negative, but sestamibi-positive, locoregional recurrence. All patients underwent a preoperative imaging work-up, including sestamibi scintigraphy (doubletracer subtraction scan in PHPT patients and single-tracer, wash-out scan in DTC patients) and high-resolution neck ultrasonography (US). The LSD protocol we developed consists of the intravenous injection of a very low (1 mCi) sestamibi dose in the operating theater just 10 minutes before commencing intervention for the purpose of radioguided surgery only. At variance with the traditional "high (20-25 mCi) sestamibi dose (HSD)" protocol in which imaging and radioguided surgery are obtained in the same day, in the LSD protocol, imaging and radioguided surgery are performed in different days. The LSD protocol allows some advantages over the HSD protocol: (1) more time for acquiring and interpreting preoperative imaging (planar scintigraphy, single-photon emission computed tomography [SPECT], US); (2) an accurate selection of patients to whom MIRS is offered, especially in countries where the prevalence of nodular goiter with sestamibi-avid thyroid nodules (exclusion criteria for MIRS) is relatively high, as in mid-south-European countries; (3) it facilitates the work planning in the operating theater (bilateral neck exploration requires an operating time of at least double to that of MIRS); and (4) the radiation exposure dose to operating theater personnel is very low-substantially negligible, using the LSD protocol: This aspect assumes great importance in countries where radioproteximetric rules are stringent, as in Europe. RESULTS PHPT patients. MIRS was successfully performed by a 1.5-2-cm skin incision in 287 of 298 PHPT patients (96.3%) in whom such an approach was scheduled on the basis of preoperative imaging, including 41 of 57 patients (71.9%) who had previously received thyroid or unsuccessful parathyroid surgery in another center. No case of major intraoperative complication was recorded. No case of persistent or recurrent PHPT was observed during postsurgical follow-up. DTC patients. A total of 79 metastatic lesions were intraoperatively detected by the gamma probe and successfully removed (68 of them had been correctly visualized at preoperative sestamibi scintigraphy). During subsequent follow-up, 18 patients (72%) were considered disease-free, whereas 7 had persistent disease (increased serum thyroglobulin levels). The radiation exposure dose to the surgeon using the LSD protocol was 1.2 uSi/hour, that is, 20-30-fold lower than that delivered with the HSD protocol used for PHPT patients and with the 131I protocol used for DTC patients with recurrence. CONCLUSIONS On the basis of our data, it can be concluded that the LSD protocol is a safe and effective protocol to perform in both MIRS in PHPT patients and radioguided reoperation in DTC patients with 131I-negative recurrence. Furthermore, from a radioproteximetric point of view, in comparison with other radioguided protocols used for the same purposes, the LSD protocol minimizes the radiation-exposure dose to the surgeon and operating theater personnel.
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Affiliation(s)
- Domenico Rubello
- Nuclear Medicine Service, S. Maria della Misericordia Hospital, Rovigo, Italy.
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Grady JA, Bumpous JM, Fleming MM, Flynn MB, Turbiner E, Lentsch EJ, Ziegler CH. Advantages of a Targeted Approach in Minimally Invasive Radioguided Parathyroidectomy Surgery for Primary Hyperparathyroidism. Laryngoscope 2006; 116:431-5. [PMID: 16540904 DOI: 10.1097/01.mlg.0000195288.06601.18] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE In a large series of patients, we associated the need for preoperative parathyroid hormone (PTH) and calcium levels as a vital component in our approach to the radioguided minimally invasive parathyroidectomy (MIRP) procedure. Our objective was to determine whether these preoperative levels indeed complemented the procedure. Our study also included a postoperative assessment of excised gland volume and length of operation. STUDY DESIGN This was a prospective cohort study. METHODS : One hundred seventy-three patients with primary hyperparathyroidism enrolled in our radioguided MIRP protocol. Patients were divided into groups based on the results of sestamibi scans. Comparisons were made between these results and the assessed preoperative PTH and calcium levels and the postoperative excised gland volume and length of operation. RESULTS PTH and calcium levels did not statistically relate with the likelihood of having a "positive," "equivocal," or "negative" sestamibi scan, but the volume of excised gland was significantly different among the three groups (P < .01). There was no significant difference between positive and equivocal scans (P = .40). Operative time was significantly different between positive and equivocal scans (P < .01), positive and negative scans (P < .01), and equivocal and negative scans (P < .01). CONCLUSIONS Routine preoperative PTH and calcium levels are necessary for the biologic diagnosis of hyperparathyroidism, but they do not appear to relate to the outcome of a sestamibi scan and therefore do not complement the radioguided MIRP procedure. Because the size of the affected gland, however, did correlate with a positive sestamibi scan, we conclude that as the volume of the gland increases, so does the likelihood of a successfully chosen minimally invasive surgical approach.
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Affiliation(s)
- Jennifer A Grady
- Division of Otolaryngology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA
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Hanif F, Coffey JC, Romics L, O'Sullivan K, Aftab F, Redmond HP. Rapid Intraoperative Parathyroid Hormone Assay—More than Just a Comfort Measure. World J Surg 2006; 30:156-61. [PMID: 16425080 DOI: 10.1007/s00268-005-0293-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Minimally invasive radio-guided parathyroidectomy (MIRP) has been embraced as an acceptable therapeutic approach to primary hyperparathyroidism. Preoperative sestamibi scanning has facilitated this technique. Here we evaluate the addition of a rapid intraoperative parathyroid hormone (iPTH) assay for patients undergoing MIRP. METHODS A series of 51 patients underwent sestamibi localization of parathyroid glands followed by MIRP for primary hyperparathyroidism. Using peripheral venous samples, iPTH levels were measured prior to gland excision, as well as post-excision at 5, 10, and 15 minutes, taking a 50% reduction in iPTH level as indicative of complete excision. Next, changes in serum iPTH were compared with preoperative and postoperative changes in serum calcium, as well as levels of intraoperative ex-vivo radiation counts taken by hand-held gamma probe. RESULTS In this series, a drop of greater than 50% in iPTH levels was observed in 94% of patients (n=48). Moreover, a significant drop in iPTH occurred within 10 minutes of excision in the majority (n=42) of cases (P<0.004). Changes in iPTH were comparable with the therapeutic reduction in calcium levels, as well as with the change in intraoperative ex-vivo gamma counts. CONCLUSIONS This study demonstrates that the addition of an iPTH assay to MIRP provides a quick and reliable intraoperative diagnostic modality in confirming correct adenoma removal. Moreover, it precludes the requirement of frozen section.
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Affiliation(s)
- F Hanif
- Department of Surgery, National University of Ireland, Cork, and Cork University Hospital, Cork, Ireland
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Brunaud L, Ayav A, Bresler L, Boissel P. [Open minimally invasive parathyroid and thyroid surgery]. ANNALES DE CHIRURGIE 2005; 131:62-7. [PMID: 16242113 DOI: 10.1016/j.anchir.2005.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Open minimally invasive parathyroidectomy or thyroidectomy (small-incision technique) are frequently performed. Benefits and disadvantages of this approach are discussed in this review. Preoperative patients selection is mandatory and is also discussed.
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Affiliation(s)
- L Brunaud
- Service de chirurgie générale, digestive et endocrinienne, CHU de Nancy-Brabois, hôpital d'adultes, 11, allée du Morvan, 54511 Vandoeuvre-lès-Nancy, France.
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Ruda JM, Hollenbeak CS, Stack BC. A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg 2005; 132:359-72. [PMID: 15746845 DOI: 10.1016/j.otohns.2004.10.005] [Citation(s) in RCA: 469] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism. STUDY DESIGN A systematic literature review. RESULTS Of the 20,225 cases of primary hyperparathyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc 99m -sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries. CONCLUSION The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normocalcemia than is typically quoted. IOPTH was a helpful but not "fool-proof" adjunct in parathyroid exploration surgery. SIGNIFICANCE These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.
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Affiliation(s)
- James M Ruda
- Pennsylvania State College of Medicine, Penn State College of Medicine, Hershey, USA
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Affiliation(s)
- Brenda Satchie
- Department of Surgery, University of Wisconsin Medical School, Madison 53792, USA
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Rubello D, Piotto A, Medi F, Gross MD, Shapiro B, Erba P, Mariani G, Pelizzo MR. ‘Low dose’ 99mTc-Sestamibi for radioguided surgery of primary hyperparathyroidism. Eur J Surg Oncol 2005; 31:191-6. [PMID: 15698737 DOI: 10.1016/j.ejso.2004.10.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2004] [Indexed: 11/19/2022] Open
Abstract
AIM In this study, we evaluated the efficacy of low dose (99m)Tc-Sestamibi administration for radioguided parathyroid surgery in patients with primary hyperparathyroidism (PHPT). METHODS Three hundred consecutive PHPT patients were studied between September, 1999 and July, 2003. Pre-operative work-up included (99m)Tc-pertechnetate/(99m)Tc-Sestamibi subtraction scintigraphy and high resolution ultrasonography (US). 37MBq of (99m)Tc-Sestamibi was injected i.v. in the operating suite approximately 10 min prior to the beginning of the surgical procedure for intraoperative radiolocalization; quick parathyroid hormone (QPTH) assays were performed. RESULTS Two hundred and seven of the 211 patients selected for minimally-invasive radioguided parathyroidectomy (MIRP) were successfully treated for a solitary parathyroid adenoma (PA) through a 2-2.5 cm skin incision (mean operative time 35 min, mean hospital stay 1.2 days). In the 89 patients selected for traditional bilateral neck exploration (BNE), radioguided surgery was not as successful in the identification of the PA, especially in patients with (99m)Tc-Sestamibi-avid thyroid nodules. Nevertheless, the combination of probe and QPTH measurement was very helpful in patients with multigland disease. CONCLUSIONS Low-dose (99m)Tc-Sestamibi administered few minutes before surgery is sufficient for MIRP in patients with high likelihood of a solitary PA and without concomitant (99m)Tc-Sestamibi-avid thyroid nodules. The combination of radioguided surgery and QPTH measurements is very useful in the early identification of unanticipated multigland disease.
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Affiliation(s)
- D Rubello
- Nuclear Medicine Service, S. Maria della Misericordia Hospital, Istituto Oncologico Veneto, Viale Tre Martiri, 140, I-45100 Rovigo, Italy.
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Koren I, Shpitzer T, Morgenshtern S, Shvero J. Lateral minimal parathyroidectomy: safety and cosmetic benefits. Am J Otolaryngol 2005; 26:83-6. [PMID: 15742258 DOI: 10.1016/j.amjoto.2004.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Surgery has been the cornerstone of treatment for primary hyperparathyroidism for almost three decades. The recent application of state-of-the art imaging technologies to localize hyperfunctioning adenomas preoperatively has enabled surgeons to minimize the surgical procedure, reduce total operation time and improve cosmetic results without compromising the cure rate. STUDY DESIGN Twenty-one patients with a diagnosis of primary hyperparathyroidism were selected for treatment with the lateral minimal parathyroidectomy approach following preoperative imaging with ultrasonography, Tc-sestamibi scan, or both. All patients were followed during hospitalization and for three months after for calcium levels and cosmetic results. RESULTS The procedure was performed by the same surgical team for all 21 patients; under general anesthesia in 20 patients and under deep sedation in 1 patient at high surgical risk. In all cases, parathyroid adenoma was accurately localized by at least one of the imaging modalities before surgery: ultrasonography in 16 patients (76%), Tc-sestamibi scan in 15 (71%), and both in 10 (48%). Average total operative time for the lateral minimal invasive approach was 46 minutes (range 30-65 minutes). Blood calcium levels returned to normal in all patients, and cosmetic results were graded good to excellent. CONCLUSIONS With accurate preoperative localization of unilateral parathyroid adenoma by any imaging modality and careful patient selection, lateral minimal parathyroidectomy performed by a skilled surgeon may serve as a safe, effective procedure with good clinical and aesthetic outcomes.
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Affiliation(s)
- Ilan Koren
- Department of Otolaryngology, Head and Neck Surgery, Rabin Medical Center, Petah Tiqva, Israel.
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Lee WJ, Ruda J, Stack BC. Minimally invasive radioguided parathyroidectomy using intraoperative sestamibi localization. Otolaryngol Clin North Am 2004; 37:789-98, ix. [PMID: 15262516 DOI: 10.1016/j.otc.2004.02.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article presents the authors' technique of minimally invasive radio guided parathyroidectomy (MIRP) with intra-operative use of the hand-held gamma probe for primary HPT caused by a solitary adenoma. It points out how this approach varies from that of others who perform MIRP. It also illustrates ways to troubleshoot common problems with the technique in inexperienced hands. The goal is to present an understandable and systematic approach to MIRP for surgeons who do not currently use this technique. This article is not intended to replace formalized training, which is essential to master the technique.
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Affiliation(s)
- Wha-Joon Lee
- Ear, Nose Throat and Plastic Surgery Associates PA, 201 Lakemont Avenue, Winter Park, FL 32764, USA
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Rubello D, Casara D, Giannini S, Piotto A, Dalle Carbonare L, Pagetta C, Boni G, Mariani G, Muzzio PC, Pelizzo MR. Minimally invasive radioguided parathyroidectomy: an attractive therapeutic option for elderly patients with primary hyperparathyroidism. Nucl Med Commun 2004; 25:901-8. [PMID: 15319595 DOI: 10.1097/00006231-200409000-00007] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM Surgery for primary hyperparathyroidism (PHPT) due to a solitary parathyroid adenoma (PA) is moving from traditional bilateral neck exploration (BNE) towards the use of limited neck exploration. The aim of the present study was to define the efficacy of minimally invasive radioguided surgery (MIRS) in PHPT patients with a high probability of a solitary PA with particular regard to benefits achievable in elderly patients. PATIENTS AND METHODS The study population included a total of 266 consecutive PHPT patients who had undergone surgery at our centre between September 1999 and February 2003. Preoperative imaging consisted of [Tc]pertechnetate/Tc sestamibi (TcO4/sestamibi) scintigraphy and neck ultrasound obtained in the same session. One hundred and eighty-seven patients from the whole series (75 of whom were older than 65 years) with a high scan/ultrasound probability of a solitary PA, a high PA sestamibi uptake, and a normal thyroid gland were selected for MIRS. The other 79 patients were selected for traditional BNE. The intra-operative technique was based on the injection of a low dose (37 MBq) of sestamibi in the operating theatre a few minutes before the beginning of intervention and on the use of an 11 mm collimated gamma probe. RESULTS MIRS was successfully performed in 97.8% of all PHPT patients selected for this type of surgery and, in particular, in 100% of the subgroup (n=75) of elderly patients. MIRS required a mean operating time of 35 min and a mean hospital stay of 1.2 days; that is, approximately half of that required for traditional BNE. Moreover, local anaesthesia was successfully performed in 27 patients, 19 of whom were >65 years with concomitant invalidating diseases contraindicating general anaesthesia. No major surgical complications were recorded. Transitory hypocalcaemia was observed in 9% of cases treated with MIRS compared with 27% of patients treated with BNE. CONCLUSION MIRS can be accurately planned in elderly PHPT patients with a solitary PA on the basis of a TcO4/sestamibi scan and neck ultrasound. MIRS has been proven to be safe and effective in our experience, and allows a significant reduction of operating and recovery time, as well as the possibility of using local anaesthesia, especially in elderly patients with concomitant invalidating diseases.
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Affiliation(s)
- Domenico Rubello
- Nuclear Medicine Service, S. Maria della Misericordia Rovigo Hospital, Azienda ULSS 18 Rovigo, Istituto Oncologico Veneto, Viale Tre Martiri 140, 45100 Rovigo, Italy.
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Ruda J, Stack BC, Hollenbeak CS. The cost-effectiveness of sestamibi scanning compared to bilateral neck exploration for the treatment of primary hyperparathyroidism. Otolaryngol Clin North Am 2004; 37:855-70, x-xi. [PMID: 15262521 DOI: 10.1016/j.otc.2004.02.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article presents a cost-effectiveness analysis to determine whether preoperative imaging with Tc99m-sestamibi for detection and treatment of solitary adenomas associated with primary hyperparathyroidism is cost-effective compared with routine bilateral neck exploration.
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Affiliation(s)
- James Ruda
- Pennsylvania State University College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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Saint Marc O, Cogliandolo A, Pidoto RR, Pozzo A. Prospective evaluation of ultrasonography plus MIBI scintigraphy in selecting patients with primary hyperparathyroidism for unilateral neck exploration under local anaesthesia. Am J Surg 2004; 187:388-93. [PMID: 15006568 DOI: 10.1016/j.amjsurg.2003.12.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2003] [Revised: 05/26/2003] [Indexed: 11/17/2022]
Abstract
BACKGROUND Unilateral neck exploration (UNE) is currently replacing conventional bilateral neck exploration with cervicotomy for the surgical treatment of primary hyperparathyroidism (PHPT). However, many concerns still exist about the indications and the effectiveness of this minimally invasive approach. METHODS Prospective evaluation of operative results in consecutive patients having indications for UNE on the basis of strict selection criteria consisting of ultrasound-MIBI agreement in adenoma localization, absence of thyroid disease, and psychological suitability for undergoing a procedure under local anesthesia. No intraoperative confirmation study was adopted. RESULTS Among 149 consecutive PHPT patients, 45 (30.2%) had indications for UNE. No operative morbidity or mortality was observed. Mean operative time for the UNE procedure was 42 minutes (range 25 to 57). Conversion to general anesthesia was chosen for 5 patients (11.1%), whereas conversion to bilateral neck exploration was chosen for 3 patients (6.6%). For the UNE procedure, the success rate was as high as 91.7%. When the only factor indicated UNE, ultrasound-MIBI localization agreement had low sensibility (44.1%) and specificity (55.6%) but a high positive predictive value (91.1%). CONCLUSIONS We concluded that UNE performed under local anesthesia, without intraoperative confirmation studies, could be considered a safe and effective approach to treating patients with PHPT, but we regret the low rate of patients selected for this procedure because of the low sensitivity of the imaging-inclusion criterion.
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Affiliation(s)
- Olivier Saint Marc
- Service de Chirurgie Generale Digestive et Endocrinienne, Hôpital de la Source-14, Avenue de l'Hôpital, BP 6709 45067 Orléans Cedex 2, France.
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Chen H, Mack E, Starling JR. Radioguided parathyroidectomy is equally effective for both adenomatous and hyperplastic glands. Ann Surg 2003; 238:332-7; discussion 337-8. [PMID: 14501499 PMCID: PMC1422704 DOI: 10.1097/01.sla.0000086546.68794.9a] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the utility of radioguided parathyroidectomy for patients with hyperparathyroidism, we studied the properties of 180 resected, hyperfunctioning parathyroid glands. SUMMARY AND BACKGROUND DATA Radioguided resection of hyperfunctioning parathyroid glands has been shown to be technically feasible in patients with parathyroid adenomas. Radioguided excision may obviate the need for intraoperative frozen section because excised parathyroid adenomas uniformly have radionuclide ex vivo counts >20% of background. The feasibility and applicability of radioguided techniques for patients with parathyroid hyperplasia are unclear. METHODS Between March 2001 and September 2002, 102 patients underwent neck exploration for primary (n = 77) and secondary/tertiary (n = 25) hyperparathyroidism. All patients received an injection of 10 mCi of Tc-99m sestamibi the day of surgery. Using a gamma probe, intraoperative scanning was performed, looking for in vivo radionuclide counts > background to localize abnormal parathyroid glands. After excision, radionuclide counts of each ex vivo parathyroid gland were determined and expressed as a percentage of background counts.RESULTS Although patients with single adenomas had higher mean background radionuclide counts, the average in vivo counts of all enlarged glands were higher than background. Notably, in vivo counts did not differ between adenomatous and hyperplastic glands, suggesting equal sensitivity for intraoperative gamma detection. Ectopically located glands were identified in 22 cases and all were accurately localized using the gamma probe. Postresection, mean ex vivo radionuclide counts were highest in the single parathyroid adenomas and lowest in hyperplastic glands. Importantly, in all hyperplastic glands, the ex vivo counts were >20%. CONCLUSIONS In patients with hyperparathyroidism, radioguided surgery is a sensitive adjunct for the intraoperative localization of both adenomatous and hyperplastic glands. In this series, all 180 enlarged parathyroids were located with the gamma probe. We have also shown that the ">20% rule" for ex vivo counts not only applies to parathyroid adenomas but also to hyperplastic glands. Therefore, radioguided resection is equally effective and informative for both adenomatous and hyperplastic glands.
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Affiliation(s)
- Herbert Chen
- University of Wisconsin Medical School Department of Surgery, H4/750 CSC 600 Highland Avenue, Madison, WI, USA.
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