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

Treatment for secondary hyperparathyroidism focusing on parathyroidectomy

Secondary hyperparathyroidism (SHPT) is a major problem for patients with chronic kidney disease and can cause many complications, including osteodystrophy, fractures, and cardiovascular diseases. Treatment for SHPT has changed radically with the advent of calcimimetics; however, parathyroidectomy (PTx) remains one of the most important treatments. For successful PTx, removing all parathyroid glands (PTGs) without complications is essential to prevent persistent or recurrent SHPT. Preoperative imaging studies for the localization of PTGs, such as ultrasonography, computed tomography, and 99mTc-Sestamibi scintigraphy, and intraoperative evaluation methods to confirm the removal of all PTGs, including, intraoperative intact parathyroid hormone monitoring and frozen section diagnosis, are useful. Functional and anatomical preservation of the recurrent laryngeal nerves can be confirmed via intraoperative nerve monitoring. Total or subtotal PTx with or without transcervical thymectomy and autotransplantation can also be performed. Appropriate operative methods for PTx should be selected according to the patients' need for kidney transplantation. In the case of persistent or recurrent SHPT after the initial PTx, localization of the causative PTGs with autotransplantation is challenging as causative PTGs can exist in the neck, mediastinum, or autotransplanted areas. Additionally, the efficacy and cost-effectiveness of calcimimetics and PTx are increasingly being discussed. In this review, medical and surgical treatments for SHPT are described.

Two parathyroid adenomas in a Saudi female on hemodialysis diagnosed with tertiary hyperparathyroidism: a case report

A case of a 51-year-old female on hemodialysis 3 times per week for the past seven years was admitted to the endocrine surgery department on July of 2018 in Al-Hada Armed Forces hospital in Taif city, Saudi Arabia. Presented with complains of bone ache in her hip and lower limbs. Her labs showed that parathyroid hormone (PTH) has reached 4,267.2 pg/mL and her calcium was 2.82 mmol/L, phosphate was 0.84. Her case was suggesting Tertiary Hyperparathyroidism (HPT). She was scheduled for total parathyroidectomy. Histopathological analysis of the resected parathyroid glands confirmed the presence of two parathyroid adenomas. Retrospective progression of PTH, calcium and phosphate were documented, starting from the time she started the hemodialysis seven years ago and it eliminated the presence of preexisting functioning adenomas prior to the kidney failure. The development of multiple parathyroid adenomas in a patient with Tertiary HPT who is on hemodialysis is rare with only one study of a similar case in Japan in 1982. We present a rare case of Tertiary HPT patient on hemodialysis for seven years with double parathyroid adenomas that developed after the establishment of kidney failure. This case may give some insight to the factors that might lead to the formation of parathyroid adenomas, and it provides a unique follow-up of biochemical parameters during 7 years of parathyroid adenomas development.

Parathyroidectomy for tertiary hyperparathyroidism: A systematic review

OBJECTIVE

Analyze the efficacy and indications for parathyroidectomy as an intervention for tertiary hyperparathyroidism.

DATA SOURCES

PubMed, MEDLINE, and Cochrane Library databases.

REVIEW METHODS

A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms ("tertiary hyperparathyroidism" OR "3HPT") AND "parathyroidectomy". Articles were analyzed in regards to their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management.

RESULTS

Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. The majority of studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches.

CONCLUSION

Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a >50% drop in PTH level even if PTH remains above normal. Additionally, "success" or "cure" is defined as normal calcium levels regardless of whether or not PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.

The utility of the radionuclide probe in parathyroidectomy for primary hyperparathyroidism

INTRODUCTION Parathyroidectomy is the definitive treatment for primary hyperparathyroidism but the intraoperative identification of adenomas is challenging. The aim of this study was to evaluate the utility of a radionuclide probe (RNP) in addition to intraoperative parathyroid hormone ( IOPTH) measurement as an intraoperative diagnostic adjunct in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS This was a retrospective cohort study of patients treated between 2004 and 2015 in a university affiliated teaching hospital. Patients were grouped into those with RNP use (RNP+) and those without (RNP-). The primary outcome measure was rate of operative failure, which included false positives. The diagnostic sensitivity and positive predictive value of both RNP and IOPTH were also evaluated. RESULTS A total of 298 patients were included in the study, 127 (42.6%) being in the RNP+ group and 171 (57.4%) in the RNP- group. The false positive rate for the RNP+ patients was 1.6% compared with 9.4% for RNP- patients (p=0.006, hazard ratio [HR]: 6.45). The rates of operative failure were 6.3% and 11.7% respectively (p=0.159, HR: 1.97). RNP use had a sensitivity of 92.0% and a positive predictive value of 98.3% compared with 78.6% and 95.2% respectively for IOPTH monitoring. CONCLUSIONS RNP use is associated with fewer false positives and reduced operative failure than IOPTH measurement. It also has a higher sensitivity and positive predictive value. RNP use is recommended in centres that have the required facilities.

The efficacy of low and high dose (99m)Tc-MIBI protocols for intraoperative identification of hyperplastic parathyroid glands in secondary hyperparathyroidism

OBJECTIVE

The aim of this study was to compare the efficacy of low- and high-dose (99m)Tc-MIBI protocols for intraoperative identification of hyperplastic parathyroid glands via gamma probe in secondary hyperparathyroidism.

MATERIAL AND METHODS

This retrospective study was conducted using a prospective database of 59 patients who had undergone radioguided subtotal parathyroidectomy between 2004-2012. The patients were studied in 2 groups. Group 1 (n=31) received 37 MBq (99m)Tc-MIBI intravenously in the surgical room approximately 10 min before the beginning of the intervention and surgery was performed under gamma probe guidance. Group 2 (n=28) received 555 MBq (99m)Tc- MIBI intravenously 2h before surgery, which was also performed under gamma probe guidance. Intraoperative gamma probe findings, laboratory findings, and histopathological findings were evaluated together.

RESULTS

Using acceptance of the histopathological findings as gold standard, sensitivity and specificity of intraoperative gamma probe for identifying hyperplastic parathyroid glands was 98% and 100%, respectively, in both groups.

CONCLUSIONS

In the light of these findings, it is concluded that the low-dose (99m)Tc-MIBI protocol might be preferable for intraoperative identification of hyperplastic parathyroid glands in secondary hyperparathyroidism patients because it was observed to be as effective as the high-dose (99m)Tc-MIBI protocol. Furthermore, the low-dose protocol does not have the disadvantages that are associated with the high-dose protocol.

Total Parathyroidectomy versus Subtotal Parathyroidectomy in the Treatment of Tertiary Hyperparathyroidism

The purposes of this study are to evaluate the merits of surgical treatment, including subtotal parathyroidectomy (SP) and total parathyroidectomy (TP), in patients with tertiary hyperparathyroidism (THPT) and compare the outcome of the two surgical options. Medical records of patients undergoing parathyroidectomy for THPT were retrospectively reviewed and long-term outcomes between the two groups were compared. Fourteen out of 488 renal transplantation recipients required parathyroidectomy for THPT during a 24-year follow-up period with a median follow-up of 35.5 [interquartile range (IQR), 19.3–133.3] months. All patients had hypercalcemia, whereas 13 had varying symptoms and one was asymptomatic. Median serum calcium level decreased from 12.4 (IQR, 11.9–12.6) mg/dL preoperatively to 8.9 (IQR, 8.1–9.4) mg/dL postoperatively ( P = 0.001), whereas median intact parathyroid hormone (iPTH) dropped from a preoperative level of 340.5 (IQR, 247–540) pg/mL to 55.1 (IQR, 24.4–66.4) pg/mL after surgery ( P = 0.018). Comparison between patients receiving TP and SP revealed no difference in incidence of recurrence or permanent complications, whereas the former had significantly lower calcium levels ( P = 0.048) and higher phosphorus levels ( P = 0.017) compared with the latter. Moreover, a significant reduction in calcium level was noted in TP group on long-term follow-up compared with their immediately postoperative level (8.1 vs 9.0 mg/dL, respectively, P < 0.05), whereas there was no significant decrease in SP group. We concluded that parathyroidectomy is efficient and safe in treating THPT. Because TP would increase the risk of hypocalcemia, a less radical procedure (SP) is preferred.

Secondary and tertiary hyperparathyroidism: the utility of ioPTH monitoring

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Secondary and tertiary hyperparathyroidism, state of the art surgical management

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

Radioguided parathyroidectomy for hyperparathyroidism in the reoperative neck

BACKGROUND

The purpose of this study was to determine if radioguided parathyroidectomy (RGP) is effective for hyperparathyroidism (HPT) in the reoperative neck.

METHODS

We retrospectively reviewed all patients with HPT and a history of neck surgery who underwent RGP over a 7-year period. Data are reported as mean +/- SEM.

RESULTS

We identified 110 patients with primary (n = 94), secondary (n = 7), or tertiary (n = 9) HPT who underwent 138 previous neck operations. The average hospital stay was 0.6 +/- 0.1 days. The in and ex vivo counts obtained with the gamma probe were 310 +/- 26 and 130 +/- 13, respectively. The ex vivo percentage of background was 69% +/- 9%, and virtually all resected parathyroids had ex vivo counts > or =20%. After RGP, 96% of patients were cured, and 5% experienced complications (all transient). Cure rates after RGP decreased as the number of previous neck operations increased (P = .002). Additionally, reoperative neck patients with single adenomas were more likely to experience cure than patients with hyperplasia (P = .02).

CONCLUSION

These results illustrate that RGP is valuable in treatment of the reoperative neck. In addition, RGP allows similar lengths of stay, efficacy, and complication rates as those reported for patients undergoing initial parathyroidectomy.