Radioguided parathyroidectomy effective in pediatric patients

Adolescent Hyperparathyroidism: An Updated Contemporary Surgical Experience at a Tertiary Center

INTRODUCTION

Primary hyperparathyroidism (pHPT) in children is uncommon, resulting in a paucity of data describing the disease process in this population. Herein, in an effort to bridge the information gap, we review our experience with pHPT in adolescent patients under 20 y of age at a specialized tertiary referral center.

METHODS

A retrospective chart review included all adolescent patients with pHPT, who underwent surgery at our institution between 2004 and 2023. Presenting symptoms, biochemical workup, intraoperative findings, and outcomes were collected and analyzed.

RESULTS

Forty-nine adolescent patients were included, with 45% (n = 22) being male. The median age at diagnosis was 16.6 y (14.1-20). On presentation, 71% (n = 35) were symptomatic, most commonly nephrolithiasis (35%, n = 17). The median preoperative calcium and parathyroid hormone were 12 mg/dL (11.3-12.6) and 128pg/mL (105-170.5), respectively. Focused parathyroidectomy was performed in 61% (n = 30) and four-gland exploration in 39% (n = 19) of patients. Eighty-six percent were found to have a single adenoma and 14% had multigland disease. Preoperative localization with ultrasound and Sestamibi had a sensitivity of 57% and 59%, respectively. When combining both imaging modalities, sensitivity increased to 78% (positive predictive value 91%). There were no surgical complications. At the median follow-up of 61.0 mo, 4% of patients were found to have recurrent pHPT. Younger age (OR 0.64, P = 0.038) and sporadic disease (OR 0.04, P = 0.050) had less likelihood of recurrence.

CONCLUSIONS

Most adolescent patients with pHPT present with symptoms and have single gland disease. Adolescent pHPT should be treated like adult pHPT, utilizing intraoperative PTH and two preoperative imaging modalities.

Low-dose radio-guided parathyroidectomy: A non-inferiority systematic review and meta-analysis

BACKGROUND

Performing MIRP procedure with a 20-fold less MIBI isotope dose allows lower radiation exposure risk for both patient and staff and reduce the overall cost of the procedure. The main goal of this systemic review and meta-analysis is to prove the non-inferiority of the very low dose MIRP compared to the standard dose.

METHODS

We performed a systemic review and meta-analysis of three different electronic databases - PubMed, Web of Science and google scholar. Meta-extraction was conducted in accordance with PRISMA guidelines.

RESULTS

Among 4750 studies imported for screening, only 13 studies were selected for the meta-analysis. Analyzed data from the 13 selected studies performed with low dose MIRP demonstrated a detection rate greater than 97 ​% and a success rate greater than 95 ​%, which is comparable to the cure rate required by current guidelines, as well as to data published by studies using the original high dose protocol.

CONCLUSION

Very low dose MIRP is not inferior to the high dose original MIRP and may be used in separate day protocol routinely.

Outpatient parathyroidectomy in the pediatric population: An 18-year experience

BACKGROUND

Parathyroidectomy for primary hyperparathyroidism (pHPT) is safely performed in the outpatient setting in the adult population. However, concern that children and adolescents have higher complication rates and are unable to recognize and communicate symptoms of hypocalcemia has limited same-day discharges in the pediatric population.

METHODS

Nineteen patients aged 8-18 years (14.1 ± 0.7) underwent outpatient parathyroidectomy for pHPT by a single high-volume endocrine surgeon from 2002-2020. Patient demographics, disease, operations, and complications were reviewed.

RESULTS

Sixteen of 19 patients were symptomatic with fatigue (62.5%), joint pain (37.5%) and nephrolithiasis (18.7%) most common. Mean preoperative Ca and PTH were 11.7 ± 0.3 mg/dL and 102.3 ± 11.8pg/mL, respectively. Ten of 19 had a single adenoma and 9 had multigland hyperplasia including one MEN1 and one MEN2A patient. We performed 11 four-gland explorations, 8 unilateral parathyroidectomies; including 9 transcervical thymectomies, 1 total thyroidectomy, and 1 bilateral central neck dissection. Mean 6-month postoperative Ca and PTH levels were 9.5 ± 0.3 mg/dL (range 7.3-10.3) and 29±5.0pg/mL (range 6.3-77), respectively. One patient developed permanent hypoparathyroidism and 1 had temporary hypocalcemia. No temporary or permanent hoarseness, unplanned same-day admission, wound complications, or Emergency Department visits occurred.

CONCLUSION

Outpatient parathyroidectomy can be safely and effectively performed in pediatric patients with primary HPT.

LEVEL OF EVIDENCE

Treatment Study, Level III.

"Primary Hyperparathyroidism (PHPT) in Children: Two Case Reports and Review of the Literature"

Primary hyperparathyroidism (PHPT) is a rare disorder in children and adolescents. Typical biochemical features are hypercalcemia and hypophosphatemia, but the clinical features can be heterogeneous, and in some cases, symptoms are vague and nonspecific, leading to misdiagnosis or late diagnosis. Herein, we report two cases of PHPT in pediatric age with different presenting symptoms, pain in the foot, and progressive alteration of the gait in the first case and recurrent abdominal pain with emotional lability in the second. Biochemical and radiological assessment confirmed PHPT. Both cases were treated surgically as definitive treatment, but in the second case, previous medical treatment with cinacalcet, a calcimimetic agent, was required to reduce serum PTH and calcium levels. After surgery, despite conventional treatment with calcium and calcitriol, case 1 developed a hungry bone syndrome. The analysis of the MEN-1 (Multiple Endocrine Neoplasia) gene was negative in both cases. A diagnosis of PHPT should be considered when children or adolescents present bone pain with radiological imaging of osteolytic lesion and biochemical feature of hypercalcemia associated with hypophosphatemia. In PHPT, the gold standard treatment is represented by surgery followed by strict postoperative endocrine monitoring to maintain adequate homeostasis of calcium and bone metabolism.

Clinical profile of juvenile primary hyperparathyroidism: a prospective study

INTRODUCTION

Juvenile primary hyperparathyroidism is uncommon and more symptomatic than the adult counterpart. The aim of this prospective monocentric study, conducted in a tertiary referral center, was to evaluate the clinical, biochemical, and densitometric data, and the outcome of a series of patients with juvenile primary hyperparathyroidism.

MATERIAL AND METHODS

The study group included 154 patients with sporadic and familial juvenile primary hyperparathyroidism, aged ≤40 years. Relative frequency of sporadic and familial forms, comparison of the clinical and biochemical characteristics, rate of cure after parathyroidectomy and the outcome of patients not undergoing surgery were evaluated.

RESULTS

Familial cases (n = 42) were younger, less frequently females, and had milder disease compared to sporadic cases (n = 112). No difference was observed in biochemical and densitometric parameters. Among patients undergoing parathyroidectomy (n = 116), familial cases had a higher rate of multigland disease and a higher persistence/relapse rate compared to sporadic cases (73 vs. 3.6% and 48.1 vs. 5.7%, respectively). Patients who did not undergo parathyroidectomy had stable clinical, biochemical, and densitometric parameters during follow-up (median 27 months). Using the cut-off age of 25 years, there was no difference in clinical, biochemical and densitometric parameters between younger and older patients, with the exception of parathyroid hormone and phosphate, which were significantly lower and higher, respectively, in patients <25 years.

CONCLUSIONS

In conclusion, this prospective study shows that juvenile primary hyperparathyroidism is frequently a sporadic disease, with no difference in the biochemical phenotype between sporadic and familial forms. Patients with familial juvenile primary hyperparathyroidism have a milder clinical phenotype and higher rate of persistence/recurrence after PTx than those with sporadic juvenile primary hyperparathyroidism.

John M. Dynamic Optical Contrast Imaging: A Technique to Differentiate Parathyroid Tissue from Surrounding Tissues

The variable location and indistinct features of parathyroid glands can make their intraoperative identification challenging. Currently, there exists no routine use of localization methods during surgery. Dynamic optical contrast imaging (DOCI) leverages a novel realization of temporally dependent measurements of tissue autofluorescence that allows the acquisition of specific tissue properties. A prospective series of patients with primary hyperparathyroidism was examined. Parathyroid lesions and surrounding tissues were collected; fluorescence decay images were acquired via DOCI. Ex vivo samples (81 patients) were processed for histologic assessment. DOCI extracts relative fluorescence decay information in a surgically relevant field of view with a clinically accessible acquisition time <2 minutes. Analysis of DOCI revealed microscopic characterization sufficient for tissue type identification consistent with histology ( P < .05). DOCI is capable of efficiently distinguishing parathyroid tissue from adjacent tissues. Such an intraoperative tool would be transformative, helping surgeons to identify lesions, preserve healthy tissue, and improve patient outcomes.

Outcomes of minimally invasive parathyroidectomy in pediatric patients with primary hyperparathyroidism owing to parathyroid adenoma: A single institution experience

BACKGROUND

Guidelines for treatment of primary hyperparathyroidism (PHPT) in young patients recommend surgery. Outcomes of minimally invasive parathyroidectomy (MIP) are well established in adults, but not in pediatric patients.

OBJECTIVE

The objective of the study is to determine effectiveness of preoperative imaging and MIP aided by intraoperative PTH (ioPTH) measurement in children with primary hyperparathyroidism (PHPT).

METHODS AND DESIGN

This is a retrospective chart review of diagnostic and follow-up data up to 12months post-MIP of patients with PHPT who underwent parathyroidectomy at the Children's Hospital of Philadelphia between January 1, 2009 and March 31, 2015.

RESULTS

Data were available for 16 of 17 patients age 8-17years (11 females, 6 males): 2 had ectopic intrathymic adenomas while 14 had eutopic adenomas. Fifteen patients had ioPTH, including 14 who underwent MIP, defined as a 2cm central neck incision. All patients with data at 6months postparathyroidectomy (13/16) showed normal PTH and calcium. Ultrasound and sestamibi scans had a combined sensitivity of 87.5%.

CONCLUSIONS

MIP is an appropriate alternative to standard neck exploration in pediatric patients with PHPT with a single parathyroid adenoma. ioPTH is especially useful to confirm cure and limit surgical exploration when imaging studies are negative. Sestamibi scans and ultrasound are complementary studies.

The changing pattern of diagnosing primary hyperparathyroidism in young patients

BACKGROUND

Primary hyperparathyroidism (PHPT) is increasing in adults but rarely reported in young patients where routine blood work is obtained more judiciously. We aim to determine how PHPT is currently being diagnosed in young patients and examine surgical outcomes.

METHOD

We retrospectively analyzed PHPT patients 24 years of age or less who underwent parathyroidectomy from 2001 to 2014. Patients were divided into 2 time periods: 2001 to 2007 (A) and 2008 to 2014 (B). Incidentally, diagnosed patients lacked objective symptoms of PHPT and had no family history.

RESULTS

Forty young patients met inclusion criteria: 16 in group A and 24 in group B. Those in group A compared with group B had similar mean age, preoperative calcium, and parathyroid hormone (P > .05). Incidental diagnosis was more common in the contemporary group (42% vs 25%, P = .001).

CONCLUSIONS

Current diagnosis of PHPT in young patients is increasingly incidental. This trend may be attributed to the more liberal use of labs in younger patients.

Focused image-guided parathyroidectomy in the current management of primary hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism (PHPT) in childhood and adolescence has been considered a different disease to that seen in adults, with predominantly familial aetiology mandating open exploration to exclude parathyroid hyperplasia in contrast to the adoption of focused image-guided parathyroidectomy (FP) in adults.

STUDY DESIGN

A retrospective cohort study in a tertiary referral hospital setting of all children and adolescents (<18 years) undergoing parathyroid surgery for PHPT. Data were obtained from a dedicated endocrine surgery database and hospital medical records.

RESULTS

Over the 35-year study period (1980-2014), there were 31 patients who underwent parathyroidectomy for PHPT. 3 patients were from known multiple endocrine neoplasia type 1 syndrome (MEN1) families, 3 had an isolated family history of PHPT and 25 were sporadic. In the sporadic group, 24 (96%) presented with symptomatic hypercalcaemia, affecting the gastrointestinal, musculoskeletal, genitourinary or neuropsychiatric systems. In the 25 patients with sporadic PHPT, nine (36%) had FP with a single adenoma removed with a 100% initial cure rate. Sixteen patients (64%) in the sporadic group had an open exploration: 14 had single gland disease while 2 patients required a second procedure to achieve a final cure rate of 100%. Of the three patients with MEN1, one was cured, one has persistent hyperparathyroidism after FP and the third has permanent hypoparathyroidism after open exploration.

CONCLUSIONS

The majority of children and adolescents with PHPT have symptomatic disease due to a single adenoma. They can therefore be managed in a similar fashion to their adult counterparts with preoperative localisation studies aiming to permit FP in a day case setting.

Aetiology, Diagnosis and Surgical Treatment of Primary Hyperparathyroidism in Children: New Trends

Primary hyperparathyroidism (PHPT) in children is a rare disorder with sharp contrasts in its presentation and aetiology compared with the disease process in adults. This review outlines the current literature, which is limited to about 200 cases, with reference to the aetiology, clinical features, outcomes of investigations, and surgery in children affected by PHPT. Familial conditions account for almost half of all cases of PHPT in children, suggesting that routine genetic testing would be appropriate. Neonatal severe hyperparathyroidism requires urgent medical attention, and performing total parathyroidectomies offers cure, though conservative management is successful in selected cases. Familial hyperparathyroidism in older children can be caused by conditions such as multiple endocrine neoplasia types 1 and 2a, hyperparathyroidism-jaw tumour syndrome and familial hyperparathyroidism. The role of surgery for this group is discussed. The use of ultrasound and MIBI (99mTc-methoxyisobutylnitrile) scanning appears to accurately localise solitary adenomas in sporadic PHPT, thereby supporting the role of minimally invasive parathyroidectomy in children. © 2015 S. Karger AG, Basel.

A meta-analysis comparing the biochemistry of primary hyperparathyroidism in youths to the biochemistry of primary hyperparathyroidism in adults

CONTEXT

The distinctive presentation of primary hyperparathyroidism (PHPT) in adults and youths suggest that PHPT is a fundamentally different disease in these two groups.

OBJECTIVE

To understand the difference in PHPT between adults and youths we compared the biochemistry of PHPT in these two groups.

DESIGN

This study is a systematic review and meta-analysis of retrospective studies published 1966-2014 on PHPT.

DATA SOURCES

All studies were obtained through Medline (1966-2014).

STUDY SELECTION AND DATA EXTRACTION

Only studies that included post-surgical subjects and that explicitly described biochemical results from more than one decade were included. Data were extracted from each article to generate the mean and SE for multiple biochemical parameters.

DATA SYNTHESIS

We analyzed 16 studies describing 268 unique youths and 2405 adults with PHPT. Youths with PHPT had significantly (P < .05) greater serum and urinary calcium than adults with PHPT (3.2 ± 0.1 mmol/L vs 2.8 ± 0.0 mmol/L for serum calcium, and 9.95 ± 1.26 mmol/d vs 7.15 ± 0.56 mmol/d for urine calcium, [mean ± SEM]). There were no significant differences in serum intact PTH, phosphorus, or alkaline phosphatase.

CONCLUSIONS

Juvenile PHPT has greater hypercalcemia and hypercalciuria than adult PHPT at similar concentrations of serum intact PTH. These observations suggest that there are differences in the pathophysiology of PHPT between juvenile and adult patients who reflect an apparent decrease in the sensitivity of the parathyroid adenoma to negative feedback by calcium and increased sensitivity of target tissues to the effects of PTH.

Primary hyperparathyroidism across the ages: presentation and outcomes

BACKGROUND

Primary hyperparathyroidism (PHPT) is a disease process traditionally thought to present during middle age, but can occur at any age. The purpose of this study was to compare PHPT patient characteristics based on patient age at the time of surgical referral.

METHODS

A retrospective review of a prospectively managed database of adult patients undergoing parathyroid surgery for PHPT was conducted. Patients with a negative family history, no previous parathyroid surgery, and ≥6-mo follow-up were included. Patients were grouped by age for comparison.

RESULTS

From 2001-2012, 1372 patients met inclusion criteria. Age groups were as follows: ≤50 y, 51-60 y, 61-70 y, and >70 y. Female predominance increased with age (P>0.01). Baseline serum parathyroid hormone levels were higher at the extremes of age (P<0.001). Young patients had the highest serum calcium (P<0.01), urinary calcium (P<0.001), and T-score (P<0.001) measures, and greater incidence of vitamin D deficiency (P=0.03). The use of local anesthesia increased with age, whereas use of outpatient parathyroidectomy decreased with age (both P<0.01). Rates of disease persistence (2.3%-2.9%, P=0.95) and recurrence (2.1%-3.3%, P=0.75) were low, and did not differ.

CONCLUSIONS

Patients at the extremes of age are referred with more elevated laboratory indices whereas those in the traditional age range have milder biochemical indices. This may result from differential surgical referral. Individuals with laboratory evidence of abnormal calcium and parathyroid hormone regulation should be evaluated for parathyroidectomy regardless of age because all ages can be successfully treated.

Parathyroid conditions in childhood

This review of parathyroid surgery in children will briefly discuss parathyroid gland embryology and anatomy before focusing on the pathophysiology, clinical presentation, and treatment of hyperparathyroidism in children. Hyperparathyroidism (HPT) is the overproduction of PTH and it is rare in children, with an incidence of 2-5 per 100,000. This rarity means that the principles of caring for children with parathyroid disease are largely extrapolated from the richer adult experience; however, the unique pediatric aspects of parathyroid problems and their surgical treatment, including presentation, imaging, operative approach, and complications, will be considered.