Role of cervical ultrasound in detecting thyroid pathology in primary hyperparathyroidism

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Preoperative parathyroid localization does not improve surgical outcomes for patients with primary hyperparathyroidism

BACKGROUND

Most patients with primary hyperparathyroidism undergo localization prior to operation with variable success. Therefore, in this study we investigated the safety of parathyroidectomy without imaging.

METHODS

A prospective database of 2057 surgical patients with primary hyperparathyroidism from 2001 to 2019 was reviewed. Patients were categorized by use of preoperative imaging (ultrasound, sestamibi, CT scan), pathology, and cure.

RESULTS

1879 (91%) patients underwent preoperative imaging. CT scan was the most sensitive study (92%), though specificity was only 64%. Patients with imaging were older, had higher pre- and postoperative calcium, more likely to undergo unilateral exploration and have an adenoma (p < 0.001-0.038). No differences were seen in nerve injury (<1%), postoperative hypocalcemia (<1%), or cure rate.

CONCLUSIONS

While localization may lead to minimally-invasive operations, we observed no differences in postoperative complications or cure rates in the hands of an experienced surgeon. Therefore, preoperative parathyroid localization does not improve outcomes for hyperparathyroidism and can be ordered sparingly.

Are Tc-99m-Sestamibi Scans in Patients With Secondary Hyperparathyroidism and Renal Failure Needed?

BACKGROUND

Parathyroidectomy for patients with secondary hyperparathyroidism (sHPT) generally requires a four-gland exploration. Some groups have strongly recommended routine preoperative Tc-99m-sestamibi scans; others practice scanning for only selected patients. To determine the utility of sestamibi scans in this patient population, we reviewed our experience.

METHODS

We performed a retrospective review of patients who underwent parathyroidectomy for sHPT by one surgeon between 2000 and 2018. Data reviewed included patient demographics, laboratory results, pathology and radiology reports, and clinical and operative notes.

RESULTS

Of the 72 patients in the cohort, mean age was 47.2 ± 15.6, and 50% were female. The preoperative mean calcium and parathyroid hormone levels were 9.6 ± 1.1 mg/dL and 1192.1 ± 914.1 pg/mL, respectively. Sestamibi scans were performed in 21 patients (29%). Of these, 17 were reoperative cases. Of all sHPT patients, 27.8% had ectopic glands. In the sestamibi cohort, only four patients had ectopic glands identified on the scan. Among the 51 patients without preoperative imaging, 16 had ectopic glands (26.2% of nonimaged patients). All these 16 ectopic glands were found by the surgeon at the time of operation without the need for preoperative imaging. All patients in the series were cured with a minimum follow-up of 6 mo.

CONCLUSIONS

Ectopic parathyroid glands are commonly seen in patients undergoing parathyroidectomy for sHPT. The majority of ectopic glands were successfully identified during the operation without preoperative sestamibi scan. Therefore, routine preoperative Tc-99m-sestamibi scans are not needed for successful parathyroidectomy for sHPT.

Does levothyroxine administration impact parathyroid localization?

BACKGROUND

Proper localization is crucial in performing minimally invasive parathyroidectomy for primary hyperparathyroidism. Ultrasonography (US) and Tc-99m sestamibi (MIBI) scintigraphy are common methods used for localization. As the appearance and activity of the thyroid gland may impact parathyroid localization, the purpose of this study was to determine how exogenous use of the thyroid hormone, levothyroxine (LT), affects parathyroid localization.

METHODS

Adult patients with non-familial primary hyperparathyroidism who underwent initial parathyroidectomy from 2000-2014 were retrospectively identified. LT (+LT) and non-LT (-LT) patients were matched 1:3 based on age, gender, goiter status, and preoperative parathyroid hormone levels. Subgroup analysis was performed on patients previously treated with radioactive iodine and patients undergoing single adenoma resection.

RESULTS

Of the 1737 patients that met inclusion criteria, 286 were on LT at the time of their parathyroid localization scan. Use of LT did not impact the percentage of correct MIBI localization scans when compared with -LT patients (P = 0.83). Interestingly, use of LT significantly hindered localization by US in comparison with the -LT group (48.4 versus 62.2%, P < 0.01). When examining only patients where a single upper gland was removed, the +LT group was less likely to have a correct US compared with the -LT group (50 versus 72.8%, P < 0.01). However, there was no difference in US accuracy for patients who only had a single lower gland removed (P = 0.51).

CONCLUSIONS

Exogenous LT is associated with impaired parathyroid localization with US but not MIBI. Surgeons should be aware of localization efficiency for this subset of patients in the era of personalized medicine and cost effectiveness.