Intraoperative rapid parathyroid hormone monitoring in parathyroid surgery

Minimally invasive parathyroidectomy: benefits and requirements of localization, diagnosis, and intraoperative PTH monitoring. long-term results

BACKGROUND

Surgery is the only curative treatment for primary hyperparathyroidism. Initial parathyroidectomy procedures fail due to ectopic gland location and unappreciated multigland disease.

METHODS

An evidence-based literature review was performed,which surveyed all human studies in PubMed, searching for parathyroidectomy in humans between 1990 and 2009. Between 10 and 30% of patients have multigland disease caused by double adenomas or hyperplasia. Use of preoperative imaging studies and intraoperative PTH monitoring helps parathyroid surgeons overcome these obstacles.

RESULTS

Sestamibi nuclear scan and neck ultrasound identify 70-80% of abnormal glands in patients with single adenomas. The sensitivity of ultrasound or sestamibi to identify all abnormal glands in patients with multigland disease is extremely low. Intraoperative PTH monitoring should be utilized in all patients who undergo neck exploration for primary hyperparathyroidism to reduce failures due to multigland disease. Blood samples should be drawn from peripheral veins only and a postresection level 10-15 min after gland removal should have a >50%decrease from baseline preoperative levels, and also must go to the normal range for the PTH assay being used.

CONCLUSIONS

Contemporary prospective studies (level of evidence III/IV) show that by combining preoperative imaging and IOPTH it is possible to maximize performance of successful outpatient minimally invasive parathyroidectomy.

Surgical technique refinements in head and neck oncologic surgery

The head and neck region poses a challenging arena for oncologic surgery. Diseases and their treatment can affect a myriad of functions, including sight, hearing, taste, smell, breathing, speaking, swallowing, facial expression, and appearance. This review discusses several areas where refinements in surgical techniques have led to improved patient outcomes. This includes surgical incisions, neck lymphadenectomy, transoral laser microsurgery, minimally invasive thyroid surgery, and the use of vascularized free flaps for oromandibular reconstruction.

Minimally invasive parathyroidectomy using local anesthesia with intravenous sedation and targeted approaches

OBJECTIVES

Minimally invasive parathyroidectomy (MIP) is generally performed under general anesthesia. This study evaluates the efficacy and safety of MIP performed under intravenous sedation with local anesthesia.

STUDY DESIGN

Historical cohort study.

SUBJECTS

One hundred eighty-six consecutive patients undergoing MIP using sedation with local anesthesia.

METHODS

Two different targeted approaches were used to achieve good exposure with minimal retraction, which allows the procedure to be performed with little discomfort. In all patients, an adenoma was localized preoperatively and its depth mapped by sestamibi scan with single-photon emission computed tomography and/or ultrasound. A midline anterior approach was used for inferior glands that were superficially located. A lateral approach was used for glands that were located posteriorly or superiorly.

RESULTS

MIP was successfully completed under local/sedation in 177 patients; 167 were discharged the same day. Complications include two pneumothorax, one small hematoma, and one transient vocal cord paralysis.

CONCLUSIONS

By using a targeted approach, MIP can be safely performed under local anesthesia in appropriately selected patients.

Correlation of intraoperative parathyroid hormone levels with parathyroid gland size

OBJECTIVES

To study the relationship of intraoperative intact parathyroid hormone levels (iPTH) with parathyroid adenoma weight and volume in patients with primary hyperparathyroidism.

METHODS

Retrospective evaluation of consecutive patients undergoing minimally invasive parathyroidectomy with iPTH measurement. Data collected include preoperative serum calcium, ionized calcium, and serum parathyroid hormone (PTH) levels, iPTH levels at baseline, 5 minutes, and 10 minutes, and parathyroid adenoma weight. Adenoma volume was calculated using an equation for the volume of a spheroid object.

RESULTS

Thirty patients underwent minimally invasive parathyroidectomy with iPTH measurement for a single parathyroid adenoma between March 2004 and January 2006. There were 8 men and 22 women, with a mean age of 59.3 (range 26-92) years. A significant correlation between preoperative serum calcium and ionized calcium levels and parathyroid adenoma weight was identified (P = .0008 and P = .03, respectively). A significant correlation was also shown between baseline iPTH measurements and parathyroid adenoma volume (P = .03). There was no correlation between baseline iPTH levels and parathyroid adenoma weight. There was a significant correlation between parathyroid adenoma weight and percentage decrease of iPTH levels at 10 minutes compared to baseline (P = .04).

CONCLUSION

Preoperative serum calcium and baseline iPTH levels may be useful in predicting parathyroid adenoma weight and volume, respectively. Adenoma weight may relate to the percentage decrease of iPTH levels at the 10-minute postparathyroidectomy interval.

Normocalcemic parathyroid carcinoma: an unusual clinical presentation

Background

Parathyroid carcinoma is a rare cause of primary hyperparathyroidism and may be associated with significant disease related morbidity and mortality. Preoperative diagnosis remains a challenge, which may jeopardize appropriate and successful patient treatment.

Case presentation

We report a case of parathyroid carcinoma diagnosed in a 60-year-old woman that presented with a tender nodule located at the left lower thyroid pole and had been present for several years. Ultrasound examination revealed a 2.7 × 1.6 × 2.7 cm mass within the lower left lobe of the thyroid with cystic and solid areas. Lab measurement of the intact PTH level revealed it to be three times the upper limit of normal and the serum calcium level was within normal limits. A left thyroid lobectomy and isthmusectomy was carried out. Histopathological evaluation was diagnostic for a parathyroid carcinoma. At greater than two years of follow-up, the patient has had no evidence of disease recurrence and her serum PTH and calcium levels have remained within normal.

Conclusion

Parathyroid carcinoma is a rare endocrine tumor which must be considered in the differential diagnosis of a nodular thyroid mass. En bloc resection remains the treatment of choice for this malignancy. Disease prognosis is influenced by the extent of the initial resection, the presence of metastases, and adequate long-term follow-up.