The cost-effectiveness of sestamibi scanning compared to bilateral neck exploration for the treatment of primary hyperparathyroidism

Less Than Subtotal Parathyroidectomy for Multiple Endocrine Neoplasia Type 1 Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN1)-associated primary hyperparathyroidism (pHPT) is classically associated with an asymmetric and asynchronous parathyroid involvement. Subtotal parathyroidectomy (STP), which is currently the recommended surgical treatment, carries a high risk of permanent hypoparathyroidism. The results of less than subtotal parathyroidectomy (LSTP) are conflicting, and its place in this setting is still a matter of debate. The aim of this study was to identify the place of LSTP in the surgical management of patients with MEN-associated pHPT.

METHODS

A systematic literature review was conducted in accordance with PRISMA and MOOSE guidelines, for studies comparing STP and LSTP for MEN1-associated pHPT. The results of the two techniques, regarding permanent hypoparathyroidism, persistent hyperparathyroidism and recurrent hyperparathyroidism were computed using pairwise random-effect meta-analysis.

RESULTS

Twenty-five studies comparing STP and LSTP qualified for inclusion in the quantitative synthesis. In total, 947 patients with MEN1-associated pHPT were allocated to STP (n = 569) or LSTP (n = 378). LSTP reduces the risk of permanent hypoparathyroidism [odds ratio (OR) 0.29, confidence interval (CI) 95% 0.17-0.49)], but exposes to higher rates of persistent hyperparathyroidism [OR 4.60, 95% CI 2.66-7.97]. Rates of recurrent hyperparathyroidism were not significantly different between the two groups [OR 1.26, CI 95% 0.83-1.91].

CONCLUSIONS

LSTP should not be abandoned and should be considered as a suitable surgical option for selected patients with MEN1-associated pHPT. The increased risk of persistent hyperparathyroidism could improve with the emergence of more efficient preoperative localization imaging techniques and a more adequate patients selection.

Systematic Review of the Quality of Economic Evaluations in the Otolaryngology Literature

Objective

To evaluate the quality of economic evaluations published in the otolaryngology—head and neck surgery literature, which will identify methodologic weaknesses that can be improved on in future studies. A secondary objective is to identify factors that may be associated with higher quality economic evaluations.

Data Sources

Ovid Medline (including PubMed), Embase, and the National Health Services Economic Evaluation databases.

Review Methods

A systematic search was performed of the aforementioned databases according to PRISMA guidelines. The search was performed using otolaryngology key terms combined with the term cost. A manual search of 36 otolaryngology journals was also performed. Included studies were graded using the Quality of Health Economics Studies instrument, a 16-item checklist providing a total quality score of 100.

Results

Fifty studies were identified, and the mean quality rating was 54.7/100 (SD = 30.9). The most commonly omitted methodology components were a lack of discussion of limitations and biases, failure to address the negative outcomes of examined interventions, and a lack of a robust sensitivity analysis. Higher quality economic evaluations were associated with a higher journal impact factor (correlation coefficient r = 0.62, P = .0001), having an author with a PhD in health economics ( r = 0.56, P = .0001), and having authors who have published prior economic evaluations ( r = 0.46, P = .001).

Conclusion

Results from this study have demonstrated that there are several methodological domains that can be improved on when publishing economic evaluations in the otolaryngology literature. Authors should follow recommended methodological and reporting guidelines to optimize the transparency and accuracy of the overall conclusions.

Endocrine scintigraphy with hybrid SPECT/CT

Nuclear medicine imaging of endocrine disorders takes advantage of unique cellular properties of endocrine organs and tissues that can be depicted by targeted radiopharmaceuticals. Detailed functional maps of biodistributions of radiopharmaceutical uptake can be displayed in three-dimensional tomographic formats, using single photon emission computed tomography (CT) that can now be directly combined with simultaneously acquired cross-sectional anatomic maps derived from CT. The integration of function depicted by scintigraphy and anatomy with CT has synergistically improved the efficacy of nuclear medicine imaging across a broad spectrum of clinical applications, which include some of the oldest imaging studies of endocrine dysfunction.

Preoperative localization strategies for primary hyperparathyroidism: an economic analysis

BACKGROUND

Strategies for localizing parathyroid pathology preoperatively vary in cost and accuracy. Our purpose was to compute and compare comprehensive costs associated with common localization strategies.

METHODS

A decision-analytic model was developed to evaluate comprehensive, short-term costs of parathyroid localization strategies for patients with primary hyperparathyroidism. Eight strategies were compared. Probabilities of accurate localization were extracted from the literature, and costs associated with each strategy were based on 2011 Medicare reimbursement schedules. Differential cost considerations included outpatient versus inpatient surgeries, operative time, and costs of imaging. Sensitivity analyses were performed to determine effects of variability in key model parameters upon model results.

RESULTS

Ultrasound (US) followed by 4D-CT was the least expensive strategy ($5,901), followed by US alone ($6,028), and 4D-CT alone ($6,110). Strategies including sestamibi (SM) were more expensive, with associated expenditures of up to $6,329 for contemporaneous US and SM. Four-gland, bilateral neck exploration (BNE) was the most expensive strategy ($6,824). Differences in cost were dependent upon differences in the sensitivity of each strategy for detecting single-gland disease, which determined the proportion of patients able to undergo outpatient minimally invasive parathyroidectomy. In sensitivity analysis, US alone was preferred over US followed by 4D-CT only when both the sensitivity of US alone for detecting an adenoma was ≥ 94 %, and the sensitivity of 4D-CT following negative US was ≤ 39 %. 4D-CT alone was the least costly strategy when US sensitivity was ≤ 31 %.

CONCLUSIONS

Among commonly used strategies for preoperative localization of parathyroid pathology, US followed by selective 4D-CT is the least expensive.

Contemporary parathyroidectomy: exploiting technology

BACKGROUND

Conventional parathyroidectomy, as practiced only 10 years ago, has given way to considerable change, largely as a result of the evolution of technology. Several of these important technologies include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and rapid intraoperative parathyroid hormone (IOPTH) monitoring. Modern parathyroid surgeons should maintain familiarity with the appropriate role of these approaches.

STUDY DESIGN

Evidence-based analysis of state-of-the-art approaches to the diagnosis and management of primary hyperparathyroidism.

METHODS AND MATERIALS

Four distinct technologies are analyzed in detail, with particular attention to their impact on the practice of parathyroid surgery. These include radio-guided surgery, ultrasound imaging, high-resolution endoscopy, and IOPTH.

RESULTS

Each of the technologies examined has substantial value in the current practice of parathyroidectomy. Judicious implementation of these technologies will vary from practice to practice. Radio-guided surgery may obviate the need for IOPTH monitoring, therefore resulting in the fastest procedural times. Ultrasound imaging is useful as an adjunct to sestamibi scanning to localize adenomatous parathyroid glands. Endoscopic techniques facilitate visualization through small openings and may help surgeons achieve minimal access incisions. Finally, the use of IOPTH is a useful adjunct to directed explorations, and it imparts confidence that all hyperfunctioning parathyroid tissue has been removed.

CONCLUSIONS

The practice of parathyroid surgery has undergone tremendous change in the past decade, and this change has largely been a technology-driven phenomenon. Acquisition of familiarity and skill with these new technologies will be necessary for the endocrine head and neck surgeon wishing to stay abreast of modern surgical techniques and provide quality care.

Parathyroidectomy Versus Cinacalcet Hydrochloride–Based Medical Therapy in the Management of Hyperparathyroidism in ESRD: A Cost Utility Analysis

BACKGROUND

Previously, patients with end-stage renal disease (ESRD) with uncontrolled hyperparathyroidism had few options other than parathyroidectomy, which was reserved for patients refractory to medical therapy. Newer calcimimetic agents, such as cinacalcet, may be an alternative, but raise the possibility of indefinite medical treatment that also would increase costs.

STUDY DESIGN

Cost utility analysis.

SETTING & POPULATION

Base case consisted of prevalent adult US patients with ESRD refractory to management with standard medical therapy. Characteristics were obtained from patients who underwent parathyroidectomy in 2001, and, for purposes of comparison, patients in whom cinacalcet was used were assigned similar characteristics. All data came from preexisting literature and trials or from US Renal Data System analysis files.

INTERVENTION

Use of cinacalcet hydrochloride versus parathyroidectomy.

PERSPECTIVE & TIME FRAME

Medicare and societal costs and quality-adjusted life-years from the date of parathyroidectomy or use of cinacalcet followed up for 2 years, respectively.

MODEL & OUTCOMES

Primary outcomes were cost (measured in US dollars) and cost utility measured using cost per quality-adjusted life-years.

RESULTS

At base-case surgical and drug costs, surgical and drug success rates, complication rates/costs, and benefit from correction of hyperparathyroidism, parathyroidectomy was found to be both less expensive and more cost-effective at 7.25 +/- 0.25 months. Parathyroidectomy became more cost-effective at 15.28 to 16.32 months at the upper limit of sensitivity analysis, when drug/surgical costs and success/complication rates/costs were maximally weighted to favor cinacalcet-based medical therapy.

LIMITATIONS

We assumed current costs of both cinacalcet and parathyroidectomy and assumed cinacalcet use would be indefinite.

CONCLUSIONS

For patients with ESRD with uncontrolled hyperparathyroidism who are good candidates for either drug therapy or surgery, cinacalcet hydrochloride is the most cost-effective modality if the patient is to remain on dialysis therapy for 7.25 +/- 0.25 months. Cinacalcet may be more optimal if used in patients who have high risk of mortality or who would expect to receive a kidney transplant quickly. For other subgroups, parathyroidectomy dominated.

Hyperparathyroidism but a negative sestamibi scan: a clinical dilemma

BACKGROUND

The outcomes of patients with biochemically confirmed hyperparathyroidism but a negative Tc-99 Sestamibi scan are unclear. We examined the outcomes and quality of life of patients having surgery and those who had medical therapy.

METHODS

Patients having a diagnosis of hyperparathyroidism with confirmed elevated calcium and parathormone levels, yet negative sestamibi scans were identified. The RAND SF-36 Health Survey was administered via mail to these patients. The patient's charts were then reviewed to verify treatments and to determine outcomes.

RESULTS

Ninety-five patients fitting the criteria were identified. Twenty patients completed all aspects of the study. Ten of the respondents had undergone parathyroidectomy, and 10 had not. The surgical patients scored more favorably in all 8 of the measured parameters than patients treated medically. The differences in 3 domains, physical functioning, pain, and social functioning, were statistically significant.

CONCLUSIONS

Our findings suggest that surgical therapy confers a better quality of life and is superior to medical therapy in the treatment of primary hyperparathyroidism, even in patients having a negative sestamibi scan.

A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003

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.

Synchronous thyroid pathology in patients presenting with primary hyperparathyroidism

BACKGROUND

Thyroid and parathyroid pathology may coexist; classically, this is described in multiple endocrine neoplasia. Other nonsyndromic scenarios result in pathologies of these endocrine organs coexisting. This can create a challenge in the clinical decision making and management of these patients. It is optimal to deal with both problems in one operative procedure, if surgery is required.

METHODS

A retrospective review of cases of synchronous thyroid and parathyroid pathology that were managed surgically over a 3-year period by a single endocrine surgeon at a single university medical center.

RESULTS

Seventeen cases of synchronous thyroid and parathyroid disease were discovered. All required surgical management of thyroid and parathyroid conditions. Reasons included removal of thyroid goiter for access to an adenoma, worrisome thyroid lesions coexistent with a parathyroid adenoma, and an intrathyroid parathyroid adenoma. Cases of incidental discovery of a second endocrine condition while the first was evaluated will be reported.

CONCLUSIONS

A head and neck endocrine surgeon needs to be aware of the possible coexistence of thyroid and parathyroid pathologies so that, when encountered, they can be safely and efficiently managed in a single procedure.

An update from the latest workshop on asymptomatic primary hyperparathyroidism

Considerable data have accumulated since 1990 concerning the natural history of asymptomatic primary hyperparathyroidism,the extent of target organ involvement, techniques for preoperative localization of parathyroid glands, and new surgical approaches for parathyroidectomy. Therefore a Workshop on Asymptomatic Primary Hyperparathyroidism: a Perspective for the Twenty-first Century was held in April 2002 with a goal of reevaluating the conclusions from the 1990 National Institutes of Health (NIH)Consensus Development Conference. This article presents the recommendations of the workshop panel and discusses the evidence leading to the changes in the recommendations of the 1990 NIH conference.