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Kurtom S, Carty SE. Primary Hyperparathyroidism: Part Two: Surgical Management. Surg Clin North Am 2024; 104:799-809. [PMID: 38944500 DOI: 10.1016/j.suc.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Primary hyperparathyroidism (PHPT) is caused by the overproduction of parathyroid hormone by 1 or more parathyroid glands resulting in hypercalcemia and its downstream clinical consequences. The definitive management of PHPT is surgery. Approaches to successful surgery include bilateral exploration or focused parathyroidectomy with intraoperative parathyroid hormone monitoring, which in experienced hands are both associated with a low risk of complications.
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Affiliation(s)
- Saba Kurtom
- Department of Surgical Oncology, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Suite 101, Pittsburgh, PA 15213, USA
| | - Sally E Carty
- Department of Surgical Oncology, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Suite 101, Pittsburgh, PA 15213, USA.
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Lawrence E, Johri G, Dave R, Li R, Gandhi A. A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease. Langenbecks Arch Surg 2023; 408:389. [PMID: 37806985 PMCID: PMC10560634 DOI: 10.1007/s00423-023-03087-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity. METHODS We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy. CONCLUSION Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.
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Affiliation(s)
- E Lawrence
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - G Johri
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - R Dave
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - R Li
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - A Gandhi
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, M20 4GJ, Manchester, UK.
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Buzanakov DM, Sleptsov IV, Semenov AA, Chernikov RA, Novokshonov KY, Karelina YV, Timofeeva NI, Uspenskaya AA, Makarin VA, Chinchuk IK, Fedorov EA, Gorskaya NA, Sablin IV, Malugov YN, Alekseeva SA, Gerasimova KA, Pushkaruk AA, Lyubimov MV, Rebrova DV, Shikhmagomedov SS, Dzhumatov TA, Zolotoukho AV, Bubnov AN. Persistence of primary hyperparathyroidism: a single-center experience. Langenbecks Arch Surg 2022; 407:3651-3659. [PMID: 36251078 DOI: 10.1007/s00423-022-02711-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/09/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Parathyroidectomy is the only definitive treatment for primary hyperparathyroidism (PHPT). Precise localization of abnormal glands is a key to a successful surgery. Most patients are expected to be successfully treated with focused parathyroidectomy. However, this approach is associated with a risk of existing multiglandular disease which may lead to the postoperative persistence of PHPT. METHODS Eight hundred ten patients who underwent an initial surgery for PHPT at SPBU Hospital in 2017-2018 were included in the study. Preoperative imaging results were evaluated. Multivariate logistic regressions were calculated to estimate predictive values of preoperative data for the risk of postoperative persistence and risk of MGD. RESULTS Multiglandular disease was found to be a leading cause of persistent hyperparathyroidism. An anamnesis of thyroid surgery was found to be a significant risk factor for the persistence of hyperparathyroidism. The rate of persistence did not differ significantly between groups with bilateral neck exploration and focused parathyroidectomy. Age, sex, body mass index as well as negative results of preoperative US, MIBI, and 4D CT were not independently associated with a higher risk of MGD. All preoperative imaging modalities showed from low to moderate sensitivity for the detection of MGD. The frequency of cases of a missed second adenoma did not differ significantly between patients with concordant and discordant preoperative data. There were 7 cases with previously unsuspected second adenomas found solely due to bilateral neck exploration. CONCLUSIONS None of the combination of preoperative visualization modalities was able to rule out the MGD and reliably identify patients for focused parathyroidectomy. Additional preoperative visualization failed to improve overall results. Bilateral neck exploration appeared to have a slight benefit for the patients with concordant preoperative imaging results.
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Affiliation(s)
- Dmitrii M Buzanakov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation.
| | - Ilya V Sleptsov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Arseny A Semenov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Roman A Chernikov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Konstantin Y Novokshonov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Yulia V Karelina
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Natalya I Timofeeva
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Anna A Uspenskaya
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Viktor A Makarin
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Igor K Chinchuk
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Elisey A Fedorov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Natalya A Gorskaya
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Ilya V Sablin
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Yuriy N Malugov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Svetlana A Alekseeva
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Ksenya A Gerasimova
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Alexander A Pushkaruk
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Mikhail V Lyubimov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Dina V Rebrova
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Shamil S Shikhmagomedov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
| | - Timur A Dzhumatov
- Faculty of Medicine, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Anna V Zolotoukho
- Faculty of Medicine, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Alexander N Bubnov
- Saint Petersburg State University Hospital, Saint Petersburg, Saint Petersburg, Russian Federation
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Akgün IE, Ünlü MT, Aygun N, Kostek M, Uludag M. Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy. Front Surg 2022; 9:1024350. [PMID: 36211265 PMCID: PMC9532520 DOI: 10.3389/fsurg.2022.1024350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
Background The contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients. Methods The data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2). Results There were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%–97.6% according to the 20 min intraoperative parathyroid hormone value. Conclusion The cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.
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Бузанаков ДМ, Слепцов ИВ, Семенов АА, Черников РА, Новокшонов КЮ, Карелина ЮВ, Тимофеева НИ, Яневская ЛГ, Джуматов ТА. [Role of preoperative visualization in the choice of surgery for primary hyperparathyroidism]. PROBLEMY ENDOKRINOLOGII 2022; 68:22-29. [PMID: 36689708 PMCID: PMC9939960 DOI: 10.14341/probl13096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/07/2022] [Accepted: 08/08/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Precise localization of abnormal parathyroid glands is important for a successful surgery for primary hyperparathyroidism (PHPT). While a large number of patients can be successfully treated with the focused parathyroidectomy, there is a considerable rate of the persistent PHPT mostly because of undetected multiglandular disease (MGD). AIM The aim of the study was to evaluate the meaning of preoperative visualization data for planning the surgery for patients with PHPT. MATERIALS AND METHODS The study was conducted at SPBU Hospital in 2017-2018. 810 patients who underwent a primary surgery for PHPT were included in the study. Preoperative imaging results were investigated and multivariative logistic regressions were calculated to assess the predictive values of preoperative data. The rate of cases with persistent disease and cases with MGD were compared between patients with different results of preoperative data. RESULTS Age, sex, body mass index, negative results of preoperative US, MIBI and 4D CT were not independently associated with the higher risk of multiglandular disease. The larger number of performed preoperative visualization studies were associated with the higher risk of persistence. 37% cases of MGD were not identified preoperatively. There were 7 cases with previously unsuspected second adenomas found only due to bilateral neck exploration. CONCLUSION Any combination of preoperative visualization modalities was not able to rule out the MGD reliably. Efficacy of surgical treatment was not associated with the higher number of preoperative studies. Bilateral neck exploration may decrease the rate of the persistent hyperparathyroidism improving the identification of multiglandular disease.
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Affiliation(s)
- Д. М. Бузанаков
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - И. В. Слепцов
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - А. А. Семенов
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - Р. А. Черников
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - К. Ю. Новокшонов
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - Ю. В. Карелина
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - Н. И. Тимофеева
- Клиника высоких медицинских технологий им. Н. И. Пирогова Санкт-Петербургского Государственного Университета
| | - Л. Г. Яневская
- Национальный медицинский исследовательский центр им. В.А. Алмазова
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