Radioguided parathyroidectomy in patients with secondary hyperparathyroidism due to chronic renal failure

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.

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.

Intraoperative 99mTc-MIBI-Guided Parathyroidectomy Improves Curative Effect of Parathyroidectomy, Bone Metabolism, and Bone Mineral Density

This study aimed to compare the postoperative effects of total parathyroidectomy plus forearm transplantation and radioguided parathyroidectomy on bone metabolism and bone mineral density (BMD). From June 2013 to October 2017, 67 patients with renal secondary hyperparathyroidism (SHPT) received surgical treatment. The control group included 30 cases of classical total parathyroidectomy plus forearm transplantation for SHPT. In the experimental group, 37 patients underwent 99mTc-MIBI-guided parathyroidectomy. Demographics, parathyroid hormone (PTH) level, blood calcium level, and pathological results were compared between the 2 groups. The curative effect of parathyroidectomy and its effect on BMD were also compared. The BMDs in the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The T scores of the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The improvement in the T score of the L4 in the experimental group was significantly higher than that in the control group (P < .05). No significant differences in the improvement in the L1-L3 segments and femoral neck were found between the 2 groups. Both traditional total parathyroidectomy plus forearm transplantation and 99mTc-MIBI-guided parathyroidectomy can improve PTH level, blood calcium level, phosphorus level, bone metabolism, and BMD to varying degrees in patients with SHPT. Compared with the traditional surgery, 99mTc-MIBI-guided parathyroidectomy can improve blood calcium and phosphorus metabolisms, reduce PTH level, and improve the T scores of L4 to a greater extent.

Application of carbon nanoparticles in localization of parathyroid glands during total parathyroidectomy for secondary hyperparathyroidism

BACKGROUND

Intraoperative imaging is used to address the challenges of parathyroidectomy, but no standard modality has been established. This study aimed to assess whether carbon nanoparticle injection is useful in localizing parathyroid glands (PGs) during parathyroidectomy.

METHODS

Patients who underwent total parathyroidectomy (TPTX) between September 2015 and November 2018 were included. The operative duration and intact parathyroid hormones (iPTH) were analyzed.

RESULTS

A total of 61 patients were included; of these, 32 with carbon nanoparticle injection (TPTX + CN group) and 29 without (TPTX group). The operative duration in the TPTX + CN group was significantly shorter (90.6 ± 21.2 vs 101.4 ± 19.4 min, P = 0.042), which is more apparent in those with normal sized PGs. For those with four enlarged PGs, iPTH levels on 1 day and 1 year postoperatively were significantly lower in the TPTX + CN group (P = 0.032 and P = 0.036, respectively).

CONCLUSION

Carbon nanoparticles are useful in the identification normal sized PGs and complete resection of enlarged PGs.

Safety and efficacy of subtotal or total parathyroidectomy for patients with secondary or tertiary hyperparathyroidism in four academic centers in the Netherlands

Purpose

Hyperparathyroidism (HPT) is a common abnormality in patients with end-stage renal disease (ESRD). Since the introduction of cinacalcet in 2004, a shift from surgery toward predominantly medical treatment has occurred. Surgery is thought to be associated with more complications than oral medication. The aim of this retrospective study was to evaluate 30-day outcomes and effectiveness of parathyroidectomy (PTx) in ESRD patients in the Netherlands.

Methods

A national database containing data from four academic medical centers in the Netherlands of patients with ESRD-related HPT, who had undergone PTx and kidney transplantation between 1994 and 2015, was established. Primary endpoints were 30-day mortality and complication rate. Secondary endpoints were biochemical measurements.

Results

We identified 187 HPT patients undergoing PTx, with a median age of 46 years. Median preoperative PTH level was 866 pg/mL (interquartile range [IQR] 407–1547 pg/mL). At 3 months, the median PTH drop from baseline was 93% (IQR, 71–98%) to a median of 61 pg/mL (IQR, 23–148 pg/mL, p < 0.001). Over the 25-year inclusion period, 13 patients (7.0%) required re-exploration for persistent or recurrent disease. Thirty-day mortality and complication rate were 0.0% and 7.9% respectively. Median serum calcium levels improved significantly postoperatively from 2.6 (2.4–2.8) mmol/L to 2.3 (2.1–2.5) mmol/L (p < 0.001).

Conclusions

PTx is a safe and effective procedure in the frail ESRD population. These data show that there should be no reluctance for surgical intervention and when indicated, nephrologists can safely refer these patients for PTx.

Combined use of a nanocarbon suspension and 99mTc-MIBI for the intra-operative localization of the parathyroid glands

OBJECTIVE

To investigate the combined use of a nanocarbon (NC) suspension and low-dose ^99mTc-MIBI for parathyroid localization during surgery in patients with secondary hyperparathyroidism (sHPT).

METHODS

Between March 2010 and September 2015, 40 patients with sHPT were enrolled in this study and were randomized to receive either low-dose ^99mTc-MIBI+NC (group I) or low-dose ^99mTc-MIBI (group II). Pre- and post-operative serum levels of intact PTH (iPTH), calcium and phosphorus between groups were compared and the intra-operative radioactive counts of the parathyroid glands were measured.

RESULTS

The post-operative iPTH level was significantly lower in patients of group I (24.2±31ng/L) than in those of group II (106±155ng/L) (P=0.03) while there were no significant differences in intra-operative parathyroid gland radioactive counts between the groups. The duration of the surgical procedure was shorter for patients of group I than patients of group II. There were no serious intra-operative or post-operative complications.

CONCLUSION

The combined use of an NC suspension and ^99mTc-MIBI for patients with sHPT is strongly recommended for the localization of parathyroid glands during surgery and is likely to improve clinical outcomes for patients.

The utility of the radionuclide probe in parathyroidectomy for primary hyperparathyroidism

INTRODUCTION Parathyroidectomy is the definitive treatment for primary hyperparathyroidism but the intraoperative identification of adenomas is challenging. The aim of this study was to evaluate the utility of a radionuclide probe (RNP) in addition to intraoperative parathyroid hormone ( IOPTH) measurement as an intraoperative diagnostic adjunct in patients undergoing parathyroidectomy for primary hyperparathyroidism. METHODS This was a retrospective cohort study of patients treated between 2004 and 2015 in a university affiliated teaching hospital. Patients were grouped into those with RNP use (RNP+) and those without (RNP-). The primary outcome measure was rate of operative failure, which included false positives. The diagnostic sensitivity and positive predictive value of both RNP and IOPTH were also evaluated. RESULTS A total of 298 patients were included in the study, 127 (42.6%) being in the RNP+ group and 171 (57.4%) in the RNP- group. The false positive rate for the RNP+ patients was 1.6% compared with 9.4% for RNP- patients (p=0.006, hazard ratio [HR]: 6.45). The rates of operative failure were 6.3% and 11.7% respectively (p=0.159, HR: 1.97). RNP use had a sensitivity of 92.0% and a positive predictive value of 98.3% compared with 78.6% and 95.2% respectively for IOPTH monitoring. CONCLUSIONS RNP use is associated with fewer false positives and reduced operative failure than IOPTH measurement. It also has a higher sensitivity and positive predictive value. RNP use is recommended in centres that have the required facilities.

Impact of the Introduction of Calcimimetics on Timing of Parathyroidectomy in Secondary and Tertiary Hyperparathyroidism

BACKGROUND

Hyperparathyroidism (HPT), both secondary and tertiary, is common in patients with end-stage renal disease, and is associated with severe bone disorders, cardiovascular complications, and increased mortality. Since the introduction of calcimimetics in 2004, treatment of HPT has shifted from surgery to predominantly medical therapy.

OBJECTIVE

The aim of this study was to evaluate the impact of this change of management on the HPT patient population before undergoing (sub-)total parathyroidectomy (PTx).

METHODS

Overall, 119 patients with secondary or tertiary HPT undergoing PTx were included in a retrospective, single-center cohort. Group A, who underwent PTx before January 2005, was compared with group B, who underwent PTx after January 2005. Patient characteristics, time interval between HPT diagnosis and PTx, and postoperative complications were compared.

RESULTS

Group A comprised 70 (58.8 %) patients and group B comprised 49 (41.2 %) patients. The median interval between HPT diagnosis and PTx was 27 (interquartile range [IQR] 12.5-48.0) and 49 (IQR 21.0-75.0) months for group A and B, respectively (p = 0.007). Baseline characteristics were similar among both groups. The median preoperative serum parathyroid hormone (PTH) level was 936 pg/mL (IQR 600-1273) for group A versus 1091 pg/mL (IQR 482-1373) for group B (p = 0.38). PTx resulted in a dramatic PTH reduction (less than twofold the upper limit: A, 80.0 %; B, 85.4 %), and postoperative complication rates were low in both groups (A: 7.8 %; B: 10.2 %) [p = 0.66].

CONCLUSIONS

The introduction of calcimimetics in 2004 is associated with a significant 2-year delay of surgery with continuously elevated preoperative PTH levels, while parathyroid surgery, even in a fragile population, is considered a safe and effective procedure.

Surgical management of secondary hyperparathyroidism: how to effectively reduce recurrence at the time of primary surgery

BACKGROUND

Successful parathyroidectomy (PTX) often results in a dramatic drop in the parathyroid hormone (PTH) levels, relieves the patient from clinical symptoms, and reduces mortality. Although PTX is generally a successful treatment for progressive secondary hyperparathyroidism (SHPT) patients subjected to surgery, a significant proportion develops recurrent SHPT following PTX.

KEY MESSAGE

SHPT requiring PTX occurs more commonly in progressive chronic kidney disease and in long-term lithium therapy. Operative approaches include subtotal PTX, total PTX with or without autotransplantation, and possible thymectomy. Each approach has its proponents, advantages, and disadvantages. Although PTX offers the highest percentage cure for SHPT, compared to all other medical and surgical treatment, recurrent hyperparathyroidism can be observed in some patients dependent on follow-up time. A literature review and analysis of recent data regarding how to reduce recurrence of SHPT at the time of primary surgery was performed. The current literature and our own experience in the field have confirmed that pre-operative imaging, thymectomy, stereo magnifier, and surgical procedure may effectively reduce recurrence of SHPT at the time of primary surgery.

Dual-phase 99mTc-MIBI imaging findings in sporadic primary hyperplasia of parathyroid glands

Primary hyperplasia of parathyroid is uncommon and rarely documented in literatures. We report an 18-year-old female patient with hyperparathyroidism due to unifocal primary hyperplasia of parathyroid glands. Dual-phase Tc-MIBI imaging was performed for this patient. We found remarkably increased MIBI uptake in the hyperplastic lesion in early imaging and no extinction of the uptake in delayed imaging. These results suggest that the dual-phase Tc-MIBI imaging is useful in localizing the hyperfunctioning lesions of primary hyperplasia of parathyroid glands.