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Yang X, Chen X, Xu H, Chen J, Yao B, Lin Q, Deng H, Xu W. Selective venous sampling in primary hyperparathyroidism caused by ectopic parathyroid gland: a case report and literature review. BMC Endocr Disord 2023; 23:141. [PMID: 37415163 DOI: 10.1186/s12902-023-01376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 05/16/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND As an invasive technique, selective venous sampling (SVS) is considered a useful method to identify a lesion's location to increase the success rate of secondary surgery in patients with primary hyperparathyroidism (pHPT) caused by ectopic parathyroid adenomas. CASE PRESENTATION We present a case of post-surgical persistent hypercalcemia and elevated parathyroid hormone (PTH) levels in a 44-year-old woman with previously undetected parathyroid adenoma. An SVS was then performed for further localization of the adenoma, as other non-invasive methods showed negative results. After SVS, an ectopic adenoma was suspected in the sheath of the left carotid artery, previously considered as a schwannoma, and was pathologically confirmed after the second operation. Postoperatively, the patient's symptoms disappeared and serum levels of PTH and calcium normalized. CONCLUSIONS SVS can provide precise diagnosis and accurate positioning before re-operation in patients with pHPT.
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Affiliation(s)
- Xubin Yang
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Xueyan Chen
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Huan Xu
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Junwei Chen
- Department of Interventional Radiology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong Province, China
| | - Bin Yao
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China
| | - Qiongyan Lin
- Department of Endocrinology, Jieyang People's Hospital (Jieyang Affiliated Hospital, Sun Yat-Sen University), Jieyang, Guangdong, China
| | - Hongrong Deng
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China.
| | - Wen Xu
- Department of Endocrinology and Metabolic Diseases, Guangdong Provincial Key Laboratory of Diabetology, the Third Affiliated Hospital of Sun Yat-Sen University, No. 600 Tianhe Road, Guangzhou, 510630, Guangdong Province, China.
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Mi J, Fang Y, Xian J, Wang G, Guo Y, Hong H, Chi M, Li YF, He P, Gao J, Liao W. Comparative Effectiveness of MRI, 4D-CT and Ultrasonography in Patients with Secondary Hyperparathyroidism. Ther Clin Risk Manag 2023; 19:369-381. [PMID: 37159605 PMCID: PMC10163888 DOI: 10.2147/tcrm.s379814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 02/13/2023] [Indexed: 05/11/2023] Open
Abstract
Objective Accurate preoperative localization of abnormal parathyroid glands is crucial for successful surgical management of secondary hyperparathyroidism (SHPT). This study was conducted to compare the effectiveness of preoperative MRI, 4D-CT, and ultrasonography (US) in localizing parathyroid lesions in patients with SHPT. Methods We performed a retrospective review of prospectively collected data from a tertiary-care hospital and identified 52 patients who received preoperative MRI and/or 4D-CT and/or US and/or 99mTc-MIBI and subsequently underwent surgery for SHPT between May 2013 and March 2020. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each imaging modality to accurately detect enlarged parathyroid glands were determined using histopathology as the criterion standard with confirmation using the postoperative biochemical response. Results A total of 198 lesions were identified intraoperatively among the 52 patients included in this investigation. MRI outperformed 4D-CT and US in terms of sensitivity (P < 0.01), specificity (P = 0.455), PPV (P = 0.753), and NPV (P = 0.185). The sensitivity and specificity for MRI, 4D-CT, and US were 90.91%, 88.95%, and 66.23% and 58.33%, 63.64%, and 50.00%, respectively. The PPV of combined MRI and 4D-CT (96.52%) was the highest among the combined 2 modalities. The smallest diameter of the parathyroid gland precisely localized by MRI was 8×3 mm, 5×5 mm by 4D-CT, and 5×3 mm by US. Conclusion MRI has superior diagnostic performance compared with other modalities as a first-line imaging study for patients undergoing renal hyperparathyroidism, especially for ectopic or small parathyroid lesions. We suggest performing US first for diagnosis and then MRI to make a precise localization, and MRI proved to be very helpful in achieving a high success rate in the surgical treatment of renal hyperparathyroidism in our own experience.
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Affiliation(s)
- Jiaoping Mi
- Department of Otolaryngology Head and Neck Surgery, The First Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yijie Fang
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Jianzhong Xian
- Department of Ultrasound, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Guojie Wang
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yuanqing Guo
- Department of Spinal Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Haiyu Hong
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Mengshi Chi
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Yong-Fang Li
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Peng He
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
| | - Jiebing Gao
- Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Jiebing Gao, Department of Radiology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China, Email
| | - Wei Liao
- Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, People’s Republic of China
- Correspondence: Wei Liao, Department of Otolaryngology Head and Neck Surgery, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong, 519020, People’s Republic of China, Email
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Lee SW, Shim SR, Jeong SY, Kim SJ. Direct Comparison of Preoperative Imaging Modalities for Localization of Primary Hyperparathyroidism: A Systematic Review and Network Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:692-706. [PMID: 34081083 DOI: 10.1001/jamaoto.2021.0915] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Accurate preoperative localization of primary hyperparathyroidism (pHPT) is an important and challenging issue for a successful parathyroidectomy. Although new imaging modalities have been introduced during the past decade, direct comparative studies on advanced imaging techniques are limited. Objective To compare the performance of different preoperative imaging modalities for the localization of pHPT by performing a network meta-analysis (NMA). Data Sources PubMed, Embase, and the Cochrane Library were searched from the earliest available indexing date through September 28, 2020. Study Selection The inclusion criteria were diagnostic tests with sensitivities of 2 or more different preoperative imaging modalities for the same indivduals. Data Extraction and Synthesis Two researchers independently reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension statement of health care intervention guidelines for network meta-analyses. Main Outcomes and Measures After classifying various imaging modalities into 8 representative imaging categories, the pooled estimation between the odds ratio and 95% credible intervals (CrIs) was calculated in the sensitivity for localization of pHPT. The surface under the cumulative ranking curve (SUCRA) values were obtained to calculate the probability of each imaging modality being the most effective diagnostic method. Results A total of 8495 patients from 119 direct comparative studies using 2 or more imaging modalities for localization of pHPT were included. The sensitivity of choline positron emission tomography and computed tomography (PET-CT) was significantly higher than that of technetium 99m sestamibi single-photon emission computed tomography (MIBI SPECT) in both patient-based and lesion-based analyses (patient-based analysis: odds ratio, 5.22; 95% CrI, 2.36-11.80; lesion-based analysis: odds ratio, 17.70; 95% CrI, 5.79-60.10). Among 8 representative imaging modality categories, choline PET-CT showed the highest SUCRA value in both patient-based and lesion-based analyses. In patient-based analysis after 2010, choline PET-CT showed the highest SUCRA value, followed by the CT category, although MIBI SPECT had the highest SUCRA value in analysis before 2009. Conclusions and Relevance The results from this network meta-analysis suggest that choline PET-CT showed the best performance in both patient-based and lesion-based analyses and that choline PET-CT would be the best preoperative imaging modality for localization of pHPT.
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Affiliation(s)
- Sang-Woo Lee
- Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu, South Korea
| | - Sung Ryul Shim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Shin Young Jeong
- Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu, South Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea.,Department of Nuclear Medicine, College of Medicine, Pusan National University, Yangsan, South Korea.,BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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Lee J, Hong N, Kim BM, Kim DJ, Yun M, Jeong JJ, Rhee Y. Evaluation of an optimal cutoff of parathyroid venous sampling gradient for localizing primary hyperparathyroidism. J Bone Miner Metab 2020; 38:570-580. [PMID: 32100109 DOI: 10.1007/s00774-020-01085-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 01/17/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Parathyroid venous sampling (PVS) has been reported to be a useful adjunctive test in localizing lesions in elusive cases of primary hyperparathyroidism (PHPT). Conventional cutoff (twofold) is now widely being used, but optimal cutoff threshold for PVS gradient based on discriminatory performance remains unclear. MATERIALS AND METHODS Among a total of 197 consecutive patients (mean age 58.2 years, female 74.6%) with PHPT who underwent parathyroidectomy at a tertiary center between 2012 and 2018, we retrospectively analyzed 59 subjects who underwent PVS for persistent or recurrent disease after previous parathyroidectomy, or for equivocal or negative results from conventional imaging modalities including ultrasonography (US) and Tc99m-Sestamibi SPECT-CT (MIBI). True parathyroid lesions were confirmed by combination of surgical, pathological findings, and intraoperative parathyroid hormone (PTH) changes. Optimal PVS cutoff were determined by receiver-operating characteristics (ROC) analysis with Youden and Liu method. RESULTS Compared to subjects who did not require PVS, PVS group tends to have lower PTH (119.8 pg/mL vs 133.7 pg/mL, p = 0.075). A total of 79 culprit parathyroid lesions (left 40; right 39) from 59 patients (left 24; right 26; bilateral 9) were confirmed by surgery. The optimal cutoff for PVS gradient was estimated as 1.5-fold gradient (1.5 ×) with sensitivity of 61.8% and specificity of 84%. When 1.5 × cutoff was applied, PVS improved the discrimination for true parathyroid lesions substantially based on area under ROC (0.892 to 0.942, p < 0.001) when added to US and MIBI. CONCLUSION Our findings suggest that PVS with cutoff threshold 1.5 × can provide useful complementary information for pre-operative localization in selected cases.
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Affiliation(s)
- Jooyeon Lee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Joon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Mijin Yun
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jong Ju Jeong
- Department of Surgery, Thyroid Cancer Clinic, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Severance Hospital, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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Ginsburg M, Christoforidis GA, Zivin SP, Obara P, Wroblewski K, Angelos P, Grogan RH, Kaplan EL. Adenoma Localization for Recurrent or Persistent Primary Hyperparathyroidism Using Dynamic Four-Dimensional CT and Venous Sampling. J Vasc Interv Radiol 2015; 26:79-86. [DOI: 10.1016/j.jvir.2014.09.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/17/2014] [Accepted: 09/27/2014] [Indexed: 11/16/2022] Open
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Karakas E, Müller HH, Schlosshauer T, Rothmund M, Bartsch DK. Reoperations for primary hyperparathyroidism--improvement of outcome over two decades. Langenbecks Arch Surg 2012; 398:99-106. [PMID: 23001050 DOI: 10.1007/s00423-012-1004-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Accepted: 09/10/2012] [Indexed: 11/30/2022]
Abstract
PURPOSE Reoperations (R-PTX) for primary hyperparathyroidism (pHPT) are challenging, since they are associated with increased failure and morbidity rates. The aim was to evaluate the results of reoperations over two decades, the latter considering the implementation of Tc(99m)sestamibi-SPECT (Mibi/SPECT), intraoperative parathormone (IOPTH) measurement, and intraoperative neuromonitoring (IONM). PATIENTS AND METHODS Data of 1,363 patients who underwent surgery for pHPT were retrospectively analyzed regarding reoperations. Causes of persistent (p) pHPT or recurrent (r) pHPT, preoperative imaging studies, surgical findings, and outcome were analyzed. Data of patients who underwent surgery between 1987 and 1997 (group 1; G1) and between 1998 and 2008 (group 2; G2) with the use of Mibi/SPECT, IOPTH, and IONM were evaluated. RESULTS One hundred twenty-five patients with benign ppHPT (n = 108) or rpHPT (n = 17) underwent reoperations (R-PTX). Group 1 included 54, group 2 71 patients. Main cause of ppHPT (G1 = 65 % vs. G2 = 53 %) and rpHPT (G1 = 80 % vs. G2 = 60 %) was the failed detection of a solitary adenoma (p = 0.2). Group 1 patients had significantly less unilateral/focused neck re-explorations (G1 = 23 % vs. G2 = 57 %, p = 0.0001), and more sternotomies (G1 = 35 vs. G2 = 14 %, p = 0.01). After a median follow-up of 4 (range 0.9-23.4) years, reversal of hypercalcemia was achieved in 91 % (G1) and in 98.6 % in group 2 (p = 0.08, OR 7.14 [0.809-63.1]). The rates of permanent recurrent laryngeal nerve palsy (G1 = G2 = 9 %, p = 1) and of postoperative permanent hypoparathyroidism (G1 = 9 % vs. G2 = 6 %, p = 0.5) were not significantly different. Other complications such as wound infection, postoperative bleeding, and pneumonia were significantly lower in group 2 (p < 0.001). CONCLUSION Nowadays, cure rates of R-PTX are nearly the same as in primary operations for pHPT. These results can be achieved in high-volume centers by routine use of well-established preoperative Mibi/SPECT and US in combination with IOPTH. However, morbidity is still considerably high.
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Affiliation(s)
- Elias Karakas
- Department of Visceral-, Thoracic and Vascular Surgery, Philipps-University Marburg, Baldingerstraße, 35043 Marburg, Germany.
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Prieto Tenreiro AM, García López JM, García Vázquez M, Puñal Rodríguez JA, Casanueva FF. [The value of selective parathyroid venous sampling for localizing occult parathyroid adenomas]. ENDOCRINOLOGIA Y NUTRICION : ORGANO DE LA SOCIEDAD ESPANOLA DE ENDOCRINOLOGIA Y NUTRICION 2012; 59:73-76. [PMID: 21763221 DOI: 10.1016/j.endonu.2011.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2010] [Revised: 04/26/2011] [Accepted: 05/01/2011] [Indexed: 05/31/2023]
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Grayev AM, Gentry LR, Hartman MJ, Chen H, Perlman SB, Reeder SB. Presurgical Localization of Parathyroid Adenomas with Magnetic Resonance Imaging at 3.0 T: An Adjunct Method to Supplement Traditional Imaging. Ann Surg Oncol 2011; 19:981-9. [DOI: 10.1245/s10434-011-2046-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2011] [Indexed: 11/18/2022]
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Witteveen JE, Kievit J, Stokkel MPM, Morreau H, Romijn JA, Hamdy NAT. Limitations of Tc99m-MIBI-SPECT imaging scans in persistent primary hyperparathyroidism. World J Surg 2011; 35:128-39. [PMID: 20957360 PMCID: PMC3006642 DOI: 10.1007/s00268-010-0818-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background In primary hyperparathyroidism (PHPT) the predictive value of technetium 99m sestamibi single emission computed tomography (Tc99m-MIBI-SPECT) for localizing pathological parathyroid glands before a first parathyroidectomy (PTx) is 83–100%. Data are scarce in patients undergoing reoperative parathyroidectomy for persistent hyperparathyroidism. The aim of the present study was to determine the value of Tc99m-MIBI-SPECT in localizing residual hyperactive parathyroid tissue in patients with persistent primary hyperparathyroidism (PHPT) after initial excision of one or more pathological glands. Method We retrospectively evaluated the localizing accuracy of Tc99m-MIBI-SPECT scans in 19 consecutive patients with persistent PHPT who had a scan before reoperative parathyroidectomy. We used as controls 23 patients with sporadic PHPT who had a scan before initial surgery. Results In patients with persistent PHPT, Tc99m-MIBI-SPECT accurately localized a pathological parathyroid gland in 33% of cases before reoperative parathyroidectomy, compared to 61% before first PTx for sporadic PHPT. The Tc99m-MIBI-SPECT scan accurately localized intra-thyroidal glands in 2 of 7 cases and a mediastinal gland in 1 of 3 cases either before initial or reoperative parathyroidectomy. Conclusions Our data suggest that the accuracy of Tc99m-MIBI-SPECT in localizing residual hyperactive glands is significantly lower before reoperative parathyroidectomy for persistent PHPT than before initial surgery for sporadic PHPT. These findings should be taken in consideration in the preoperative workup of patients with persistent primary hyperparathyroidism.
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Affiliation(s)
- Janneke E Witteveen
- Department of Endocrinology & Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Witteveen JE, Kievit J, van Erkel AR, Morreau H, Romijn JA, Hamdy NAT. The role of selective venous sampling in the management of persistent hyperparathyroidism revisited. Eur J Endocrinol 2010; 163:945-52. [PMID: 20870706 DOI: 10.1530/eje-10-0654] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Localization studies are mandatory prior to revision surgery in patients with persistent hyperparathyroidism in order to improve surgical outcome and reduce the risk of lengthy explorations. However, in this case, noninvasive localization studies are reported to have a poor sensitivity. The aim of our study is to determine the accuracy of selective venous sampling (SVS) for parathyroid hormone (PTH) in localizing residual hyperactive parathyroid glands in patients with persistent or recurrent hyperparathyroidism. PATIENTS AND METHODS We retrospectively evaluated the localizing accuracy of 20 PTH SVS performed prior to revision surgery in 18 patients with persistent or recurrent primary hyperparathyroidism (n=11) or autonomous (tertiary) hyperparathyroidism (n=7). Tc99m-methoxy-isobutyle-isonitrile (MIBI)-single photon emission computed tomography (SPECT) was also performed in all patients prior to revision surgery. Operative and pathological data were obtained from hospital records. RESULTS The SVS was able to accurately localize 15 of the 20 pathological glands removed at revision surgery, representing a sensitivity of 75%. This sensitivity is significantly higher than that of Tc99m-MIBI-SPECT, which was only 30% (P=0.012). CONCLUSION Our findings demonstrate that SVS is a valuable localization study in patients with persistent or recurrent hyperparathyroidism, with a sensitivity significantly higher than that of Tc99m-MIBI-SPECT. Our data suggest that SVS represents a useful addition to the preoperative workup of these patients prior to revision surgery.
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Affiliation(s)
- Janneke E Witteveen
- Department of Endocrinology and Metabolic Diseases, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Rubello D, Gross MD, Mariani G, AL-Nahhas A. Scintigraphic techniques in primary hyperparathyroidism: from pre-operative localisation to intra-operative imaging. Eur J Nucl Med Mol Imaging 2007; 34:926-33. [PMID: 17351774 DOI: 10.1007/s00259-007-0388-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2006] [Accepted: 01/19/2007] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is an increasingly diagnosed disease worldwide. In most cases, PHPT is related to the presence of a solitary parathyroid adenoma (PA). Fifty percent or more of newly diagnosed PHPT patients are asymptomatic, and there is debate among endocrinologists and endocrine surgeons about whether or not such patients should be treated. LOCALIZATION Usually, in a PHPT patient with a solitary PA that is well localised pre-operatively, a parathyroidectomy with limited or minimally invasive neck exploration is offered. The diffusion of minimally invasive neck exploration procedures is a consequence of the significant improvement in the accuracy of pre-operative imaging (mainly scintigraphic) techniques; these techniques have changed the surgical strategy to PHPT, from the wide traditional bilateral neck exploration to limited neck exploration. REVIEW The present review considers developments during the past 10-15 years with regard to both the accuracy of pre-operative localising imaging techniques and intra-operative minimally invasive procedures in order to provide endocrinologists and endocrine surgeons with further information about the newly available diagnostic and therapeutic tools for use in PHPT patients with a solitary PA.
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Affiliation(s)
- Domenico Rubello
- Service of Nuclear Medicine, S. Maria della Misericordia Hospital, Viale Tre Martiti, 140, 45100, Rovigo, and Regional Center of Nuclear Medicine, University of Pisa, Italy.
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Maser C, Donovan P, Santos F, Donabedian R, Rinder C, Scoutt L, Udelsman R. Sonographically Guided Fine Needle Aspiration with Rapid Parathyroid Hormone Assay. Ann Surg Oncol 2006; 13:1690-5. [PMID: 17009140 DOI: 10.1245/s10434-006-9180-z] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2006] [Revised: 05/23/2006] [Accepted: 05/23/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Persistent or recurrent primary hyperparathyroidism (1 degrees HPTH) is ideally treated with limited dissection, based on accurate localization, to minimize operative risks. To accurately localize parathyroid tissue, we employed ultrasound-guided fine needle aspiration (US FNA) with an on-site rapid parathyroid hormone (PTH) assay to confirm localization. METHODS Of the 272 patients evaluated for 1 degrees HPTH, 34 had persistent or recurrent disease. Standard localization was equivocal in 12, who were referred for US FNA. Suspicious tissue was identified on US and FNA was performed. Analysis with a rapid PTH assay provided on-site result within 12 min. Patients were monitored clinically, and then discharged after observation. RESULTS Twelve patients were referred for US FNA; eight were female. Ten patients had persistent disease, one had recurrent, and one had 1 degrees HPTH following thyroidectomy. Two of the 12 were excluded due to negative ultrasound examination. Of the remaining ten, positive aspirates were found in nine, and seven proceeded to surgery. In six patients there was 100% correlation between sonographic and operative findings. The remaining patient had no identifiable adenoma, but PTH normalized after arterial ligation. All patients received a limited directed surgical approach, employing cervical block anesthesia in three. Four were discharged on the day of surgery and all were cured. There was one infectious complication of US FNA. CONCLUSIONS The use of rapid PTH assay can be effectively utilized for localization of parathyroid tissue in remedial parathyroid surgery. Confirmation of localization markedly improves subsequent surgery and allows selective use of minimally invasive techniques.
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Affiliation(s)
- Christina Maser
- Department of Surgery, Yale New Haven Hospital, Yale University School of Medicine, 330 Cedar Street, FMB 102, P.O. Box 208062, New Haven, CT 06520-8062, USA
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Saeed S, Yao M, Philip B, Blend M. Localizing hyperfunctioning parathyroid tissue: MRI or nuclear study or both? Clin Imaging 2006; 30:257-65. [PMID: 16814142 DOI: 10.1016/j.clinimag.2006.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Accepted: 02/16/2006] [Indexed: 10/24/2022]
Abstract
The surgical approach to primary hyperparathyroidism patients has changed recently with minimally invasive surgery becoming more common. This retrospective study reviews the relative sensitivities of dual-phase sestamibi (DP-SI) and magnetic resonance imaging (MRI) in preoperative patients. We found that MRI was more sensitive, but the difference was not statistically significant. Magnetic resonance imaging enhanced the ability to localize abnormal tissues when the DP-SI was negative. Together, both tests demonstrated a sensitivity of 92%. We recommend performing DP-SI initially, and if negative, MRI. This should provide the highest imaging sensitivity at the lowest cost.
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Affiliation(s)
- Shabana Saeed
- Department of Radiology, Section of Nuclear Medicine, University of Illinois at Chicago, 1740 West Taylor Street, 60612, USA
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Abstract
While the initial treatment for primary hyperparathyroidism (pHPT), if managed by an experienced surgeon, is almost always successful, reoperations are challenging. Patients are at high risk for complications and the rates of success are plainly below those of primary cervical explorations. In this paper the reasons for failure during initial procedures are reviewed, as are the most important localization procedures and the prerequisites with regard to technical infrastructure as well as personnel, when planning repeat operations for a missed parathyroid adenoma. Provided that a standardized diagnostic and surgical approach is used, the surgeon is experienced, and up-to-date technical equipment is available, permanent normocalcemia following reoperations in pHPT is more frequently achieved than it used to be. The best option to avoid reoperations and associated complications is a successful initial intervention by an experienced surgeon. However, reoperations should always be performed by an experienced surgeon.
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Affiliation(s)
- E Karakas
- Klinik für Visceral-, Thorax- und Gefässchirurgie, Philipps-Universität Marburg.
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15
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Chaffanjon PCJ, Voirin D, Vasdev A, Chabre O, Kenyon NM, Brichon PY. Selective Venous Sampling in Recurrent and Persistent Hyperparathyroidism: Indication, Technique, and Results. World J Surg 2004; 28:958-61. [PMID: 15573246 DOI: 10.1007/s00268-004-7449-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Between 1992 and 2002, 542 patients underwent a surgical treatment for hyperparathyroidism in our department. Twenty-three selective venous sampling procedures (SVS) were performed because of the failure of the other methods of diagnosis. These patients have recurrent or persistent hyperparathyroidism. Noninvasive methods of topographical diagnosis have failed or they have given contradictory results. In our experience, the surgeon needs a precise localization of the pathological glands in these difficult cases. In our series of SVS, specificity was 85.7% and sensitivity was 94.7%. Our results show that a high postoperative gradient of parathyroid hormone in the internal thoracic veins indicates an ectopic pathological gland in the thymus. A high gradient in a vertebral vein indicates a pathological superior parathyroid gland, usually in a retro-esophageal position.
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Affiliation(s)
- Philippe C J Chaffanjon
- Service de Chirurgie Générale et Thoracique, CHU de Grenoble, BP217, 38043, Grenoble Cedex 09, France.
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Carter AB, Howanitz PJ. Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature. Arch Pathol Lab Med 2003; 127:1424-42. [PMID: 14567726 DOI: 10.5858/2003-127-1424-itfpha] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The rapid intraoperative parathyroid hormone assay is transforming the parathyroidectomy procedure. We present a review of the literature on the use of the assay as an adjunct to surgery. To our knowledge, this is the first review of the literature to encompass and compare all known primary studies of this assay in parathyroidectomy patients. DATA SOURCES Articles were collected by searching MEDLINE databases using relevant terminology. The references of these articles were reviewed for additional studies. Supplementary articles pertinent to the parathyroidectomy procedure, preoperative parathyroid localization studies, and intraoperative parathyroid hormone assay development also were examined. STUDY SELECTION AND DATA EXTRACTION One hundred sixty-five references were analyzed and categorized separately into groups. DATA SYNTHESIS The primary studies of intraoperative data on patients undergoing parathyroidectomy were compared when possible. Studies were analyzed by type of assay used, where performed, turnaround time, and efficiency of use. Reviews of the types of parathyroid surgery and preoperative localization were included for educational purposes.Conclusions.-The intraoperative parathyroid hormone assay is a useful adjunct to preoperative imaging and parathyroid surgery because of its unique ability to detect an occult residuum of hyperfunctioning parathyroid tissue. Use of this assay will obviate the need for frozen section in most routine cases. The test facilitates minimally invasive parathyroidectomy for single parathyroid adenomas, which, in turn, improves cost-effectiveness and cosmetic outcome. Its use in patients with known preoperative multiglandular disease is promising but requires further study.
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Affiliation(s)
- Alexis Byrne Carter
- Department of Pathology & Laboratory Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, USA.
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Estella E, Leong MSZ, Bennett I, Hartley L, Wetzig N, Archibald CA, Harper JS, Cuneo RC. Parathyroid hormone venous sampling prior to reoperation forprimary hyperparathyroidism. ANZ J Surg 2003; 73:800-5. [PMID: 14525570 DOI: 10.1046/j.1445-2197.2003.02678.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The surgical cure rate for primary hyperparathyroidismis greater than 95%. For those who have recurrent or persistent disease, preoperative localization improves reoperation success rates. Selective parathyroid venous sampling (SPVS) for intact parathyroid hormone is particularly useful when non-invasive localization techniques are negative or inconclusive. METHODS We present all known cases (n = 13)between 1994 and 2002 who had venous sampling for localization a tour institution prior to reoperation for recurrent or persistent primary hyperparathyroidism. Comparison was made with non-invasive localization procedures. Results of invasive and non-invasive localization were correlated with surgical findings. RESULTS Of the nine reoperated cases, eight had positive correlations between SPVS and operative findings and histopathology. SPVS did not reveal the parathyroid hormone source in one case with negative non-invasive localization procedures. Comparisons between SPVS,computerized tomography (CT), and parathyroid scintigraphy (MIBI)as expressed in terms of true positive (TP), false positive (FP)and false negative (FN) were: SPVS - TP88.8%, FP 0%, FN 11.1%; CT - TP22.2%, FP 22.2%, FN 55.5%; and MIBI - TP33.3%, FP 0%, FN 66.6%. At least seven of the nine operated cases have been cured; another remained normocalcaemic 2 weeks after subtotal parathyroidectomy. CONCLUSION In our institution SPVS has proven to be a valuable tool in cases with recurrent or persistent primary hyperparathyroidism and negative non-invasive localization procedures.
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Affiliation(s)
- E Estella
- Department of Diabetes and Endocrinology, University of Queensland,The Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.
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Griffiths PA, Marshall C. The importance of audit in diagnostic imaging. J Eval Clin Pract 2002; 8:421-4. [PMID: 12421392 DOI: 10.1046/j.1365-2753.2002.00308.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- P A Griffiths
- Medical Physics Department, County Hospital, Lincoln, UK
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Scheiner JD, Dupuy DE, Monchik JM, Noto RB, Cronan JJ. Pre-operative localization of parathyroid adenomas: a comparison of power and colour Doppler ultrasonography with nuclear medicine scintigraphy. Clin Radiol 2001; 56:984-8. [PMID: 11795928 DOI: 10.1053/crad.2001.0793] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIM To compare power and colour Doppler ultrasonography (US) with nuclear medicine scintigraphy (NM) in the preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism (PHPT). MATERIALS AND METHODS Thirty-one patients with biochemical evidence of PHPT underwent pre-operative US and NM for parathyroid adenoma localization. Both studies were interpreted independently without prior knowledge of the other study's findings. All patients had surgical removal of the parathyroid adenoma utilizing standard neck exploration or minimally invasive unilateral surgical techniques with rapid serum assay of circulating parathyroid hormone levels. RESULTS All patients had single parathyroid adenomas at surgery. Prospective sensitivities for US, NM and both studies combined were 65%, 68%, and 74%, respectively, with a positive predictive value of 100% each. The adenoma was localized by only one imaging modality in 16% of cases. CONCLUSIONS US and NM provide complementary roles in the pre-operative localization of parathyroid adenomas in patients with PHPT.
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Affiliation(s)
- J D Scheiner
- Department of Diagnostic Imaging, Brown University School of Medicine, Rhode Island Hospital, Providence, Rhode Island 02903, USA.
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Gotway MB, Reddy GP, Webb WR, Morita ET, Clark OH, Higgins CB. Comparison between MR imaging and 99mTc MIBI scintigraphy in the evaluation of recurrent of persistent hyperparathyroidism. Radiology 2001; 218:783-90. [PMID: 11230657 DOI: 10.1148/radiology.218.3.r01fe38783] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To compare the sensitivity and positive predictive value of magnetic resonance (MR) imaging and technetium 99m 2-methoxyisobutyl-isonitrile (MIBI) scintigraphy for the detection of hyperfunctioning parathyroid tissue when used alone and in combination in a large patient population with recurrent or persistent hyperparathyroidism (HPT). MATERIALS AND METHODS In 98 consecutive patients with biochemically proved recurrent or persistent HPT after surgery, MR imaging and 99mTc MIBI study findings were retrospectively reviewed and compared with surgical and histopathologic findings. The sensitivity and positive predictive value of MR imaging and 99mTc MIBI scintigraphy were compared with each other and in combination. RESULTS In these patients, 130 abnormal parathyroid glands were identified at surgery. The sensitivity and positive predictive value of MR imaging were 82% (95% CI: 75%, 89%) and 89%, respectively; those for (99m)Tc MIBI scintigraphy were 85% (95% CI: 79%, 91%) and 89%. No significant difference was found between MR imaging and 99mTc MIBI scintigraphy for sensitivity (P =.7). The sensitivity and positive predictive value for the detection of abnormal parathyroid tissue on a per-gland basis increased to 94% (95% CI: 90%, 98%) and 98%, respectively, when only one of the two tests was required to be positive. CONCLUSION MR imaging and 99mTc MIBI scintigraphy have similarly good sensitivity and positive predictive value for the detection of hyperfunctioning parathyroid tissue in patients after surgery. The combination of the two tests provided a substantial increase in sensitivity and positive predictive value.
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Affiliation(s)
- M B Gotway
- Thoracic Imaging Section, Department of Radiology, University of California, San Francisco General Hospital, 1001 Potrero Ave, Rm 1X 55A, Box 1325, San Francisco, CA 94110, USA.
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Abstract
BACKGROUND New radionuclide agents and scanning procedures have markedly improved preoperative parathyroid gland localization. The aim of this review was to evaluate the results of parathyroid scanning and to clarify its current place in the clinical management of parathyroid diseases. METHODS The literature describing the different radioisotopes and available scanning techniques was analysed and their clinical outcome in various parathyroid diseases was evaluated. RESULTS Using 99mTc-radiolabelled sestamibi or other 9mTc-labelled cationic complexes, parathyroid scintigraphy detects 87 per cent of solitary adenomas (n=894), 55 per cent of abnormal glands in patients with multiglandular disease (n=303) and 75 per cent of persistent or recurrent lesions in patients with previous neck surgery (n=240). If necessary, three-dimensional imaging techniques can clarify the spatial localization of an ectopic uptake focus. The positive predictive value of the available scanning procedures is over 95 per cent, but false-positive uptake may be encountered. CONCLUSION Radionuclide parathyroid gland scanning with 99mTc-labelled cationic complexes is the initial non-invasive method of choice for preoperative parathyroid gland localization in patients at special risk and/or with previous neck exploration. While scanning has also been proposed to facilitate parathyroidectomy, there is no objective evidence to support its routine use before a first-time surgical procedure.
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Affiliation(s)
- F Pattou
- Department of General and Endocrine Surgery, University Hospital, Lille, France
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Robinson P. Technetium-99m sestamibi scintigraphy, MRI and venous blood sampling in persistent and recurrent hyperparathyroidism. Br J Radiol 1998; 71:108-9. [PMID: 9534711 DOI: 10.1259/bjr.71.841.9534711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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