Preoperative Imaging for Parathyroid Localization in Primary Hyperparathyroidism

Background : We retrospectively studied the results of diagnostic imaging using 3 different modalities to determine their usefulness for preoperative localization of the parathyroid, and whether accurate preoperative localization information could be used to modify the surgical approach for parathyroidectomy in patients with primary hyperparathyroidism.
Methods : Images of 37 parathyroid adenomas or hyperplasias in 35 patients with primary hyperparathyroidism were obtained using ultrasonography, computed tomography, and subtraction scintigraphy (using thallium 201 [thallous chloride] and either iodine 123 or technetium 99m pertechnetate [^99mTcO₄]).
Results : Approximately three fourths of the adenomas or hyperplasias were successfully identified by ultrasound (76.7%) and computed tomography (76.4%), even when the weight of the tumor was less than 500 mg. However, subtraction scintigraphy was of limited use (61.3% successfully identified). A combination of these modalities gave excellent results for detecting adenomas and hyperplasias, leading to an accurate prediction rate of 96.0%.
Conclusion : We conclude that using the combination of these 3 imaging modalities is very useful for the detection of parathyroid adenomas and hyperplasias, and that with such accurate localization information, the unilateral approach alone, or even simple excision of the parathyroid tumors might be feasible, enabling less invasive surgical treatment.     

Surgeon-Performed Ultrasound for Preoperative Localization of Abnormal Parathyroid Glands in Patients with Primary Hyperparathyroidism

Background The introduction of portable ultrasound equipment enables surgeons to perform ultrasound examinations in a clinic setting. This study was undertaken to evaluate surgeon-performed ultrasound (SP-US) in patients with primary hyperparathyroidism (PHPT). Methods Between July 2003 and March 2004, 65 patients with PHPT were evaluated with SP-US and 48 of these patients underwent parathyroid surgery. Among this group of 48 evaluable patients, 47 had preoperative imaging with technetium-99m sestamibi scanning (MIBI), and 12 had an additional ultrasound examination at an external radiology department (RP-US). Results All patients were cured of PHPT and the operative findings were used to determine the true status of the parathyroid glands of each patient. Twenty-four (50%) patients had concomitant thyroid nodules which were identified by SP-US, and 4 (8.3%) patients had simultaneous thyroid operations, 2 of which were for thyroid cancer. Considering data for all patients, SP-US had significantly higher sensitivity than MIBI or RP-US (60% vs. 46%, P = 0.013, and 60% vs. 11%, P = 0.004 respectively). Among the patients with a single adenoma, SP-US, MIBI, and RP-US had sensitivities of 83%, 63%, and 13% respectively. The specificities of all three imaging techniques were uniformly high and were not significantly different from each other. Conclusions Surgeon-performed ultrasound is an accurate modality for localizing abnormal parathyroid glands in patients with PHPT, with results that compare favorably with other parathyroid imaging modalities.     

18F-Fluorocholine PET/CT and Parathyroid 4D Computed Tomography for Primary Hyperparathyroidism: The Challenge of Reoperative Patients

World Journal of Surgery - To evaluate FCH-PET/CT and parathyroid 4D-CT so as to guide surgery in patients with primary hyperparathyroidism (pHPT) and prior neck surgery. Medical records of all...     

Initial Parathyroid Surgery in 606 Patients with Renal Hyperparathyroidism

Background  

The aim of the present study was to evaluate the outcome of different surgical procedures for patients on permanent dialysis who underwent initial parathyroidectomy for renal hyperparathyroidism (rHPT).     

Intraoperative Parathyroid Hormone Monitoring in Patients with Recognized Multiglandular Primary Hyperparathyroidism

Background  

Intraoperative parathyroid hormone (IOPTH) monitoring reliably predicts cure of primary hyperparathyroidism (PHPT) due to single-gland disease. However, its utility in PHPT caused by multiple-gland disease (MGD) is still debated, for both detection and prediction of adequate resection. Our hypothesis is that once MGD is encountered during an operation, more stringent criteria for determining adequate resection can improve cure rates.     

A Meta-analysis of Preoperative Localization Techniques for Patients with Primary Hyperparathyroidism

Background  

Reported accuracy of preoperative localization imaging for primary hyperparathyroidism (pHPT) varies. The purpose of this study is to determine the accuracy of ultrasound, sestamibi-single photon emission computed tomography (SPECT), and four-dimensional computed tomography (4D-CT) as preoperative localization strategies.     

25-Hydroxyvitamin D Status Does Not Affect Intraoperative Parathyroid Hormone Dynamics in Patients with Primary Hyperparathyroidism

Background  

Deficiency of 25-hydroxyvitamin D (25OHD) is a stimulus for the secretion of parathyroid hormone (PTH). During surgery for primary hyperparathyroidism, 25OHD deficiency may artificially elevate PTH, decreasing the sensitivity of intraoperative PTH (ioPTH) measurements.     

Inframanubrial Parathyroid Glands in Patients with Primary Hyperparathyroidism: Alternatives to Sternotomy

Deep inframanubrial parathyroid tumors have traditionally been excised through a median sternotomy. With the advent of minimally invasive surgical access, we chose to examine the treatment options and outcomes of patients with inframanubrial mediastinal parathyroid tumors. Patients with primary hyperparathyroidism seen at a university medical center over a 12-year period were retrospectively reviewed. The utility of localization studies, methods of treatment, complications, and outcomes were examined in patients with a parathyroid tumor located in the mediastinum inferior to the manubrium. Patients with parathyroid adenomas located at the thoracic inlet were excluded. Sixteen patients with inframanubrial mediastinal tumors were treated during the study period. Altogether, 81% of the patients had undergone at least one prior neck exploration for primary hyperparathyroidism. Preoperative calcium and parathyroid hormone levels were 12.4 ± 0.36 mg/dl and 273 ± 70 pg/ml, respectively. Localization studies identified mediastinal parathyroid adenomas in the following locations: anterior mediastinum (n = 8), middle mediastinum (n = 7), posterior mediastinum (n = 1). Mediastinal computed tomography and technetium-sestamibi scans demonstrated the best sensitivity, 92% and 85%, respectively. Seven patients underwent successful excision of the mediastinal adenoma by transcervical mediastinal exploration with the Cooper retractor. The other patients underwent angiographic ablation (n = 4), anterior mediastinotomy (n = 3), video-assisted thoracoscopy (VATS) (n = 1), and VATS plus thoracotomy (n = 1). The mean hospital stay for the study group was 2.9 ± 0.7 days. The complication rate was 25%. All patients were normocalcemic after a mean follow-up of 15 ± 7 months. Most inframanubrial mediastinal parathyroid tumors can be successfully managed without median sternotomy.     

Parathyroid Adenomas versus Four-gland Hyperplasia as the Cause of Primary Hyperparathyroidism in Patients with Prolonged Lithium Therapy

Chronic lithium therapy in patients with affective psychiatric disorders has been implicated as the cause of hypercalcemia and primary hyperparathyroidism. Our objective was to evaluate whether primary hyperparathyroidism was caused by an adenoma or four-gland hyperplasia. The medical records of 15 patients with affective psychiatric disorders who were treated with chronic lithium therapy from 1982 to 1997, all of whom were operated on for primary hyperparathyroidism, were reviewed. Data on age, symptoms, duration of lithium therapy, pre- and postoperative calcium levels, and parathyroid hormone levels were collected. Parathyroid histology for each patient was independently and blindly reviewed. The mean age was 58 +/- 10 years, the mean duration of lithium therapy 10.7 +/- 6 years, and the mean preoperative calcium level 11.7 +/- 0.5 mg/dl. All patients underwent bilateral neck exploration with selective resection of enlarged glands. Of the 15 patients, 14 (92%) had adenomas (11 single, 3 double), and 1 (8%) had four-gland hyperplasia. All patients were rendered eucalcemic, with a postoperative calcium level of 9.2 +/- 0.5 mg/dl ( p < 0.005). All patients resumed their lithium therapy, with 1 of 15 patients developing recurrent hyperparathyroidism 2 years following the first operation; this patient required reexploration, at which time an adenoma was resected. In our experience hyperparathyroidism in patients who have undergone prolonged therapy with lithium is associated with a high incidence of parathyroid adenomas versus four-gland hyperplasia. This suggests that lithium selectively stimulates growth of parathyroid adenomas in susceptible patients, who are best treated with adenoma excision rather than subtotal parathyroidectomy.     

Cases with Fewer than Four Parathyroid Glands in Patients withRenal Hyperparathyroidism at Initial Parathyroidectomy

In the surgical treatment of secondaryhyperparathyroidism (2HPT) due to uremia, it is considered necessary toremove all parathyroid glands from the neck to prevent persistent andrecurrent parathyroid hyperfunction. However, in some cases fewer thanfour parathyroid glands can be recognized at initial operation; in thepresent study, we evaluated the long-term prognosis and estimatedsurgical strategy in such cases. Between March 1981 and January 1999,822 patients underwent total parathyroidectomy (PTx) with forearmautograft for advanced 2HPT at the Department of Transplant Surgery of Nagoya Second Red Cross Hospital. In 21 cases (2.6%) fewer than fourparathyroid glands were macroscopically found at the initial operation.These cases were followed up and their parathyroid function wasevaluated by measurement of intact parathyroid hormone (PTH). In 20 ofthe 21 cases three glands were found, in 1 patient only two glands. In5 of these cases the fourth gland was identified first afterpostoperative histopathologic evaluation. In all these cases the intactPTH level was normalized. In 8 of the remaining 16 cases high PTHlevels persisted after the initial operation, including 3 patients who underwent neck reexploration. However, in the other 7 patients PTHlevels dropped within normal range immediately after PTx and a fourthgland has never been recognized. One patient was lost to follow-up. Thus, using our operative strategy, 12 of 822 cases (0.85%) did notdevelop persistent or recurrent HPT even though only three glands wereidentified at the operation. To avoid postoperative hypoparathyroidism,autotransplantation should be performed when fewer than four parathyroid glands are found at the initial operation.     

Stepwise Approach for Parathyroid Localisation in Primary Hyperparathyroidism

World Journal of Surgery - Primary hyperparathyroidism (PHPT) is a relatively common condition in surgical practice. Availability of localisation studies has shifted the treatment from bilateral...     

Development of a Formula to Predict Parathyroid Carcinoma in Patients with Primary Hyperparathyroidism

Background

Cure of parathyroid carcinoma (PC) requires initial en bloc resection, including resection of all tumor-bearing tissue, with hemithyroidectomy and dissection of the central lymph node compartment. Unfortunately, no reliable preoperative criteria have yet been assessed to indicate a high likelihood of PC. Thus, the aim of the present study was to develop a formula to indicate preoperatively the presence of PC.

Methods

A prospective database of 1,363 patients with primary hyperparathyroidism (pHPT) was screened for patients with PC. Age, gender, surgical procedures, laboratory data, and follow-up results were evaluated and compared to a group of patients with benign pHPT. Based on preoperative serum calcium (Ca) and parathyroid hormone (PTH) levels, as well as patients’ age at the time of diagnosis, a formula was developed by a multivariate logistic model that estimates the individual risk for PC.

Results

Between 1987 and 2008, 19 patients with PC were identified. Ca (3.8?±?0.3 vs 2.9?±?0.3 mmo/l; p?=?0.0002) and PTH levels (1,250?±?769 vs 194?±?204?pg/ml; p?=?0.0030) were significantly higher in patients with PC than in those with benign pHPT. Patients with PC were also significantly younger than patients with benign pHPT (48.9?±?12.1 vs 59.1?±?13.8?years; p?<?0.05). With a ≥5?% probability that a given patient suffered from PC, the sensitivity and specificity to identify the disease were 100 and 30?%, respectively, with the new Ca, PTH, and age based logarithmic formula.

Conclusions

The new logarithmic formula can be used to calculate the individual risk for PC. If the calculated individual risk exceeds 5?%, en bloc resection seems to be justified to provide long-term cure in case of PC.     

Bilateral Internal Jugular Venous Sampling for Parathyroid Hormone Determination in Patients with Nonlocalizing Primary Hyperparathyroidism

Background  

Focused parathyroidectomy (FP) is offered to 60% to 70% of patients presenting to our unit with primary hyperparathyroidism (PHPT). A recent report identified bilateral internal jugular venous sampling (BIJVS) as a useful tool for localization of parathyroid adenomas in patients with scan-negative PHPT. The purpose of this study was to evaluate the utility of this approach in a clinical setting.     

Utility of Intraoperative Parathyroid Hormone Monitoring in Patients with Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism Undergoing Initial Parathyroidectomy

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods

We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution. Parathyroid hormone (PTH) levels were measured before skin incision and 10 min after resection of the last parathyroid gland. Variables analyzed included percent drop of PTH from baseline and the final PTH level compared to the normal reference range (RR).

Results

A total of 52 patients underwent initial subtotal parathyroidectomy with IOPTH. An IOPTH decrease cutoff of ≥75 % from baseline had the highest biochemical cure rate (87 %). In the remaining 13 % who met this cutoff, all had persistent pHPT, with ≥90 % drop of PTH from baseline. The remaining patients, who did not meet the ≥75 % cutoff, were cured. Follow-up was available for three of four patients with final IOPTH levels above the RR: one had persistent pHPT, two had hypoparathyroidism (50 %). When a postresection PTH level was within the RR, 88 % of patients were cured. While considered cured from pHPT, 7 % of patients in this group developed permanent hypoparathyroidism. When the final PTH level dropped below the RR, 28 % developed permanent hypoparathyroidism.

Conclusions

A cutoff in IOPTH decrease of ≥75 % from baseline has the highest biochemically cure rate in patients with pHPT associated with MEN1. However, a 75 % cutoff in IOPTH decrease does not exclude persistent pHPT. The absolute IOPTH value does not accurately predict postoperative hypoparathyroidism.     

Parathyroid Hormone Content Distinguishes True Normal Parathyroids from Parathyroids of Patients with Primary Hyperparathyroidism

p < 0.001) for TN parathyroid glands; however, it was not true for glands (grossly normal or otherwise) in patients with HPT. Patient groups were similar with regard to mean patient age and intracellular PTH mRNA levels. Hypercalcemic patients were similar with regard to preoperative serum calcium and PTH levels. NA parathyroids, adenomas, and hyperplasias are different from TN parathyroids with regard to their PTH content. PTH mRNA was similar across all groups. The relation between intracellular PTH mRNA and PTH was significantly absent in patients with HPT compared with TN glands. Furthermore, we have found that PTH content of normal parathyroid in patients with adenoma is similar to that of hyperplastic and adenoma tissues. These data suggest that the PTH content of parathyroid tissues may be of use in differentiating normal from abnormal parathyroids.     

Preoperative Serum Osteocalcin may Predict Postoperative Elevated Parathyroid Hormone in Patients with Primary Hyperparathyroidism

Background  

Persistent postoperative elevation of parathyroid hormone (POePTH) following successful parathyroidectomy for primary hyperparathyroidism (PHPT) is presumed to result from bone remineralization. Predicting which patients may need treatment is difficult. This study investigated whether preoperative serum osteocalcin (OC), a bone turnover marker involved in mineralization, can predict POePTH.     

Indian Primary Hyperparathyroidism Patients with Parathyroid Carcinoma do not Differ in Clinicoinvestigative Characteristics from Those with Benign Parathyroid Pathology

Introduction No foolproof preoperative diagnostic indicators of parathyroid carcinoma (PC) exist in absence of nonskeletal metastases. Palpable parathyroid tumor, advanced skeletal and renal manifestations, and very high serum calcium and parathyroid hormone levels are considered strong predictors. Most of these features are common in Indian primary hyperparathyroidism (PHPT) patients although only few have PC. The aim of this study was to identify dependable clinicoinvestigative predictors of PC in Indian PHPT patients. Materials and Methods Clinical, biochemical, radiological, and densitometric attributes of 100 PHPT patients who underwent successful parathyroidectomy (1990–2004) were studied. Various parameters of patient groups with parathyroid adenoma (n = 84), primary hyperplasia (n = 12), and carcinoma (n = 4) were compared using ANOVA, with P value < 0.05 considered significant. Results Mean age of patients was 37.4 years, with no difference in the 3 groups (P = 0.92). Patients in 3 groups had comparably severe bone disease; 36 had coexistent renal disease. Two patients with PC and 27 (32%) with adenoma had palpable parathyroid tumor. None of the biochemical parameters predicted malignant pathology. Mean tumor weight (milligram) in carcinoma patients (15,080 ± 5,638.02) was significantly higher than those with adenoma (5,724 ± 1,257.9) (P = 0.002). Postoperative course and recovery in carcinoma patients were similar to those with adenoma. In follow-up (mean: 33 months), none of the adenoma patients were found to have persistent/recurrent PHPT attributable to missed PC. Conclusion Indian patients with parathyroid adenoma, hyperplasia, and carcinoma were not found to differ in their clinical, biochemical, and pathological characteristics except for significantly higher tumor weight in the carcinoma group.     

Parathyroid Four-Dimensional Computed Tomography: Evaluation of Radiation Dose Exposure During Preoperative Localization of Parathyroid Tumors in Primary Hyperparathyroidism

Background  

Parathyroid four-dimensional computed tomography (4DCT) provides greater sensitivity than sestamibi with single photon emission CT (SPECT, or SeS) for preoperative localization of parathyroid tumors in patients with primary hyperparathyroidism (PHPT). The radiation dose imparted to the patient during preoperative parathyroid imaging, however, has not been analyzed.