Usefulness of preoperative Tc-mibi parathyroid scintigraphy in secondary hyperparathyroidism

Background and aims The usefulness of Tc-mibi parathyroid scintigraphy (Tc-PS) in planning parathyroidectomy for secondary hyperparathyroidism is not well known. The aim of this study was to review our experience with Tc-PS concerning: (1) the identification of hyperplastic glands, (2) detection of major ectopias and (3) prevention of recurrences. Patients and methods Thirty-three consecutive patients undergoing first-time subtotal parathyroidectomy for renal hyperparathyroidism had a dual-phase planar Tc-PS performed, and glands were classified as detected, weak, or not detected. The number and position of visualized glands were determined. Parathyroid weight, histology, and their relationship to Tc-PS were recorded after surgery. Results Of 132 potential glands, 48 (35%) were localized on the Tc-PS and 128 (96.9%) were identified intraoperatively. Tc-PS positive/weak glands were heavier than nonlocalized glands. Tc-PS contributed to successful surgery in four patients with a single difficult gland each (three retrieved from the neck and one—fifth gland—requiring mediastinotomy). There was one persistence (3%) because of a missed fourth undescended inferior parathyroid gland. Two recurrences 2 years after surgery were due to a fifth thoracic gland not shown in the preoperative Tc-PS. Conclusions Preoperative Tc-PS helped in the intraoperative identification of moderate or major ectopias in 4/33 patients but was not useful to prevent recurrences from highly ectopic glands not visualized before first-time surgery. Presented at the 2nd Biennial Congress of the ESES, May 2006, Krakow, Poland.     

Optimizing preoperative imaging in primary hyperparathyroidism

Background Scintigraphy of the hyperfunctioning parathyroid glands using technetium 99m (^99mTc)-methoxyisobutylisonitrile (^99mTc-MIBI) is an established and highly sensitive preoperative localization tool whose importance has been further increased by advances in minimally invasive surgery .The goal of the present prospective study was to determine the benefit of optimized imaging in a consistent patient population.Methods Eighty-four patients with first presentations of primary hyperparathyroidism were investigated with ^99mTc-MIBI scintigraphy, thyroid scintigraphy, and cervical ultrasonography. The evaluation algorithm consisted of (a) evaluation of the planar images alone, (b) additional evaluation of single-photon emission computed tomography (SPECT), (c) additional evaluation of thyroid gland scintigraphy, and (d) additional evaluation of ultrasound. All patients subsequently underwent parathyroidectomy. The intraoperative and the histologic findings were correlated with the results of the scintigraphic imaging.Results The sensitivity of planar parathyroid scintigraphy was 74% and could be increased to 91% by the additional investigations. The difference was statistically significant (p<0.05). At the same time, a small increase in specificity from 96% to 99% was seen.Conclusions Prior to minimally invasive treatment of hyperparathyroidism, we recommend combined localization studies consisting of sequential ^99mTc-MIBI scintigraphy, additional SPECT plus thyroid gland scintigraphy, plus high-resolution cervical ultrasonography.     

The problems encountered in the surgical management of primary hyperparathyroidism

The problems encountered in the diagnosis and treatment of primary hyperparathyroidism were studied in 69 cases. The accuracy of imaging for hyperplasia was less than that for adenoma or carcinoma and the major causes for multiple operations were a failure to locate the four glands and mediastinal adenoma. The intravenous administration of high doses of calcitonin could reduce the serum calcium level of patients in hypercalcemic crisis. Carcinoma required ipsilateral modified radical neck dissection because of lymph node metastases, and non-medullary thyroid carcinoma was often associated with primary hyperparathyroidism. We found removal of the parathyroid adenoma and biopsy or extirpation of only one macroscopically normal gland to be a fully satisfactory procedure after bilateral neck exploration and attempting to identify at least four glands.     

原发性甲状旁腺机能亢进症101例分析

１９６３～１９９７年共收治１０１例原发性甲状旁腺机能亢进症。临床特点为：病人年龄较轻，平均３４岁。骨病发生率高且严重，纤维囊性骨炎占６３３％。肾结石、肾钙化少，占３７６％。约４０％病人血钙不高或持续正常。术前颈部查体扪及肿物者１８例，１７例正确。间接定位体征５例均为阳性。这些病例均病程较长，腺体较大，最重１３ｇ，血钙均＞１２００ｍｇ／Ｌ。本组病理学特点腺瘤占９１例，腺癌６例，增生１例。比较了Ｂ超、ＣＴ、９９ｍＴｃＭＩＢＩ在术前定位诊断中的价值。结果表明，Ｂ超、ＣＴ、９９ｍＴｃＭＩＢＩ的灵敏性分别为４５％、８５％、９１％。特异性为９５％、９７％、１００％。准确性为８２％、９４％、９７％。目前在国内此类病例尚少，尤其是对再次手术者，这些非创伤性术前定位检查是有必要的。本组９８例探查，９６例获成功，手术成功率为９７９％。     

Pasieka Illness Questionnaire: its value in primary hyperparathyroidism

Background: A prospective study was undertaken to assess the Pasieka Illness Questionnaire (PIQ) as a clinical evaluation and outcome tool in an Australian setting. The PIQ was specifically designed to assess the impact of surgery on the preoperative symptoms of patients with primary hyperparathyroidism (1° HPT). Methods: Sixty of 71 consecutive patients referred with 1° HPT completed the PIQ preoperatively and 3 months after parathyroid surgery. Fifty‐four of the 60 patients filled in a 12‐month follow‐up questionnaire that included a quality of life (QOL) and a self‐rated health uni‐scale. Serum calcium, ionized calcium and parathyroid hormone levels were obtained on each occasion Results: Eighty per cent of patients identified a significant decrease in symptoms following surgery. QOL and self‐rated health improved after undergoing parathyroid surgery. Serum calcium levels returned to normal in 97% of patients 12 months after surgery. Conclusions: The present study supports the use of the Pasieka Illness Questionnaire as a useful method to measure disease‐specific symptoms in patients with 1° HPT and is applicable to Australian patients. It also shows, once again, that parathyroid surgery produces a significant improvement in the preoperative symptoms of 1° HPT.     

原发性甲状旁腺功能亢进术后低钙血症相关因素分析

目的 探讨原发性甲状旁腺功能亢进术后出现低钙血症及其症状的相关因素。方法 收集2009年1月至2015年3月北京协和医院行手术治疗的原发性甲状旁腺功能亢进病人临床资料,分析与术后低钙血症及其症状相关的临床因素。 结果 641例原发性甲状旁腺功能亢进病人成功接受甲状旁腺切除术治疗,并得到术后病理学诊断及长期随访证实。118例（18.4%）术后第一日血清总钙低于正常值下限,210例（32.8%）出现低钙血症相关的临床症状。多因素相关分析发现：原发性甲状旁腺病人术后出现低钙血症相关症状,与病人年龄、术前血清无机磷及碱性磷酸酶（ALP）相关;术后第一日血清总钙水平低于正常与术前血清全片段甲状旁腺激素（iPTH）水平相关。 结论 青年病人、术前血清iPTH和ALP水平增高、血清无机磷水平低可能是原发性甲状旁腺功能亢进术后低钙的相关因素。     

超声引导下微波消融治疗原发性甲状旁腺功能亢进症

正甲状旁腺功能亢进症(简称甲旁亢)为甲状旁腺激素(parathyroid hormone,PTH)分泌异常增多导致钙、磷代谢失常的内分泌系统疾病,分为原发性和继发性,前者多由甲状旁腺腺瘤所致,后者常为慢性肾病长期透析引起甲状旁腺增生而引发~([1])。原发性甲旁亢临床表现无明显特异性,患者可出现情绪低落、低热、乏力,因病灶局部压迫导致不适,或因骨量减少或泌尿系结石于检查中偶然发现。对于有症状的原发性甲旁亢,原则上应予积极治疗~([2])。本研究观察超声引导下微波消融治疗原发性甲旁亢的安全性及有效性。     

肾结石合并原发性甲状旁腺功能亢进的诊治体会

目的探讨反复双肾结石患者中原发性甲状旁腺机能亢进的诊断和治疗,提高对本病的认识。方法回顾性分析2009年2月～2011年3月因反复双肾结石就诊,临床诊断原发甲旁亢5例的资料。结果 5例病理证实为甲状旁腺腺瘤,男2例,女3例,年龄18～56岁,平均年龄（35.6±9.6）岁,结石病史0.5～3.0年,平均时间（2.4±0.3）年。血钙和甲状旁腺激素明显升高,血磷降低。切除腺瘤后,患者血钙、血磷和甲状旁腺激素恢复正常。结论手术是治疗原发甲旁亢的有效方法。甲状旁腺手术可以明显降低结石复发,甲旁亢的早期诊治有益于减少结石复发和保护肾功能。术后应密切随访尿路结石,必要时予相应治疗。     

Surgery for patients with primary hyperparathyroidism and negative sestamibi scintigraphy—a feasibility study

Background  We report the surgical treatment of a consecutive series of scan negative patients with the intention of unilateral parathyroid exploration with the aid of intraoperative quick PTH (qPTH). Materials and methods  The study included 35 consecutive sestamibi scan negative patients (27 women, eight men) with sporadic pHPT subjected to first time surgery. Median age was 70 years and median preoperative calcium level 2.8 mmol/L. Results  Thirty-three patients had a histological diagnosis of a parathyroid adenoma (median weight 0.48 g [range 0.12 g–2.5 g]). Nineteen patients were explored bilaterally and 16 patients (46%) were operated unilaterally. The median operation time was 40 min in the unilateral group and 95 min in the bilateral group (p < 0.001). Three patients were treated for postoperative hypocalcemia after bilateral exploration versus none in the unilateral group (p = 0.23). With a minimum of 12 months of follow-up, 33 patients (94.3%) were cured. One case of recurrent HPT presented after bilateral exploration with visualization of four glands. One case of persistent HPT was observed after unilateral exploration. qPTH was predictive of operative failure in both patients. Conclusion  Forty-six percent of the patients in our study could be operated unilaterally with a total cure rate of 94%. Patients in the unilateral group had a significant shorter operation time and a lower incidence of postoperative hypocalcemia. In conclusion our investigation shows that limited parathyroid exploration can safely be performed on patients with negative sestamibi scintigraphy by the aid of qPTH. Best of Endocrine Surgery in Europe 2009     

A prospective evaluation of preoperative localization by technetium-99m sestamibi scintigraphy and ultrasonography in primary hyperparathyroidism

BACKGROUND: Ultrasonography (USG) and technetium-99m sestamibi (MIBI) scintigraphy are commonly used imaging modalities in the era of minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism (pHPT). However, their relative importance and actual contribution to MIP have not been prospectively assessed. METHODS: A total of 100 consecutive pHPT patients planning for MIP were recruited. Both USG and MIBI findings were correlated with intraoperative findings and postoperative outcome. Clinicopathologic factors were examined for potential association with a correct localizing result. RESULTS: Thirty men and 70 women (age range 13 to 93 years [median 55.5]) were included in the study. The final pathology included 98 patients with solitary adenoma and 2 patients with multiglandular disease. The sensitivities, accuracies, and positive predicted values for USG and MIBI alone were 57% vs 89%, 56% vs 85%, and 97% vs 94%, respectively. Correctly localized adenomas were significantly heavier than incorrectly localized ones. CONCLUSIONS: MIBI is preferred over USG in pHPT patients planning for MIP. Weight of adenoma appeared to be the only clinicopathologic factor determining localization accuracy.     

Does multiple gland disease in primary hyperparathyroidism correlate with age or sex?

Purpose  Paediatric primary hyperparathyroidism (PHPT) patients suffer more often from multiple gland disease (MGD) than adults. The question occurs whether MGD in adult PHPT patients also correlates with age or sex and whether familial PHPT plays a decisive role. This is significant, as it would influence our decision for a focused approach or the bilateral cervical exploration. Materials and methods  We retrospectively analysed 465 consecutive PHPT patients who underwent surgery in our department between September 2001 and December 2008. Results  PHPT patients aged 40 years or younger suffered significantly more often from MGD than older patients (22.9% versus 11.0%). If familial PHPT disorders, which were more common in young patients, were excluded, the divergence between these two groups vanished (12.5% versus 10.0%). There was no statistical significant difference in the frequency of MGD between men (12.2%) and women (12.3%). Conclusions  If familial PHPT can be ruled out, the frequency of MGD in adult PHPT patients does not correlate with age or with sex. Therefore, age and sex do not imply specific surgical approaches in adult PHPT patients. Best of Endocrine Surgery in Europe 2009.     

Clinical and laboratory characteristics of calcium stone-formers with and without primary hyperparathyroidism

OBJECTIVE

To compare the clinical presentation, laboratory features and outcome of treatment in stone formers (SF) with primary hyperparathyroidism (HPT) to those without systemic disease.

PATIENTS, SUBJECTS AND METHODS

We compared 105 (54 female) stone‐formers (SF) with primary hyperparathyroidism (HPT) to 2416 (835 female) common SF with no systemic disease, and 260 normal subjects (NS, 106 female) using pre‐treatment and treatment data from our kidney‐stone programme. All were assessed before treatment, with three 24‐h urine samples, for stone risk factors, each with a corresponding fasting blood sample. Records were reviewed for stone rates and urological stone‐related procedures.

RESULTS

The hypercalcaemia of HPT was modest, but hypercalciuria was far more marked than in SF because the fractional calcium excretion of HPT exceeded that of SF. Surgical cure of HPT did not completely eradicate either hypercalciuria or hypophosphataemia, suggesting that these patients have some additional mineral disorder. Serum calcium and phosphate, and fractional excretion of calcium, combined into a discriminant function provided the best separation between HPT and SF. However, we present 49 patients for whom the diagnosis (HPT vs SF) has never been resolved, despite years of observation and successful reduction of stone recurrence. Stones in HPT have slightly more phosphate than SF but the difference is not large enough to be of clinical interest. The stone frequency in HPT is about that for SF, and treatment reduces stones in HPT and SF by about the same amount, 10 times.

CONCLUSION

No study to date has compared HPT with SF and NS, as done here. SF with even slight hypercalcaemia and brisk hypercalciuria probably have this curable disease, and after cure clinicians must be wary of residual hypercalciuria that requires medical treatment. Some patients will never be fully diagnosed and remain, like ours, an enigma, albeit responsive to usual medical treatments. Although stones are modestly enriched with phosphate, most are mainly calcium oxalate, so the stone analysis is not clinically a guide to diagnosis.     

Sigmoid colon cancer associated with primary hyperparathyroidism: Report of a case

(Received for publication on Apr. 13, 1998; accepted on Jan. 7, 1999)     

Calcaneal brown tumor with primary hyperparathyroidism caused by parathyroid carcinoma: An atypical localization

Brown tumors are one of the characteristics of primary hyperparathyroidism, although, in some cases, they are noted with secondary hyperparathyroidism as well. The authors present a case of a 50-year-old woman with primary hyperparathyroidism caused by parathyroid carcinoma with an unusual location of a brown tumor in the calcaneus. She first presented with pain and swelling over the heel and ankle, and the diagnosis was suspected by radiographs. Biopsy of the calcaneal lesion confirmed a brown tumor. After the parathyroid lesion was removed surgically, her symptoms were relieved. The calcaneal lesion was treated with immobilization of the foot.