Determinants of Tc-99m sestamibi SPECT scan sensitivity in primary hyperparathyroidism

Background

The aim of this study was to evaluate the influence of patient and adenoma characteristics on ^99mTc-methoxy isobutyl isonitrile (MIBI) scan performance in individuals diagnosed with primary hyperparathyroidism (PHP).

Methods

Records of patients undergoing parathyroidectomy for PHP over 6 years at a single center were reviewed.

Results

The overall true-positive (TP) rate for ^99mTc-MIBI scans was 56%. Adenomas sized 1.9 to 3.5 cm were more likely to have TP scans than 0.3-cm to 1.8-cm adenomas (74% vs 40%, P < .001). Preoperative ionized calcium levels between 1.49 and 1.72 mmol/L were more likely to have TPs than levels between 1.27 and 1.48 mmol/L (65% vs 47%, P < .05). No single class of medication was shown to significantly effect TP rates. A decrease in TP rate was observed for larger adenomas in patients on ≥1 medication (74% vs 65%, P = .05).

Conclusions

In PHP, ^99mTc-MIBI scan positivity is most related to adenoma size and preoperative ionized calcium level.     

Treatment With Cinacalcet of Secondary Hyperparathyroidism After Renal Transplantation

Background

The treatment of posttransplant secondary hyperparathyroidism (SHP) with vitamin D analogues is determined by their effectiveness to reverse hypercalcemia. Calcimimetics inhibit parathyroid hormone (PTH) secretion by modulating the calcium-sensing receptor in the parathyroid gland. Cinacalcet, a calcimimetic drug, has proven its effectiveness for the treatment of SHP among patients in phase V of chronic renal disease.

Patients and Methods

This retrospective analysis included 48 patients with SHP who were treated with cinacalcet. The initial dose of 30 mg/d could be increased to 180 mg, administering calcitriol also, depending on the serum calcium and PTH levels. The objectives were a PTH level between 75 and 125 pg/mL or a decrease >40%, and a serum calcium level below 10.5 mg/dL.

Results

The average PTH at baseline was 244 pg/mL, decreasing to 131 pg/mL at 1 year (P < .01). The average calcium at baseline was 10.1 mg/dL descending to 9.2 mg/dL at 1 year (P < .01). Among patients with hypercalcemia, the calcium decreased from 11 to 9.6 mg/dL at 1 year (P < .01). Seventy percent of patients without hypercalcemia reached the desired value of PTH, and 100% of those with hypercalcemia. Among patients with hypercalcemia, the desired calcium level was reached in 91% of cases. Ten patients developed hypocalcemia. In 3 cases we stopped the treatment with cinacalcet due to digestive intolerance.

Conclusions

Treatment with cinacalcet controlled hyperparathyroidism and hypercalcemia among patients with posttransplant SHP. It was a safe drug, with a low incidence of side effects.     

Calcimimetics and Bone Mineral Density in Renal Transplant Patients With Persistent Secondary Hyperparathyroidism

Background

The persistence of secondary hyperparathyroidism plays an important role in posttransplant bone loss. Calcimimetics are efficient to control metabolic alterations associated with this problem, but there are few publications that assess their effects on bone density.

Patients and Methods

This prospective study assessed the effects of a single daily dose of cinacalcet on calcemia, phosphatemia, parathyroid hormone (PTH), and bone densitometry (femur and spine) values of 27 renal transplant patients with stable kidney function, calcium > 10.5 mg/dL, and PTH > 65 pg/mL.

Results

A preliminary study after 6 months showed decreased calcemia (11.05 ± 0.5 to 10.18 ± 0.6 mg/dL; P < .0001), reduced levels of intact PTH (iPTH; 258 ± 104 to 209.61 ± 127 pg/mL; P < .05), and increased phosphatemia (2.38 ± 0.45 to 2.54 ± 0.3 mg/dL; P < .05). We also observed an increase in femoral neck bone mass with improved T score (−1.36 ± 1.19 to −1.05 ± 0.84 g/cm²; P < .05).

Conclusions

Cinacalcet was effective in the management of posttransplant persistent secondary hyperparathyroidism, resulting in decreased calcemia and iPTH, while also improving femoral neck bone loss. Longer-term studies with control groups are needed to determine the drug's influence on overall bone mineral density.     

Effect of CYP3A5 Genotype on Renal Allograft Recipients Treated With Tacrolimus

Objective

Tacrolimus concentrations are associated with CYP3A5 genotype. The purpose of this study was to evaluate the outcomes and drug concentrations/doses among a posttransplant population with various CYP3A5 genotypes within 12 months.

Methods

Sixty seven kidney recipients receiving immunosuppression with tacrolimus + mycophenolate mofetil + prednisolone were grouped according to their CYP3A5 genotypes (*1/*1; *1/*3; *3/*3). The initial dose of tacrolimus (0.15 mg/kg/d) was adjusted according to achieve a target therapeutic window. All patients underwent a protocol biopsy at 1 month posttransplantation. We assayed serum creatinine and tacrolimus blood trough concentrations to calculate the concentration per dosage during follow-up. We also investigated the incidence of acute rejection episodes and the nephrotoxicity of tacrolimus according to the renal biopsy.

Results

There was no significant difference among serum creatinine concentrations. Tracrolimus blood concentrations showed a significant difference at day 7 and 1 month with no significant difference at 3, 6, or 12 months among the three groups. The CYP3A5*3/*3 group showed the largest concentration per dosage (C/D) and CYP3A5*1/*1, the smallest C/D. There was a significant difference among the three groups. The occurrence of an acute rejection episode within 3 months showed a significant difference among the three groups but not from 3 to 12 months after transplantation. Nephrotoxicity was greatest among the CYP3A5*3/*3 group.

Conclusion

CYP3A5 influenced the blood concentrations of tacrolimus. Our study suggested to choose the initial dosage according to the CYP3A5 genotype to obtain a better outcome and reduce the incidences of acute rejection episodes and nephrotoxicity.     

C4d deposition is correlated with the level of antivimentin antibody in rat kidneys undergoing chronic allograft nephropathy

Aims

Antivimentin antibody is often produced as an autoantibody after transplantation. C4d deposition, a marker of humoral immunity during transplantation, is believed to reflect alloantibodies. This study investigated the relationship between C4d deposition and humoral immunity to vimentin among rat kidneys undergoing chronic allograft nephropathy (CAN).

Methods

Fisher 344 rat renal grafts were orthotopically transplanted into Lewis rats following the procedure of Kamada with our modification. All recipients were administered cyclosporine (CsA) (10 mg/kg⁻¹ · d⁻¹ × 10 d) before being divided into 3 groups of oral treatments: (1) vehicle, (2) CsA (6 mg/kg⁻¹ · d⁻¹), and (3) mycophenolate mofetil (MMF; 20 mg/kg⁻¹ · d⁻¹). At 4, 8 and 12 weeks after transplantation, the rats were killed, the renal allografts harvested, and the sera collected. Serum creatinine (SCr) was measured and pathologic changes assessed according to the Banff 97 criteria. The antivimentin antibody was quantified by enzyme-linked immunosorbent assay. The deposition of C4d detected by immunofluorescence was analyzed by integrated optical density (IOD).

Results

Antivimentin antibody was observed in sera of all transplanted rats. The level of antivimentin antibody (IgGΔOD) increased gradually during the development of CAN from 4 weeks. Simultaneously, C4d deposition in peritubular capillaries also progressively strengthened. There was a strong positive correlation between the content of antivimentin antibody and C4d deposition (r = 0.892; P = .000). MMF simultaneously decreased antivimentin antibody formation and C4d deposition. In contrast, CsA had no significant effect.

Conclusions

We demonstrated the production of antivimentin antibodies and the deposition of C4d during the development of CAN. There was a positive correlation between them. Whether humoral immunity to vimentin contributes to C4d deposition is not clear and further studies are needed to elucidate this issue.     

Parathyroidectomy outcomes according to operative approach

Background

Parathyroidectomy for primary sporadic hyperparathyroidism (psHPT) has evolved with advances in preoperative gland localization and intraoperative parathyroid hormone (ioPTH) monitoring to minimally invasive approaches (MIPS).

Methods

Two hundred twenty patients underwent parathyroidectomy for psHPT. Forty-nine patients underwent bilateral neck exploration (BNE) (group 1), 60 patients underwent BNE with ioPTH monitoring (group 2), and 111 patients underwent MIPS with ioPTH monitoring (group 3).

Results

At 3 months postoperatively, mean serum calcium and intact parathyroid hormone (PTH) levels were similar between groups, and eucalcemia rates were 100%, 100%, and 99%. The ultimate rates of persistent disease and recurrence were also similar. Operative time was shorter in group 3 compared to group 2 (P < .001) but not group 1. Frozen sections and patient charges were significantly lower in group 3 compared to groups 1 and 2 (P < .005).

Conclusion

Parathyroidectomy for psHPT is highly successful with these techniques. When a MIPS approach can be done, it is potentially quicker and associated with lower patient charges.     

Traçabilité de la gestion de l’utilisation des curares dans le dossier d’anesthésie en chirurgie viscérale : une étude observationnelle et multicentrique

Objectives

To report any item documenting the peroperative muscle relaxant effects management in anaesthesia files issued from visceral surgery processes.

Type of study

Prospective, observational and multicenter.

Patients and methods

A single operator analysed 1453 files proposed by nine anaesthetists’ teams. The items selected concerned three periods: induction/tracheal intubation, paralysis maintenance, tracheal extubation. Reporting of 40 categories of items was studied.

Results

Items related to laryngoscopy and intubation conditions were observed in 43% (0-95) [general average (intercentres min-max)] and in 11% (0-97) of the files, respectively. At least one level of paralysis was reported in 23% (0-96) of the files. For the paralysis maintenance, documentation of an effect appeared in 53% (4-96) of the documents. Neuromuscular assessments preceding the tracheal extubation were retrieved in 43% (12-89) of the notes. Adductor pollicis was concerned for 30% (1-89) of these observations. Detection of level of spontaneous paralysis offset, satisfying to the local standard, appeared in 14% (3-19) of the documents. Pharmacological reversal was noted for 25% (4-67) of the patients; the assessment of the effects so produced was reported in 8% (0-58).

Conclusion

In the studied collection, the traceability of the peranaesthetic curarization management appears variable on both qualitative and quantitative levels. The emergence of a dedicated guideline - defining the criteria for producing a good documentation of the muscle relaxant use - becomes necessary to secure these practices for all physicians using muscle relaxants.     

Selective unilateral parathyroid exploration: an effective treatment for primary hyperparathyroidism

Background

Unilateral neck exploration (UNE) is a well-recognized approach in the treatment of primary hyperparathyroidism (PHP). The objective of this study was to review the success of an approach involving UNE guided by preoperative sestamibi (SM) scanning.

Methods

All data were gathered by retrospective chart review. All patients undergoing surgery for the treatment of primary hyperparathyroidism at a tertiary referral center over a 3-year period were included in the study cohort.

Results

Fifty-two of 80 patients (65%) had an SM scan consistent with a solitary adenoma and were eligible for a UNE, with 57.5% (46/80) undergoing a UNE. Seventy-seven of 80 (96.3%) patients were normocalcemic after initial neck exploration. UNE was curative in 50 of 52 (96.2%) UNE eligible patients and required less operative time than bilateral neck exploration (mean, 60 versus 87 minutes).

Conclusion

Selective unilateral neck exploration, guided by preoperative SM scanning, is an effective surgical approach for the management of primary hyperparathyroidism.     

Primary sternal osteomyelitis: a case series and review of the literature

Purpose

Primary sternal osteomyelitis is rare in the pediatric population.

Methods

We present 4 recent cases that demonstrate a wide range in age, presenting features, and clinical course, and we performed a literature review.

Result

A combination of diagnostic aspiration with prolonged appropriate antibiotic therapy led to successful resolution in all cases. Surgical debridement should be reserved for cases that do not respond to medical therapy.

Conclusion

Sternal osteomyelitis is a rare condition in children that usually resolves with aspiration and prolonged antibiotic therapy.     

Evaluation of Cinacalcet HCl Treatment After Kidney Transplantation

Background

Hyperparathyroidism often remains or develops after kidney transplantation. Vitamin D sterol used as treatment for an elevated parathyroid hormone (PTH) level and associated bone disease may be contraindicated due to hypercalcemia. The calcimimetic cinacalcet HCl (cinacalcet), which lowers PTH and calcium (Ca) in chronic kidney disease patients, may represent an alternate therapeutic modality.

Methods

This multicenter, retrospective, observational study examined 41 kidney transplant patients receiving cinacalcet for ≥3 months starting ≥3 months posttransplantation. Levels of intact PTH, Ca, and phosphorus (P) were examined during the assessment phase (3-6 months after initiation).

Results

Median PTH decreased 21.8% during the assessment phase (P < .001), with 32.5% of patients exhibiting a ≥30% decrease in PTH from baseline. Median Ca decreased 6.8% (P < .0001). Median serum P rose 10.0% (P = .0124), but remained within normal limits. The estimated glomerular filtration rate was stable throughout the study.

Conclusions

Cinacalcet may be useful for the treatment of hyperparathyroidism after kidney transplantation. Randomized, prospectively designed clinical trials are required to confirm these results.     

Liver Transplantation for Hepatocellular Carcinoma: Results of a Multicenter Study With Common Priorization Criteria

Objective

To evaluate the results of liver transplantation (OLT) performed for hepatocellular carcinoma (HCC) among a multicenter cohort of patients with predefined common inclusion and priorization criteria.

Patients and Methods

Over a 5-year period (January 2002-December 2006), 199 HCC patients underwent OLT in four centers in Andalusia. The morphological (Milan) inclusion criteria were priorized in two consecutive periods, according to the Model for End-stage Liver Disease score: group I, 53 patients (HCC < 2 cm = 24 points; ≥ 2 cm or multinodular = 29 points) and group II, 146 cases (HCC < 3 cm without priorization; HCC ≥ 3 cm or multinodular = 18 points).

Results

Among the 199 HCCs, 186 (93.5%) subjects were transplanted and 13 (6.5%) were excluded. There were 18 cases (9.7%) where the diagnosis was incidental and 168 were known HCC cases; 144 (85.7%) complied with the Milan criteria (Milan+); 24 (14.3%) exceeded there criteria (Milan−). According to preoperative imaging, the number of nodules and tumor mean sizes among the excluded—Milan+ and Milan− groups—were 1.8/5.3 cm, 1.4/3.5 cm, and 2.3/6.7 cm, respectively (P < .001). Percutaneous treatment during listing was delivered to 55% of the excluded cases: 49% of Milan+ and 96% of Milan−. The median time on the list was 88 days for known HCC (53 days for group I, and 97 days for group II), and 172 days for the incidental HCCs. Staging (pTNM) was correct in 64% of cases: 23% were understaged and 13% were overstaged. Overall mortality within the first 90 days was 9%, and transplant patient survival at 5 years was 61%. No differences were observed in survival rates between both study periods, although there were differences between the Milan+ (65%) and Milan− (23%) groups (P < .04). In addition, the difference in the recurrence rates was also significant between the Milan+ (7%), Milan− (24%), and the incidental (25%) groups (P < .02).

Conclusions

A common priorization policy of HCC for OLT based on morphological criteria results in a low exclusion rate on the waiting lists (6.5%). The Milan criteria are still a good cutoff to stratify the risk of recurrence, despite preoperative tumor staging being correct in only two-thirds of cases.     

Do patients undergoing parathyroidectomy for primary hyperparathyroidism in San Francisco, CA, and Bursa, Turkey, differ?

Background

To compare the preoperative clinical symptoms and associated conditions and findings in operations in age- and sex-matched patients with primary hyperparathyroidism (PHPT) living in the two different regions of the world to determine whether PHPT differs in various countries.

Methods

Fifty-two patients from Bursa, Turkey were matched with 52 age and sex matched patients from San Francisco, USA. Patients' preoperative symptoms, biochemical and radiologic findings and surgical procedures were documented.

Results

More patients in the American Group (15%) had preoperatively persistant or recurrent hyperparathyroidism, P = 0.016. Serum parathyroid hormone levels were higher in Turkish group (546 ± 75.33 pg/mL) than in American group (146 ± 75.33 pg/mL). More Turkish patients had osteoporosis (P < 0.05). The size of parathyroid adenomas was significantly greater in Turkish patients (25.2 ± 1.18 mm) than in American patients (17.5 ± 1.18 mm), P < 0.001.

Conclusions

Patients with PHPT from Bursa, Turkey have higher plasma parathyroid hormone levels, larger parathyroid adenomas and more severe bone disease than in age and sex matched patients with PHPT in San Francisco.     

Machete injuries as seen in a Nigerian teaching hospital

Background

The morbidity and mortality of machete-related injuries is rather appreciable in Nigeria although it is under-reported. Machetes are multipurpose tools in the farm, home and construction sites. Machetes may also be used as a close-range weapon. In Nigeria, there is no legislation guiding their Acquisition, so they are readily available in many homes. Injuries from machetes could be as detrimental as fatal or non-fatal with long-term morbidity.

Methods

We performed a retrospective study to assess the pattern and outcome of patients presenting with machete injuries in Ebonyi State University Teaching Hospital, Abakaliki, from January 2003 to December 2007.

Results

Of 76 patients, 74 met the criteria for the study. The male:female ratio was 10:1. The youth were commonly affected and the average age was 27.86 years. Assaults accounted for 96% of cases whilst accidental injuries accounted for 4% of cases. Early presentation, multiple machete wounds and involvement of head and upper extremities were common. Peripheral nerve palsy was the most common complication and haemorrhagic shock the most common cause of death. Sixty-one patients (87.14%) had complete recovery, and six patients (8.51%) recovered with morbidity. Death occurred in three patients (4.29%).

Conclusions

Management of machete injuries in a developing nation can be quite challenging. Assault with homicidal intention was the major aetiological factor in our own environment and may be a very important and under-recognised aspect of the injuries. Appropriate injury-prevention mechanisms and other aspects of trauma care are recommended.     

Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring

Background

Reoperative parathyroidectomy (R-PTX) in primary hyperparathyroidism (1HPT) has increased failure rates and morbidity. This study evaluated R-PTX during the era of minimal-access PTX with intraoperative parathyroid hormone (IOPTH) monitoring.

Methods

Two thousand sixty-five patients with 1HPT who underwent PTX were assessed for R-PTX. Preoperative studies, operative findings, and outcomes were evaluated.

Results

Two hundred twenty-eight patients underwent 236 R-PTX procedures. Imaging performed included sestamibi (89%), ultrasound (US; 56%), computed axial tomography/magnetic resonance imaging (5%), and selective venous sampling (1%). Sestamibi was more sensitive than US (84% vs 68%). Curative surgery was performed in 89% of patients. IOPTH was 99% sensitive. There was no relationship between cure and the following parameters: preoperative calcium or PTH levels, persistent or recurrent disease, or use of IOPTH. Solitary gland disease and a single previous operation were associated with increased likelihood of cure (P = .06). Hypoparathyroidism was decreased using IOPTH monitoring (2% vs 9%). One patient had recurrent laryngeal nerve palsy.

Conclusions

R-PTX can be performed effectively with minimal complications. IOPTH is an accurate predictor of cure and may decrease the frequency of permanent hypoparathyroidism.     

Traction-compression-closure for exomphalos major

Purpose

We present our experience with traction-compression-closure (TCC) for exomphalos major (EM) to achieve a safe and embryologically correct midline supraumbilical aesthetic closure with preservation of the umbilicus.

Methods

Nineteen neonates with EM were paralyzed and ventilated. The abdominal domain was increased by upward cord traction to assist liver-bowel reduction by gravity and sac ligation, followed by circumferential elastic body binder compression. The supraumbilical abdominal wall anomaly cicatrized spontaneously or was closed surgically as a midline scar, with preservation of the umbilicus.

Results

Over 7 years (1998-2004), 19 patients with EM were treated by TCC, 18 of whom survived. The patients' median gestational age was 36 weeks (range, 24-40 weeks); their median birth weight was 2312 g (range, 890-3000 g). The median time to reduction was 4 days (range, 3-5 days), whereas that to full enteral feeds was 6 days (range, 4-6 days). Mechanical ventilation for 7 days (range, 6-8 days) was not associated with any morbidity, and the time to home discharge was 11 days (range, 8-12 days). Five patients did not require any surgery. There was no episode of sac rupture or infection.

Conclusion

Abdominal expansion by vertical cord traction followed by compression reduction (TCC) under muscle relaxation and ventilation is time well spent toward a safe and aesthetic midline abdominal wall closure without tension for EM.     

Safety and Tolerance of Sodium Mycophenolate in Patients After Renal Transplantation—An Observational Study

Background

Enteric-coated mycophenolate sodium (EC-MPS) was developed as an alternative agent to mycophenolate mofetil (MMF), aimed at reduction of gastrointestinal (GI) complications.

Methods

Seventy-four patients (mean age 42.3 years) switched from MMF to MPS were included in the study and followed-up for 3 months (Visit 0, Visit 2 after 1 month and Visit 3 after 3 months). The mean time from transplantation to switch was 3.7 years. During Visit 2 and 3 the following were recorded: impact of treatment change on the severity of GI symptoms (4 point scale: 1-worsening, 2-no change, 3-improvement, 4-resolution), EC-MPS tolerance, adverse events (AEs), patient compliance and physician satisfaction with treatment (4 point scale: 1-bad, 2-fair, 3-good, 4-very good).

Results

Sixty-three patients completed the study (85.1%). EC-MPS dose ranged from 720 to 1440 mg. GI symptom severity score averaged at 3.41. Symptoms most commonly compelling a conversion were: abdominal pain, diarrhea, abdominal colic, nausea, anorexia and vomiting. Out of 175 complaints, 144 (82%) either improved or resolved, 5 (2.86%) aggravated, and 25 (14.86%) persisted. Patient compliance and mean physician satisfaction score averaged at 3.70 and 3.02 at Visit 3, respectively. 9 AEs (2 severe) were reported. Causal relationship with the medication was suspected in 5 cases (1 case of SAE). The most common AEs were: anemia, infection (including sepsis), GI symptoms (abdominal pain, diarrhea).

Conclusions

The following was concluded in our study: (1) sodium mycophenolate is well tolerated; (2) after switching from MMF to EC-MPS, gastrointestinal symptoms alleviated; (3) EC-MPS is a safe medication, with a low adverse events rate.     

Development of a parathyroid hormone-controlled release system as a potential surgical treatment for hypoparathyroidism

Background/Purpose

The aim of this study was to develop a surgically implantable controlled release delivery system for parathyroid hormone (PTH) that will maintain calcium homeostasis without the adverse side effects of long-term calcium and vitamin D replacement and can be used for the treatment of hypoparathyroidism.

Methods

Biodegradable poly(lactide-co-glycolide) (PLGA) microspheres loaded with PTH were made using a modification of the double emulsion (water/oil/water) solvent evaporation technique. To simulate the release of PTH from microspheres after implantation in an animal, the in vitro release profile for the PTH microspheres was determined by incubating the PTH microspheres in phosphate-buffered saline, serially sampling the effluent, and determining the concentration of PTH in the effluent over time using an enzyme-linked immunosorbent assay.

Results

(1) PTH was successfully incorporated into PLGA microspheres. (2) Controlled release of PTH was demonstrated in vitro over a 3-week period. (3) Release of physiological significant concentrations of PTH was achieved using this methodology.

Conclusions

Controlled release of physiological concentrations of PTH can be achieved using PLGA microsphere encapsulation.     

Three-Dimensional Metabolic and Radiologic Gathered Evaluation Using VR-RENDER Fusion: A Novel Tool to Enhance Accuracy in the Localization of Parathyroid Adenomas

Background

The aim of this study was to assess the accuracy of a novel imaging modality, three-dimensional (3D) metabolic and radiologic gathered evaluation (MeRGE), for localizing parathyroid adenomas (PAs).

Methods

Consecutive patients presenting with primary hyperparathyroidism who underwent both thin-slice cervical computed tomography (CT) and ^99mTc-sestamibi (MIBI) scanning were included. 3D-CT reconstruction was obtained using VR-RENDER, which was used to perform 3D virtual neck exploration (3D-VNE). The MIBI scan was then fused with the 3D reconstruction to obtain 3D-MeRGE. Sensitivity, specificity, and accuracy were assessed. Parathyroid gland volume and preoperative parathormone (PTH) levels were analyzed as predictive factors of correct localization (i.e., correct quadrant).

Results

A total of 108 cervical quadrants (27 patients) were analyzed. Sensitivities were 79.31, 75.86, 65.51, and 58.61 % with 3D-MeRGE, 3D-VNE, MIBI, and CT, respectively. Specificity was highest with CT (94.93 %) followed by 3D-VNE (92.4 %). MIBI and 3D-MeRGE had the same specificity (88.6 %). 3D-MeRGE and 3D-VNE achieved higher accuracy than MIBI or CT alone. Mean PTH values were significantly higher in patients with lesions that were correctly identified (true positive, TP) than in those whose lesions were missed (false negative, FN) with 3D-VNE (219.60 ± 212.77 vs. 98.75 ± 12.76 pg/ml; p = 0.01) and 3D-MeRGE (217.69 ± 213.76 vs. 09.75 ± 20.48 pg/ml; p = 0.02). The mean parathyroid gland volume difference between TP and FN was statistically significant with all modalities except CT.

Conclusions

3D-MeRGE and 3D-VNE showed high accuracy for localization of PAs. 3D-MeRGE performed better than MIBI or CT alone for detecting small adenomas and those with a low PTH level.     

Can the use of intraoperative intact parathyroid hormone monitoring be abandoned in patients with hyperparathyroidism?

Background

Ultrasound (US) and technetium-99m sestamibi scintigraphy (MIBI) are used to determine the localization of abnormal glands in cases of primary hyperparathyroidism (PHPT). Intraoperative intact parathyroid hormone (iPTH) monitoring is a reliable examination used to cure PHPT. The aim was to assess the necessity of intraoperative iPTH monitoring.

Methods

Sixty patients were examined using preoperative MIBI and US. iPTH was measured at 3 time points: (1) at the start of surgery; (2) 10 minutes after gland resection; and (3) more than 60 minutes after surgery. We defined a decreased iPTH level as an iPTH measured 10 minutes after resection that was less than 50% of the preoperative level.

Results

The iPTH of 55 patients with concordant lesions decreased to within the normal range more than 60 minutes after surgery.

Conclusions

It is not necessary to monitor intraoperative iPTH when single concordant lesions are preoperatively identified on both MIBI and US.