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Ladsous M, Deguelte S, Hindié E, Caiazzo R, Delemer B. Chapter 15: Recurrent or persistent primary hyperparathyroidism, parathyromatosis. ANNALES D'ENDOCRINOLOGIE 2025; 86:101704. [PMID: 39818302 DOI: 10.1016/j.ando.2025.101704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2025]
Abstract
Persistent primary hyperparathyroidism is defined as the persistence or recurrence of hypercalcemia within 6 months of parathyroid surgery. Recurrent primary hyperparathyroidism is defined as the recurrence of primary hyperparathyroidism more than 6 months after an initially curative parathyroidectomy. In these situations, it is essential to rule out differential diagnoses, and in particular secondary hyperparathyroidism and familial hypocalciuric hypercalcemia. Failure to remove the pathological parathyroid gland or glands during initial surgery for primary hyperparathyroidism is the most common situation in non-expert centers. In other situations, genetically determined multi-glandular primary hyperparathyroidism must be screened for. More rarely, a second sporadic adenoma is identified, or, exceptionally, a parathyroid carcinoma or parathyromatosis. Effective morphological evaluation, combining a morphological and functional imaging, is essential prior to any new parathyroid surgery. The indications for surgery must be discussed in a multidisciplinary team, assessing the risk/benefit ratio, since the risk of surgical complications is higher. Revision surgery should be performed using a suitable approach, after laryngoscopy, in an expert center, ideally with intraoperative PTH measurement and recurrent nerve neuromonitoring.
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Affiliation(s)
- Miriam Ladsous
- Endocrinology, Diabetology, Metabolism and Nutrition Department, CHU de Lille, hôpital Claude-Huriez, 59000 Lille, France.
| | - Sophie Deguelte
- Digestive and Endocrine Surgery Department, CHU de Reims, hôpital Robert-Debré, 51100 Reims, France.
| | - Elif Hindié
- Department of Nuclear Medicine, CHU de Bordeaux, 33000 Bordeaux, France.
| | - Robert Caiazzo
- Department of General and Endocrine Surgery, CHU de Lille, hôpital Claude-Huriez, 59000 Lille, France.
| | - Brigitte Delemer
- Department of Endocrinology Diabetes Nutrition, HU de Reims, hôpital Robert-Debré, 51100 Reims, France.
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Procopio PF, Pennestrì F, Martullo A, Raffaelli M. Persistent and recurrent hyperparathyroidism - Attitude. Am J Surg 2024; 238:115826. [PMID: 39068062 DOI: 10.1016/j.amjsurg.2024.115826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/01/2024] [Indexed: 07/30/2024]
Affiliation(s)
- Priscilla Francesca Procopio
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Pennestrì
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Annamaria Martullo
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Raffaelli
- UOC Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy; Centro di Ricerca in Chirurgia delle Ghiandole Endocrine e dell'Obesità, Università Cattolica del Sacro Cuore, Rome, Italy.
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Miller JA, Gundara J, Harper S, Herath M, Ramchand SK, Farrell S, Serpell J, Taubman K, Christie J, Girgis CM, Schneider HG, Clifton-Bligh R, Gill AJ, De Sousa SMC, Carroll RW, Milat F, Grossmann M. Primary hyperparathyroidism in adults-(Part II) surgical management and postoperative follow-up: Position statement of the Endocrine Society of Australia, The Australian & New Zealand Endocrine Surgeons, and The Australian & New Zealand Bone and Mineral Society. Clin Endocrinol (Oxf) 2024; 101:516-530. [PMID: 34927274 DOI: 10.1111/cen.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/29/2021] [Accepted: 11/02/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations to guide the surgical management and postoperative follow-up of adults with primary hyperparathyroidism. METHODS Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing eight key questions. RESULTS Diagnostic imaging does not determine suitability for surgery but can guide the planning of surgery in suitable candidates. First-line imaging includes ultrasound and either parathyroid 4DCT or scintigraphy, depending on local availability and expertise. Minimally invasive parathyroidectomy is appropriate in most patients with concordant imaging. Bilateral neck exploration should be considered in those with discordant/negative imaging findings, multi-gland disease and genetic/familial risk factors. Parathyroid surgery, especially re-operative surgery, has better outcomes in the hands of higher volume surgeons. Neuromonitoring is generally not required for initial surgery but should be considered for re-operative surgery. Following parathyroidectomy, calcium and parathyroid hormone levels should be re-checked in the first 24 h and repeated early if there are risk factors for hypocalcaemia. Eucalcaemia at 6 months is consistent with surgical cure; parathyroid hormone levels do not need to be re-checked in the absence of other clinical indications. Longer-term surveillance of skeletal health is recommended. CONCLUSIONS This position statement provides up-to-date guidance on evidence-based best practice surgical and postoperative management of adults with primary hyperparathyroidism.
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Affiliation(s)
- Julie A Miller
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Endocrine Surgical Centre, Epworth Hospital Network, Richmond, Victoria, Australia
| | - Justin Gundara
- Department of Surgery, Redland Hospital, Metro South and Faculty of Medicine, University of Queensland, Saint Lucia, Queensland, Australia
- Department of Surgery, Logan Hospital, Metro South and School of Medicine and Dentistry, Griffith University, Nathan, Queensland, Australia
| | - Simon Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Department of Surgery, University of Otago, Wellington, New Zealand
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Farrell
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
- Department of Surgery, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Surgery, Austin Health, Heidelberg, Victoria, Australia
- Department of Surgery, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Jonathan Serpell
- Department of General Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Endocrine Surgery, Monash University, Victoria, Clayton, Australia
| | - Kim Taubman
- Department of Medical Imaging, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Endocrinology, St Vincent's Hospital, Fitzroy, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - James Christie
- PRP Diagnostic Imaging, Sydney, New South Wales, Australia
| | - Christian M Girgis
- Department of Diabetes and Endocrinology, Westmead Hospital, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Melbourne, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Clayton, Victoria, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony J Gill
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Sunita M C De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Richard W Carroll
- Endocrine, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Frances Milat
- Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
- Centre for Endocrinology & Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, Victoria, Australia
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Libánský P, Čarková J, Kushnir I, Matějková Běhanová M, Procyklová K, Šedý J, Vaculová M, Včelák J, Zikán V, Adámek S. Recurrent Primary Hyperparathyroidism in Multiple Endocrine Neoplasia Type 1 Syndrome. Physiol Res 2023; 72:S423-S427. [PMID: 38116778 PMCID: PMC10830164 DOI: 10.33549/physiolres.935223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 09/12/2023] [Indexed: 01/05/2024] Open
Abstract
Primary hyperparathyroidism is a common endocrinopathy. Multiple Endocrine Neoplasia Type 1 (MEN1) is a rare autosomal dominantly inherited endocrine tumor predisposition syndrome, with one of main manifestations being primary hyperparathyroidism. We retrospectively evaluated a set of 1011 patients who underwent surgery for primary hyperparathyroidism between the years 2018-2022, and found 78 (8 %) patients who underwent reoperations and 27 patients with MEN1 syndrome. In the group of patients with MEN1 syndrome, 7 (35 %) needed reoperations. Patients with multiple endocrine neoplasia syndrome have a higher risk of needing reoperation. Genetic testing can help identify MEN1 syndrome preoperatively and to better evaluate the approach to surgery.
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Affiliation(s)
- P Libánský
- 3rd Department of Surgery, 1st Faculty of Medicine, Charles University in Prague and Motol University Hospital, Prague, Czech Republic.
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Graf A, Cochran C, Sadowski S, Nilubol N, Simonds WF, Weinstein LS, Chang R, Jha S. Invasive Testing for Preoperative Localization of Parathyroid Tumors. J Endocr Soc 2023; 8:bvad158. [PMID: 38174154 PMCID: PMC10763605 DOI: 10.1210/jendso/bvad158] [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: 09/26/2023] [Indexed: 01/05/2024] Open
Abstract
Context The identification of parathyroid tumor(s) in patients with persistent/recurrent primary hyperparathyroidism (PHPT) is critical for a successful reoperative surgery. If noninvasive studies (ultrasound, computed tomography, magnetic resonance imaging, sestamibi) fail to conclusively localize the tumor, invasive procedures (arteriography and selective venous sampling) are performed. Objective To describe our experience with invasive studies for parathyroid tumor localization and provide follow-up data on selective arterial hypocalcemic stimulation with central venous sampling, a technique developed at our center. Methods We identified patients who underwent preoperative invasive testing for localization of parathyroid tumor from 1991 to 2020. The result of each invasive localization study [arteriogram, hypocalcemic stimulation and selective venous sampling (SVS)] was categorized as true-positive, false-positive, and false-negative based on histology and biochemical outcome. Results Ninety-four patients with 96 tumor occurrences underwent invasive testing for parathyroid tumor localization. Arteriogram, hypocalcemic stimulation, and SVS accurately localized the tumor in 47 of 94 (50%), 56 of 93 (60%), and 51 of 62 (82%) tumors, respectively. Hypocalcemic stimulation was more likely to correctly localize the tumor when arteriogram showed a blush [37 of 50 (74%) vs 19 of 43 (44%), P = .01]. When both arteriogram and hypocalcemic stimulation yielded concordant positive findings, SVS did not change management in the 18 cases in which all 3 were performed. Twelve patients remained with persistent PHPT; all had recurrent disease with multiple affected glands. Conclusion Hypocalcemic stimulation is a useful adjunct in patients with PHPT who require invasive localization and can obviate the need for SVS. Clinical Trial number: NCT04969926.
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Affiliation(s)
- Akua Graf
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Craig Cochran
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Samira Sadowski
- National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - Naris Nilubol
- National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, USA
| | - William F Simonds
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Lee S Weinstein
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
| | - Richard Chang
- National Institutes of Health Clinical Center, Bethesda, MD 20892, USA
| | - Smita Jha
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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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: 2] [Impact Index Per Article: 1.0] [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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Pavlidis ET, Pavlidis TE. Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy. World J Clin Cases 2023; 11:2213-2225. [PMID: 37122518 PMCID: PMC10131017 DOI: 10.12998/wjcc.v11.i10.2213] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/01/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.
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Affiliation(s)
- Efstathios T Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
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The difficult parathyroid: advice to find elusive gland(s) and avoid or navigate reoperation. Curr Probl Surg 2023; 60:101262. [PMID: 36894218 DOI: 10.1016/j.cpsurg.2022.101262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Neuberger M, Dropmann JA, Kleespies A, Fuerst H. Determinants and clinical significance of negative scintigraphic findings in primary hyperparathyroidism: a retrospective observational study. Nuklearmedizin 2022; 61:440-448. [PMID: 35913079 DOI: 10.1055/a-1868-5050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM In patients with recurrent primary hyperparathyroidism (pHPT) or preceding thyroid operation, scintigraphic localization of the pathological parathyroid gland is sometimes unsuccessful. Reason for diagnostic failure, and its clinical relevance is poorly understood. METHODS This retrospective observational study in patients suffering from a pHPT evaluated independent predictors of a negative preoperative scintigraphy (SC) result, and its relevance for intraoperative outcome using logistic regression analysis. RESULTS Among 86 pHPT patients scheduled for parathyroid operation, 63 (73%) had a history of a preceding thyroid or parathyroid operation. Preoperative SC could not identify an adenoma in 30 patients (34.9%), and in 12 patients (14.0%), the surgeon was subsequently unable to localize abnormal parathyroid tissue. Preoperative parathyroid hormone concentration was the only significant independent predictor of a negative SC finding (non-linear and indirect association). Independent from surgical history, an unsuccessful intraoperative focus localization was exclusively predicted by preoperative ultrasonographic (US) and SC findings (OR per diagnostic category 2.98; 95%-CI 1.03-8.58, p=0.043, and OR 2.26; 95%-CI: 1.10-4.63, p=0.027, respectively). Compared to exclusive US, however, the combination of SC and US significantly increased the sensitivity and predictive power to identify patients at a high risk for a complicated surgical procedure. CONCLUSION In patients before parathyroidectomy, a low preoperative parathyroid hormone concentration is significantly associated with a high likelihood for a negative SC finding. Combining US with SC before operation significantly increases the chance to identify patients prone to negative intraoperative findings.
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Affiliation(s)
- Michael Neuberger
- München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Jan Axl Dropmann
- München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Axel Kleespies
- HELIOS Amper-Klinikum Dachau, Dachau, Germany.,München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Heinrich Fuerst
- Chirurgische Klinik, Krankenhaus Martha-Maria Munchen, München, Germany
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Use of [ 11C]choline PET/CT for visualization of four hyperactive parathyroid glands in a patient with renal hyperparathyroidism. Eur J Nucl Med Mol Imaging 2022; 49:4750-4751. [PMID: 35760966 PMCID: PMC9606055 DOI: 10.1007/s00259-022-05885-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/16/2022] [Indexed: 11/18/2022]
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Parathyroid venous sampling for the preoperative localisation of parathyroid adenoma in patients with primary hyperparathyroidism. Sci Rep 2022; 12:7058. [PMID: 35487946 PMCID: PMC9054741 DOI: 10.1038/s41598-022-11238-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/18/2022] [Indexed: 12/04/2022] Open
Abstract
Preoperative localisation studies are essential for parathyroidectomy in patients with primary hyperparathyroidism. If the location of abnormal parathyroid glands cannot be identified through non-invasive studies, parathyroid venous sampling (PVS) may be employed. In this study, we evaluated the utility of preoperative PVS in parathyroid surgery. Patients with primary hyperparathyroidism who underwent preoperative PVS at Severance Hospital between January 2015 and June 2020 were identified. Patients for whom the results of non-invasive imaging studies were inconsistent or negative underwent PVS. The results of PVS were compared with operative findings and pathologic results. For 14 patients, the results of preoperative ultrasonography and 99mTc-sestamibi single-photon emission computed tomography (SPECT) were negative; for 20 patients, either the result of only one test was positive, or the results of the two tests were inconsistent. With respect to the lateralisation of diseased adenoma, the results of PVS and pathological examination were inconsistent only for one patient in either group (total: 2/34 patients). This study showed that PVS could be used effectively for preoperative localisation in patients with primary hyperparathyroidism in whom the location of diseased parathyroid glands cannot be determined through non-invasive image studies.
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Positron nuclear medicine imaging: Parathyroid diseases. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hendricks A, Lenschow C, Kroiss M, Buck A, Kickuth R, Germer CT, Schlegel N. Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery. Langenbecks Arch Surg 2021; 406:1615-1624. [PMID: 33993327 PMCID: PMC8370933 DOI: 10.1007/s00423-021-02191-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 05/04/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE Repeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse. METHODS A retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated. RESULTS Neck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24-48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%. CONCLUSION These findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.
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Affiliation(s)
- Anne Hendricks
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Christina Lenschow
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Matthias Kroiss
- Department for Diabetology and Endocrinology, Clinic for Internal Medicine I, University Hospital Wuerzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Andreas Buck
- Clinic for Nuclear Medicine, University Hospital Wuerzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Ralph Kickuth
- Institute for Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany
| | - Nicolas Schlegel
- Department of General, Visceral, Vascular and Pediatric Surgery, University Hospital Würzburg, Oberduerrbacherstrasse 6, 97080, Wuerzburg, Germany.
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Management of primary and renal hyperparathyroidism: guidelines from the German Association of Endocrine Surgeons (CAEK). Langenbecks Arch Surg 2021; 406:571-585. [PMID: 33880642 DOI: 10.1007/s00423-021-02173-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND AIMS The purpose of this review is to provide updated recommendations for the surgical management of primary (pHPT) and renal (rHPT) hyperparathyroidism, formulating a new guideline of the German Association of Endocrine Surgeons (CAEK). METHODS Evidence-based recommendations for the diagnosis and therapy of pHPT and rHPT were assessed by a multidisciplinary panel using PubMed for a comprehensive literature search together with a structured consensus dialogue (S2k guideline of the Association of the German Scientific Medical Societies, AWMF). RESULTS During the last 20 years, a variety of new preoperative localization procedures, such as sestamibi-SPECT, 4D-CT, and various PET/CT procedures, were established for pHPT. High-resolution imaging, together with intraoperative parathyroid hormone (IOPTH) measurement, enabled focused or minimally invasive surgery to become the most favored surgical technique. Patients with pHPT and nonlocalizing imaging have a higher risk of multiglandular disease. Surgical therapy provides very high cure rates, with a clear relation to the surgeon's experience in parathyroid procedures. Reoperative parathyroidectomy, children with pHPT or familial forms, and parathyroid carcinoma are addressed and require special surgical expertise. A multidisciplinary team of experienced nephrologists, transplant, and endocrine surgeons should assess the diagnosis and treatment of renal HPT. CONCLUSION Surgery is the only curative treatment for pHPT and should be considered for all patients with pHPT. For rHPT, a more selective approach is required, and parathyroidectomy is indicated only when conservative treatment options fail. In parathyroid carcinoma, the adequacy of local resection influences local disease control.
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15
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Persistent Hyperparathyroidism: How Many Cases Can Be Prevented. Indian J Surg 2021. [DOI: 10.1007/s12262-021-02742-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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16
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Re-operative parathyroidectomy: How many positive localization studies are required? Am J Surg 2020; 221:485-488. [PMID: 33220935 DOI: 10.1016/j.amjsurg.2020.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 11/03/2020] [Accepted: 11/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Re-operative parathyroidectomy in patients with recurrent or persistent hyperparathyroidism can be challenging. We review our experience to determine the optimal number of localization studies prior to re-operation. METHODS From 2001 to 2019, 251 patients underwent re-operative parathyroidectomy. Parathyroidectomies were stratified to 4 groups based upon the number of positive localization studies obtained: A) ZERO, B) 1-positive, C) 2-positive, D) 3-positive. RESULTS The overall cure rate was 97%, where 201 single gland resections, 23 two-gland resections, 22 subtotal/total, and 5 forearm autograft resections were performed. Thirty-two patients had no positive studies (A), 172 patients had 1-positive (B), 42 patients had 2-positive (C), and 5 patients had 3-positive studies (D). There was no difference in surgical cure rates between groups (p = 0.71). The majority of patients had one or no positive imaging studies yet almost all still achieved cure. CONCLUSION Successful re-operative parathyroidectomy can be performed with minimal pre-operative scans in certain clinical contexts.
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17
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Frey S, Couëtte C, Trésallet C, Hamy A, Caillard C, Blanchard C, Menegaux F, Chereau N, Wargny M, Lussey-Lepoutre C, Drui D, Ansquer C, Mirallié E. Utility of a Second 99mTc-MIBI Scintigraphy Before Reoperation for Patients With Persistent Sporadic Primary Hyperparathyroidism: Results of a Retrospective Multicenter Study. Ann Surg Oncol 2020; 27:3831-3839. [PMID: 32246313 DOI: 10.1245/s10434-020-08428-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Persistent primary hyperparathyroidism (PHPT) occurs in 2.5% to 15% of cases after parathyroidectomy. Few studies have evaluated the best pre-reoperative imaging approaches for persistent sporadic PHPT. This retrospective multicenter study aimed to evaluate the benefit of a second pre-reoperative 99mTc-methoxy-isobutyl-isonitrile (MIBI) scintigraphy for patients with persistent PHPT who had a 99mTc-MIBI before their initial surgery. METHODS The study enrolled 50 patients with persistent sporadic PHPT who had reoperation between 2006 and 2016 in three French University Hospitals (Angers, Nantes, and La Pitié Salpêtrière-Paris). Preoperative 99mTc-MIBI scan was performed before each operation. RESULTS After the reoperation, 42 patients (84%) were cured. By the second 99mTc-MIBI, 31 patients (62%) had a removed gland identified. A new pathologic gland was identified by a second 99mTc-MIBI in 25 patients (50%), and this imaging permitted correction of an initial surgical error in six patients (12%). A second 99mTc-MIBI showed a sensitivity of 63%, a specificity of 89%, a positive predictive value (PPV) of 78%, and a negative predictive value (NPV) of 80%. A concordant second 99mTc-MIBI and ultrasonography (17 patients) showed a sensitivity of 70%, a specificity of 81%, a PPV of 70%, and an NPV of 81%. CONCLUSIONS Performing a second 99mTc-MIBI scan permitted 62% of the persistent PHPT patients to be cured, allowing identification of new pathologic glands in 50% of the cases and correction of an initial surgical error in 12% of the cases, with high specificity and PPV. These results reinforce the fact that a second 99mTc-MIBI scan should be performed at first intention before reoperation of patients with persistent PHPT, regardless of the result from the initial 99mTc-MIBI scan.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Clément Couëtte
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Christophe Trésallet
- Service de Chirurgie Viscérale et Endocrinienne, La Pitié-Salpêtrière, Paris, France
| | - Antoine Hamy
- Service de Chirurgie Viscérale et Endocrinienne, Centre Hospitalier Universitaire d'Angers, Angers, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France.,Institut du Thorax, INSERM, CNRS, UNIV Nantes, Nantes, France.,Université de Nantes, quai de Tourville, Nantes, France
| | - Fabrice Menegaux
- Service de Chirurgie Viscérale et Endocrinienne, La Pitié-Salpêtrière, Paris, France
| | - Nathalie Chereau
- Service de Chirurgie Viscérale et Endocrinienne, La Pitié-Salpêtrière, Paris, France
| | - Matthieu Wargny
- La Clinique des Données, INSERM U1413, CHU de Nantes, Nantes, France
| | | | - Delphine Drui
- Clinique d'Endocrinologie-Maladies Métaboliques et Nutrition, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | - Eric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France. .,Université de Nantes, quai de Tourville, Nantes, France.
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18
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Parikh AM, Grogan RH, Morón FE. Localization of Parathyroid Disease in Reoperative Patients with Primary Hyperparathyroidism. Int J Endocrinol 2020; 2020:9649564. [PMID: 32454822 PMCID: PMC7212332 DOI: 10.1155/2020/9649564] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
The localization of persistent or recurrent disease in reoperative patients with primary hyperparathyroidism presents challenges for radiologists and surgeons alike. In this article, we summarize the relevant imaging modalities, compare their accuracy in identifying reoperative disease, and outline their advantages and disadvantages. Accurate localization by preoperative imaging is a predictor of operative success, whereas negative or discordant preoperative imaging is a risk factor for operative failure. Ultrasound is a common first-line modality because it is inexpensive, accessible, and radiation-free. However, it is highly operator-dependent and less accurate in the reoperative setting than in the primary setting. Sestamibi scintigraphy is superior to ultrasound in localizing reoperative disease but requires radiation, prolonged imaging times, and reader experience for accurate interpretation. Like ultrasound, sestamibi scintigraphy is less accurate in the reoperative setting because reoperative patients can exhibit distorted anatomy, altered perfusion of remaining glands, and interference of radiotracer uptake. Meanwhile, four-dimensional computed tomography (4DCT) is superior to ultrasound and sestamibi scintigraphy in localizing reoperative disease but requires the use of radiation and intravenous contrast. Both 4DCT and magnetic resonance imaging (MRI) do not significantly differ in accuracy between unexplored and reoperative patients. However, MRI is more costly, inaccessible, and time-consuming than 4DCT and is inappropriate as a first-line modality. Hybrid imaging with positron emission tomography and computed tomography (PET/CT) may be a promising second-line modality in the reoperative setting, particularly when first-line modalities are discordant or inconclusive. Lastly, selective venous sampling should be reserved for challenging cases in which noninvasive modalities are negative or discordant. In the challenging population of reoperative patients with PHPT, a multimodality approach that utilizes the expertise of high-volume centers can accurately localize persistent or recurrent disease and enable curative parathyroidectomy.
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Affiliation(s)
- Aaroh M. Parikh
- School of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
| | - Raymon H. Grogan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Fanny E. Morón
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA
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19
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Wu SY, Vu T, Perrier ND. Use a Standard Nomenclature to Guide a Safe and Efficient Parathyroid Surgery. VideoEndocrinology 2019. [DOI: 10.1089/ve.2019.0159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Si-Yuan Wu
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Thinh Vu
- Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nancy D. Perrier
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas
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20
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Nilsson IL. Primary hyperparathyroidism: should surgery be performed on all patients? Current evidence and residual uncertainties. J Intern Med 2019; 285:149-164. [PMID: 30289185 DOI: 10.1111/joim.12840] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Primary hyperparathyroidism (pHPT) is the third most common endocrine disease and is characterized by hypercalcaemia and elevated or inappropriately 'normal' levels of the parathyroid hormone (PTH). The main target organs of PTH are the skeletal system and the kidneys. Before the 1970s, pHPT was a rarely detected disease associated with notable morbidity and premature mortality. Introduction of biochemical screening, allowing for a wide range of indications, has contributed to the detection of the full spectrum of the disease. A new entity with an isolated elevation of PTH, normocalcaemic HP, has emerged and is currently being explored. The highest incidence of pHPT, 3-5%, is observed amongst women, and the prevalence increases with age. The female-to-male ratio is 3-4 : 1 except in younger patients where distribution is equal and known hereditary causes account for approximately 10% of the cases. In the last few decades, it has become evident that fewer patients than previously believed are truly asymptomatic. The cause of pHPT is often a benign tumour, a parathyroid adenoma, and the only definite treatment is parathyroidectomy (PTX). No medical treatment, single or combined, can achieve a curing of pHPT. Recent data indicate that PTX, despite being proven to be cost-effective compared to conservative treatment, is underutilized, especially in elderly pHPT patients. The decision of PTX should always be based on a safe diagnosis, and the potential benefits of curative treatment should not be outweighed by the risks of surgery or anaesthesia.
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Affiliation(s)
- I-L Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department ofBreast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
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21
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Sen S, Cherian AJ, Ramakant P, Reka K, Paul M, Abraham DT. Focused Parathyroidectomy Under Local Anesthesia - A Feasibility Study. Indian J Endocrinol Metab 2019; 23:67-71. [PMID: 31016156 PMCID: PMC6446694 DOI: 10.4103/ijem.ijem_590_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
PURPOSE We conducted this study to evaluate the feasibility, patient satisfaction, and cost of performing focused parathyroidectomy under local anesthesia (LA) and mild sedation, administered and monitored by a surgeon. MATERIALS AND METHODS This was a prospective observational study of 30 patients with primary hyperparathyroidism (PHPT) undergoing a focused parathyroidectomy under LA and mild sedation at a single institution. The clinical features, gland weight, operating time, procedure time, postoperative pain scores, overall patient satisfaction, postoperative nausea and vomiting, analgesic requirements, complications, cost, and cure rates were documented. Data were analyzed using SPSS software version 17.0. RESULTS In two patients (6.7%), the procedure had to be completed under general anesthesia (GA). Postoperative temporary hypocalcemia was witnessed in 14 of 30 (46.7%), but only 1 required intravenous calcium infusion. About 21 of 30 (75%) were completely satisfied with LA, whereas 25 of 30 (89%) were completely satisfied with surgical procedure. Furthermore, all patients were keen to recommend this procedure under LA to their friends and family. Comparing the cost between performing the procedure under LA with that under GA, a significant difference was witnessed (P = 0.001). Among the 26 patients reviewed at 6 months, all had a normal serum calcium and parathyroid hormone levels indicating 100% cure rate. CONCLUSION Performing focused parathyroidectomy under LA is feasible; additionally, this method can significantly reduce the cost of the procedure (P = 0.001).
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Affiliation(s)
- Supriya Sen
- Department of Endocrine Surgery, CMC Hospital, Vellore, Tamil Nadu, India
| | | | - Pooja Ramakant
- Department of Endocrine Surgery, King George Medical University, Lucknow, Uttar Pradesh, India
| | - K. Reka
- Department of Biostatistics, CMC Hospital, Vellore, Tamil Nadu, India
| | - M.J. Paul
- Department of Endocrine Surgery, CMC Hospital, Vellore, Tamil Nadu, India
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22
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Lansdown M, Cvasciuc T, Fraser S. Focused Parathyroidectomy without Intraoperative Parathyroid Hormone Testing: Acceptability after Preoperative Localization with SPECT-CT. ACTA ACUST UNITED AC 2019. [DOI: 10.5005/jp-journals-10002-1245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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23
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The devil is in the details: Assessing treatment and outcomes of 6,795 patients undergoing remedial parathyroidectomy in the Collaborative Endocrine Surgery Quality Improvement Program. Surgery 2019; 165:242-249. [DOI: 10.1016/j.surg.2018.03.026] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/14/2018] [Accepted: 03/27/2018] [Indexed: 11/17/2022]
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Abstract
Sporadic primary hyperparathyroidism (pHPT) is the commonest cause of hypercalcaemia in the ambulatory population. It has a female preponderance and its incidence is increasing. In 85% of cases it is caused by a single parathyroid adenoma, with four gland hyperplasia in up to 20%. Parathyroidectomy is the only cure and bilateral neck exploration remains the gold standard to achieve this. Several adjuncts have been developed to improve success rates or limit the extent of surgery. Pre-operative localisation permits planned targeted surgery. Ultrasound scanning and scintigraphy are the most commonly employed, although 4DCT has become a useful modality in complex cases. However, excellent rates of biochemical cure can be achieved in specialist centres when pre-operative imaging is negative. Pre-operative prediction models and intra-operative parathyroid hormone (ioPTH) assist, with high sensitivity, to predict single gland disease. Reoperations present a major challenge to the endocrine surgeon.
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Affiliation(s)
- Richard J Egan
- Morriston Hospital, Heol Maes Eglwys, Swansea, SA6 6NL, UK.
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25
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Stack BC, Tolley NS, Bartel TB, Bilezikian JP, Bodenner D, Camacho P, Cox JPDT, Dralle H, Jackson JE, Morris JC, Orloff LA, Palazzo F, Ridge JA, Scott-Coombes D, Steward DL, Terris DJ, Thompson G, Randolph GW. AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons. Head Neck 2018; 40:1617-1629. [PMID: 30070413 DOI: 10.1002/hed.25023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. METHODS A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. RESULTS Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. CONCLUSION Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
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Affiliation(s)
- Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neil S Tolley
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | | | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donald Bodenner
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Pauline Camacho
- Department of Medicine, Division of Endocrinology, Loyola University, Chicago, Illinois
| | - Jeremy P D T Cox
- Department of Metabolic Medicine, Imperial College Hospital, NHS Healthcare Trust, London, UK
| | - Henning Dralle
- Sektion Endokrine Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinisches Zentrum, Germany
| | - James E Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John C Morris
- Department of Medicine, Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Ann Orloff
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - David L Steward
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - David J Terris
- Department of Otolaryngology - Head and Neck Surgery, Augusta University, Augusta, Georgia
| | | | - Gregory W Randolph
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
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26
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Ibraheem K, Toraih EA, Haddad AB, Farag M, Randolph GW, Kandil E. Selective parathyroid venous sampling in primary hyperparathyroidism: A systematic review and meta-analysis. Laryngoscope 2018; 128:2662-2667. [PMID: 29756350 DOI: 10.1002/lary.27213] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 03/02/2018] [Accepted: 03/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Minimally invasive parathyroidectomy requires accurate preoperative localization techniques. There is considerable controversy about the effectiveness of selective parathyroid venous sampling (sPVS) in primary hyperparathyroidism (PHPT) patients. The aim of this meta-analysis is to examine the diagnostic accuracy of sPVS as a preoperative localization modality in PHPT. METHODS Studies evaluating the diagnostic accuracy of sPVS for PHPT were electronically searched in the PubMed, EMBASE, Web of Science, and Cochrane Controlled Trials Register databases. Two independent authors reviewed the studies, and revised quality assessment of diagnostic accuracy study tool was used for the quality assessment. Study heterogeneity and pooled estimates were calculated. RESULTS Two hundred and two unique studies were identified. Of those, 12 studies were included in the meta-analysis. Pooled sensitivity, specificity, and positive likelihood ratio (PLR) of sPVS were 74%, 41%, and 1.55, respectively. The area-under-the-receiver operating characteristic curve was 0.684, indicating an average discriminatory ability of sPVS. On comparison between sPVS and noninvasive imaging modalities, sensitivity, PLR, and positive posttest probability were significantly higher in sPVS compared to noninvasive imaging modalities. Interestingly, super-selective venous sampling had the highest sensitivity, accuracy, and positive posttest probability compared to other parathyroid venous sampling techniques. CONCLUSION This is the first meta-analysis to examine the accuracy of sPVS in PHPT. sPVS had higher pooled sensitivity when compared to noninvasive modalities in revision parathyroid surgery. However, the invasiveness of this technique does not favor its routine use for preoperative localization. Super-selective venous sampling was the most accurate among all other parathyroid venous sampling techniques. Laryngoscope, 2662-2667, 2018.
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Affiliation(s)
- Kareem Ibraheem
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Eman A Toraih
- Department of Histology and Cell Biology (Genetics Unit), Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Antoine B Haddad
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Mahmoud Farag
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
| | - Gregory W Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Massachusetts Eye and Ear Infirmary, Boston, U.S.A
| | - Emad Kandil
- Division of Endocrine and Oncological Surgery, Department of Surgery, Tulane University School of Medicine, New Orleans, Louisiana
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27
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Eleven-Year Retrospective Report of Super-Selective Venous Sampling for the Evaluation of Recurrent or Persistent Hyperparathyroidism in 32 Patients. Cardiovasc Intervent Radiol 2017; 41:63-72. [DOI: 10.1007/s00270-017-1757-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Accepted: 07/24/2017] [Indexed: 10/19/2022]
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Guerin C, Paladino NC, Lowery A, Castinetti F, Taieb D, Sebag F. Persistent and recurrent hyperparathyroidism. Updates Surg 2017; 69:161-169. [PMID: 28434176 DOI: 10.1007/s13304-017-0447-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/08/2017] [Indexed: 12/26/2022]
Abstract
Despite remarkable progress in imaging modalities and surgical management, persistence or recurrence of primary hyperparathyroidism (PHPT) still occurs in 2.5-5% of cases of PHPT. The aim of this review is to expose the management of persistent and recurrent hyperparathyroidism. A literature search was performed on MEDLINE using the search terms "recurrent" or "persistent" and "hyperparathyroidism" within the past 10 years. We also searched the reference lists of articles identified by this search strategy and selected those we judged relevant. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT. Then, the patient must be evaluated with new imaging modalities. A single adenoma is found in 68% of cases, multiglandular disease in 28%, and parathyroid carcinoma in 3%. Others causes (<1%) include parathyromatosis and graft recurrence. The surgeon must balance the benefits against the risks of a reoperation (permanent hypocalcemia and recurrent laryngeal nerve palsy). If surgery is necessary, a focused approach can be considered in cases of significant imaging foci, but in the case of multiglandular disease, a bilateral neck exploration could be necessary. Patients with multiple endocrine neoplasia syndromes are at high risk of recurrence and should be managed regarding their hereditary pathology. The cure rate of persistent-PHPT or recurrent-PHPT in expert centers is estimated from 93 to 97%. After confirming the diagnosis of PHPT, patients with persistent-PHPT and recurrent-PHPT should be managed in an expert center with all dedicated competencies.
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Affiliation(s)
- Carole Guerin
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France. .,Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.
| | - Nunzia Cinzia Paladino
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France
| | - Aoife Lowery
- Department of Surgery, University Hospital Limerick and Graduate Entry Medical School University of Limerick, Limerick, Ireland
| | - Fréderic Castinetti
- Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.,Department of Endocrinology, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France
| | - David Taieb
- Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.,Department of Nuclear Medicine, La Timone Hospital, Assistance Publique Hopitaux de Marseille, 264 Rue Saint-Pierre, 13385, Marseille, France
| | - Fréderic Sebag
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France.,Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France
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Is C-11 Methionine PET/CT Able to Localise Sestamibi-Negative Parathyroid Adenomas? World J Surg 2016; 41:980-985. [DOI: 10.1007/s00268-016-3795-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Taslakian B, Trerotola SO, Sacks B, Oklu R, Deipolyi A. The Essentials of Parathyroid Hormone Venous Sampling. Cardiovasc Intervent Radiol 2016; 40:9-21. [PMID: 27796535 DOI: 10.1007/s00270-016-1481-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 10/03/2016] [Indexed: 11/30/2022]
Abstract
Hyperparathyroidism is an excess of parathyroid hormone in the blood due to over-activity of one or more parathyroid gland. Localization of abnormal glands with noninvasive imaging modalities, such as technetium sestamibi scan and cross-sectional imaging, has a high success rate. Parathyroid venous sampling is performed for patients with persistent or recurrent disease after previous parathyroid surgery, when repeat noninvasive imaging studies are negative or discordant. The success of invasive localization studies and results interpretation is dependent on the interventional radiologist's understanding of the normal and ectopic anatomic locations of parathyroid glands, as well as their blood supply and venous drainage. Anatomic and technical considerations for selective parathyroid venous sampling are reviewed.
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Affiliation(s)
- Bedros Taslakian
- Department of Radiology, NYU School of Medicine, NYU Langone Medical Center, New York, NY, USA
| | - Scott O Trerotola
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Barry Sacks
- Department of Interventional Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rahmi Oklu
- Department of Interventional Radiology, Mayo Clinic, Scottsdale, AZ, USA
| | - Amy Deipolyi
- Department of Radiology, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY, 10065, USA.
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July M, Santhanam P, Giovanella L, Treglia G. Role of positron emission tomography imaging in Multiple Endocrine Neoplasia syndromes. Clin Physiol Funct Imaging 2016; 38:4-9. [DOI: 10.1111/cpf.12391] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 08/17/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Mose July
- Section of Endocrinology; Department of Internal Medicine; Joan C Edwards School of Medicine; Marshall University; Huntington WV USA
| | - Prasanna Santhanam
- Section of Endocrinology; Department of Internal Medicine; Joan C Edwards School of Medicine; Marshall University; Huntington WV USA
| | - Luca Giovanella
- Nuclear Medicine; PET/CT and Thyroid Center; Oncology Institute of Southern Switzerland; Bellinzona and Lugano Switzerland
| | - Giorgio Treglia
- Nuclear Medicine; PET/CT and Thyroid Center; Oncology Institute of Southern Switzerland; Bellinzona and Lugano Switzerland
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Varoquaux A, Kebebew E, Sebag F, Wolf K, Henry JF, Pacak K, Taïeb D. Endocrine tumors associated with the vagus nerve. Endocr Relat Cancer 2016; 23:R371-9. [PMID: 27406876 PMCID: PMC5022786 DOI: 10.1530/erc-16-0241] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 07/12/2016] [Indexed: 12/24/2022]
Abstract
The vagus nerve (cranial nerve X) is the main nerve of the parasympathetic division of the autonomic nervous system. Vagal paragangliomas (VPGLs) are a prime example of an endocrine tumor associated with the vagus nerve. This rare, neural crest tumor constitutes the second most common site of hereditary head and neck paragangliomas (HNPGLs), most often in relation to mutations in the succinate dehydrogenase complex subunit D (SDHD) gene. The treatment paradigm for VPGL has progressively shifted from surgery to abstention or therapeutic radiation with curative-like outcomes. Parathyroid tissue and parathyroid adenoma can also be found in close association with the vagus nerve in intra or paravagal situations. Vagal parathyroid adenoma can be identified with preoperative imaging or suspected intraoperatively by experienced surgeons. Vagal parathyroid adenomas located in the neck or superior mediastinum can be removed via initial cervicotomy, while those located in the aortopulmonary window require a thoracic approach. This review particularly emphasizes the embryology, molecular genetics, and modern imaging of these tumors.
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Affiliation(s)
- Arthur Varoquaux
- Department of RadiologyConception Hospital, Aix-Marseille University, Marseille, France
| | - Electron Kebebew
- Endocrine Oncology BranchNational Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Fréderic Sebag
- Department of Endocrine SurgeryConception Hospital, Aix-Marseille University, Marseille, France
| | - Katherine Wolf
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - Jean-François Henry
- Department of Endocrine SurgeryConception Hospital, Aix-Marseille University, Marseille, France
| | - Karel Pacak
- Section on Medical NeuroendocrinologyEunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health, Bethesda, Maryland, USA
| | - David Taïeb
- Department of Nuclear MedicineLa Timone University Hospital, CERIMED, Aix-Marseille University, Marseille, France
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Feng L, Zhang X, Liu ST. Surgical treatment of primary hyperparathyroidism due to parathyroid tumor: A 15-year experience. Oncol Lett 2016; 12:1989-1993. [PMID: 27602126 DOI: 10.3892/ol.2016.4905] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Accepted: 02/01/2016] [Indexed: 11/06/2022] Open
Abstract
The aim of this study was to highlight our experience over a 15-year period in dealing with primary hyperparathyroidism (PHPT) due to a parathyroid tumor. Parathyroidectomy is the standard therapy for patients with PHPT. Our study included all patients with PHPT treated by parathyroidectomy at the Affiliated Cancer Hospital of Zhengzhou University, China. Between 1998 and 2013, a total of 107 patients were recruited. Their clinical data, presentation, laboratory examinations, imageological diagnoses and surgical approaches were analyzed retrospectively. Eighty-four cases (78.5%) were followed up. During a median follow-up period of 5.7 years, a total of 80 patients were without recurrence and metastasis. The main symptoms of PHPT patients were palpable neck mass, joint pains and pathological fracture. The high levels of preoperative parathyroid hormone (PTH) and serum calcium in PHPT patients decreased to below the normal upper limit within 3 days of surgery. The sensitivity of neck ultrasonography, sestamibi scanning, CT, MRI and the combination of three or four types of test were 86.0%, 90.4%, 80.8%, 79.6% and 96.1%, respectively. A 50% or greater drop in PTH levels within 20 min compared with the highest PTH levels before surgery occurred in 95/107 cases (88.8%). Transient hypocalcemia was the most common surgical complication. The ultrasonography and sestamibi scan is the most effective examination for parathyroid tumor. The 20 min PTH measurement appears to be extremely useful, and avoids unnecessary bilateral exploration.
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Affiliation(s)
- Lu Feng
- Department of Head and Neck Surgery, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan 450008, P.R. China
| | - Xu Zhang
- Department of Head and Neck Surgery, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan 450008, P.R. China
| | - Shan-Ting Liu
- Department of Head and Neck Surgery, Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, Henan 450008, P.R. China
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Preoperative ¹¹C-methionine PET/CT enables focused parathyroidectomy in MIBI-SPECT negative parathyroid adenoma. World J Surg 2016; 39:1750-7. [PMID: 25665676 DOI: 10.1007/s00268-015-2992-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Precise preoperative localization is essential for focussed parathyroidectomy. The imaging standard consists of cervical ultrasonography (cUS) and (99m)Tc-MIBI-SPECT (MIBI-SPECT). (11)C-methionine positron emission tomography/computed tomography (Met-PET/CT) is a promising method for localizing parathyroid adenomas. The objective of our study was to elucidate whether additional Met-PET/CT increases the rate of focussed parathyroidectomy. METHODS Fourteen patients with primary hyperparathyroidism (HPT) and three patients with tertiary HPT underwent cUS and MIBI-SPECT. Met-PET/CT was carried out in patients with negative MIBI results. Subsequent surgical strategy was adapted according to imaging results. RESULTS cUS localized a single parathyroid adenoma in 10/17 patients (59 %), while MIBI-SPECT/CT identified 11/17 single adenomas (65 %). In the remaining six patients, Met-PET/CT identified five single adenomas. This step-up approach correctly identified single adenomas in 16/17 patients (94 %). CONCLUSION Met-PET/CT raises the rate of correctly localized single parathyroid adenomas in patients with negative cUS and MIBI-SPECT/CT and increases the number of focussed surgical approaches.
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Abstract
BACKGROUND AND OBJECTIVES In primary hyperparathyroidism (pHPT) preoperative localization of parathyroid adenomas enables focussed unilateral parathyroidectomy. Ultrasound and sestamibi scintigraphy are the recommended standard procedures for primary diagnostics of pHPT and C-11 methionine positron emission tomography computed tomography (Met-PET/CT) is the latest technique for localization of hyperfunctioning parathyroid glands. METHODS This review presents the results of Met-PET/CT on the basis of a selective literature search using the keywords "primary hyperparathyroidism and methionine", "primary hyperparathyroidism and PET", "parathyroid adenomas and methionine" and "parathyroid adenomas and PET". RESULTS Localization of single gland adenomas can be achieved with Met-PET/CT in 79-91 % of cases. The advantages of this procedure are a high sensitivity even in operations for recurrencies or concomitant thyroid nodules and an accurate detection even with atypical localizations. In multiglandular disease a localization of more than one hyperfunctioning gland remains difficult. Potential limitations of the method include the restricted availability and the relatively high costs of Met-PET/CT. CONCLUSIONS Using Met-PET/CT hyperfunctioning parathyroid glands can be exactly localized in most patients with pHPT. Indications for this procedure are mostly when preoperative standard tests are negative and in parathyroid surgery for recurrencies.
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Hindié E, Zanotti-Fregonara P, Tabarin A, Rubello D, Morelec I, Wagner T, Henry JF, Taïeb D. The Role of Radionuclide Imaging in the Surgical Management of Primary Hyperparathyroidism. J Nucl Med 2015; 56:737-44. [DOI: 10.2967/jnumed.115.156018] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/25/2015] [Indexed: 02/07/2023] Open
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Nawrot I, Chudziński W, Ciąćka T, Barczyński M, Szmidt J. Reoperations for persistent or recurrent primary hyperparathyroidism: results of a retrospective cohort study at a tertiary referral center. Med Sci Monit 2014; 20:1604-12. [PMID: 25201515 PMCID: PMC4166223 DOI: 10.12659/msm.890983] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Parathyroid reoperations are challenging and achieving a cure requires multidisciplinary treatment team cooperation. The aims of this study were to summarize our experience in revision surgery for persistent (pHPT) or recurrent primary hyperparathyroidism (rHPT) and to explore factors underlying failure to cure at initial surgery. MATERIAL AND METHODS This was a retrospective cohort study of patients who underwent reoperations for pHPT or rHPT at a tertiary referral center. The database of parathyroid surgery was searched for eligible patients (treated in the years 2000-2012). The primary outcome was the cure rate. All the patients were followed-up for at least 12 months postoperatively. Factors underlying failure to cure at initial surgery were reviewed based on hospital records. RESULTS The study group comprised 88 patients (69 women, 19 men) operated on for persistent (n=57) or recurrent disease (n=31), who underwent 98 reoperations, including 26 (2.4%) patients first operated on at our institution, and 72 (81.8%) patients operated on elsewhere, but referred for revision surgery. A long-term cure was achieved in 83/88 patients (94.3%). The mean post-reoperation follow-up was 91.7 (12-176) months. Missed hyperfunctioning parathyroid gland was found on reoperation in eutopic position in 49 (55.5%) patients, and in ectopic position in 39 (44.3%) patients, including 20 (22.7%) cases of cervical ectopy and 19 (21.6%) cases of mediastinal ectopy. CONCLUSIONS Multidisciplinary treatment team cooperation at a tertiary referral center, consisting of an accurate preoperative localization, expertise in parathyroid re-explorations, and correct use of intraoperative adjuncts, contribute to the high success rate of parathyroid reoperations.
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Affiliation(s)
- Ireneusz Nawrot
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Witold Chudziński
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Ciąćka
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek Szmidt
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Callender GG, Udelsman R. Surgery for primary hyperparathyroidism. Cancer 2014; 120:3602-16. [DOI: 10.1002/cncr.28891] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 03/24/2014] [Accepted: 03/31/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Glenda G. Callender
- Department of Surgery; Section of Endocrine Surgery, Yale University School of Medicine; New Haven Connecticut
| | - Robert Udelsman
- Department of Surgery; Section of Endocrine Surgery, Yale University School of Medicine; New Haven Connecticut
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Agha A, Hornung M, Stroszczynski C, Schlitt HJ, Jung EM. Highly efficient localization of pathological glands in primary hyperparathyroidism using contrast-enhanced ultrasonography (CEUS) in comparison with conventional ultrasonography. J Clin Endocrinol Metab 2013; 98:2019-25. [PMID: 23515449 DOI: 10.1210/jc.2013-1007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Preoperative detection of parathyroid gland adenoma in the presence of primary hyperparathyroidism (pHPT) represents a diagnostic challenge. We present the first prospective study with contrast-enhanced ultrasonography (CEUS) as the central diagnostic tool for the preoperative localization of parathyroid gland adenoma in pHPT in comparison with conventional ultrasonography. METHODS Between July 2010 and December 2011, 75 consecutive patients underwent surgery for pHPT. In all patients, conventional ultrasonography and CEUS were performed prospectively for localization of pathological parathyroid glands. Twenty-five patients suffered from a concomitant goiter (CG), and 12 patients had undergone previous neck surgery due to thyroid pathologies. The sensitivity of both diagnostic tools was analyzed in comparison with intraoperative and histological findings. RESULTS CEUS had a sensitivity of 97% for the detection of the correct quadrant of the pathological parathyroid gland and of 99% for the correct side in comparison with 70% for conventional ultrasonography. In multivariate regression analysis, CG, gland size, and body mass index had a relevant impact on incorrect findings by conventional ultrasonography as compared with CEUS. Follow-up with a minimum of 6 months after surgery showed normal serum levels of calcium and PTH in all 75 patients. CONCLUSIONS CEUS represents a highly reliable, noninvasive and nonradioactive diagnostic tool for localization of pathological parathyroid glands in patients with pHPT. Even in the presence of CG, previous neck surgery, or double adenomas, CEUS has a high sensitivity.
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Affiliation(s)
- Ayman Agha
- Department of Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053 Regensburg, Germany.
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Schalin-Jäntti C, Ryhänen E, Heiskanen I, Seppänen M, Arola J, Schildt J, Väisänen M, Nelimarkka L, Lisinen I, Aalto V, Nuutila P, Välimäki MJ. Planar scintigraphy with 123I/99mTc-sestamibi, 99mTc-sestamibi SPECT/CT, 11C-methionine PET/CT, or selective venous sampling before reoperation of primary hyperparathyroidism? J Nucl Med 2013; 54:739-47. [PMID: 23554505 DOI: 10.2967/jnumed.112.109561] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
UNLABELLED All patients with primary hyperparathyroidism should undergo localization studies before reoperation, but it is not known which method is most accurate. The purpose of this prospective study was to compare the performance of planar scintigraphy with (123)I/(99m)Tc-sestamibi, (99m)Tc-sestamibi SPECT (SPECT/CT), (11)C-methionine PET/CT, and selective venous sampling (SVS) in persistent primary hyperparathyroidism. METHODS Twenty-one patients referred for reoperation of persistent hyperparathyroidism were included and investigated with (123)I/(99m)Tc-sestamibi, SPECT/CT (n = 19), (11)C-methionine PET/CT, and SVS (n = 18) before reoperation. All patients had been operated on 1-2 times previously because of hyperparathyroidism. The results of the localization studies were compared with operative findings, histology, and biochemical cure. RESULTS Eighteen (86%) of 21 patients were biochemically cured. Nineteen parathyroid glands (9 adenomas, 1 atypical adenoma, and 9 hyperplastic glands) were removed from 17 patients, and 1 patient who was biochemically cured had an unclear histology result. The accuracy for localizing a pathologic parathyroid gland to the correct side of the neck was 59% (95% confidence interval [CI], 36%-79%) for (123)I/(99m)Tc-sestamibi, 19% (95% CI, 5%-42%) for SPECT/CT, 65% (95% CI, 43%-84%) for (11)C-methionine PET/CT, and 40% (95% CI, 19%-65%) for SVS (P < 0.01 for (123)I/(99m)Tc-sestamibi vs. SPECT/CT). The corresponding accuracy for the correct quadrant or more specific site was 48% (95% CI, 27%-69%) for (123)I/(99m)Tc-sestamibi, 14% (95% CI, 3%-36%) for SPECT/CT, 61% (95% CI, 39%-80%) for (11)C-methionine PET/CT, and 25% (95% CI, 9%-49%) for SVS (P < 0.02 for (123)I/(99m)Tc-sestamibi vs. SPECT/CT). In the 3 patients not cured, preoperative (123)I/(99m)Tc-sestamibi and SPECT/CT remained negative, SVS was false predictive in all, and (11)C-methionine PET/CT in 1. (11)C-methionine PET/CT accurately revealed the pathologic gland in 4 of 8 (50%) patients with a negative (123)I/(99m)Tc-sestamibi scan result, all of whom were biochemically cured after reoperation. CONCLUSION Planar scintigraphy with (123)I/(99m)Tc-sestamibi performs well in complicated primary hyperparathyroidism and is recommended as first-line imaging before reoperation. (11)C-methionine PET/CT provides valuable additional information if (123)I/(99m)Tc-sestamibi scan results remain negative. (99m)Tc-sestamibi SPECT/CT and SVS provide no additional information, compared with the combined results of (123)I/(99m)Tc-sestamibi and (11)C-methionine PET/CT imaging.
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Affiliation(s)
- Camilla Schalin-Jäntti
- Division of Endocrinology, Department of Medicine, University of Helsinki, Helsinki, Finland.
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Van Udelsman B, Udelsman R. Surgery in primary hyperparathyroidism: extensive personal experience. J Clin Densitom 2013; 16:54-9. [PMID: 23374742 DOI: 10.1016/j.jocd.2012.11.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 10/11/2012] [Accepted: 11/18/2012] [Indexed: 12/22/2022]
Abstract
Parathyroidectomy is the optimal treatment for primary hyperparathyroidism (PHPT) and provides a cure in the vast majority of cases. Over the last 2 decades, improvements in preoperative localization and the development of intraoperative parathyroid hormone monitoring have opened the door for new surgical approaches to parathyroidectomy. Minimally invasive parathyroidectomy is performed under regional or local anesthesia. It requires less surgical dissection resulting in decreased trauma to tissues and is more effective and less costly than traditional bilateral cervical exploration. This article reviews our approach reflecting advances in preoperative localization, anesthetic techniques, and intraoperative management of patients undergoing parathyroidectomy for the treatment of PHPT.
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Affiliation(s)
- Brooks Van Udelsman
- Interdepartmental Program in Vascular Biology and Therapeutics, Yale University School of Medicine, New Haven, CT, USA
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Karakas E, Kann S, Höffken H, Bartsch DK, Celik I, Görg C, Pfestroff A. Does contrast-enhanced cervical ultrasonography improve preoperative localization results in patients with sporadic primary hyperparathyroidism? J Clin Imaging Sci 2012; 2:64. [PMID: 23230546 PMCID: PMC3515932 DOI: 10.4103/2156-7514.103054] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Accepted: 09/08/2012] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE Pre-operative localization studies are inevitable in patients with primary hyperparathyroidism (pHPT), who are eligible for focused or minimally invasive parathyroidectomy (MIP). High-resolution ultrasonography (US) in combination with planar (99m)Tc-Sestamibi-scintigraphy (MIBI) and additional single-photon emission computed tomography (SPECT) are the standard procedures to localize enlarged parathyroid glands. Our aim was to evaluate the practicability and significance of contrast-enhanced ultrasonography (CEUS) in patients with pHPT. MATERIALS AND METHODS All investigations were performed at the University Hospital Marburg. Totally, 25 patients with biochemical proven pHPT underwent preoperative US, MIBI/SPECT, and CEUS. For CEUS, a suspension of phospholipid-stabilized sulfur-hexafluoride (SF6) microbubbles in combination with a special 12 MHz linear US probe was used. All patients were investigated by two sonographers, who did not get to view the findings noted by the other. Finally, surgery was performed and histopathological results were obtained from 24 patients. RESULTS In 17 (68%) patients, US and MIBI/SPECT already raised suspicion of parathyroid lesions and all suspected lesions were reassessed by CEUS. However, no additional information was obtained using CEUS. Especially in eight patients with negative or inconsistent US and MIBI/SPECT results, CEUS did not provide additional information regarding the site of the suspected parathyroid adenoma. Overall, no side effects were observed using CEUS. Surgical cure was achieved in all patients. CONCLUSION In this limited cohort of patients, no additional information could be obtained using the costly CEUS compared to results of US and MIBI/SPECT.
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Affiliation(s)
- Elias Karakas
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Marburg, Germany
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Piciucchi S, Barone D, Gavelli G, Dubini A, Oboldi D, Matteuci F. Primary hyperparathyroidism: imaging to pathology. J Clin Imaging Sci 2012; 2:59. [PMID: 23230541 PMCID: PMC3515949 DOI: 10.4103/2156-7514.102053] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 09/12/2012] [Indexed: 11/20/2022] Open
Abstract
The aim of this review is to describe the multimodal imaging (ultrasound, magnetic resonance, computed tomography, and nuclear medicine) of primary hyperparathyroidism and its correlation to the pathological findings. In the last decades, imaging science has progressed a great deal. Accurate preoperative localization of the involved glands is essential for surgical success.
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Affiliation(s)
- Sara Piciucchi
- Department of Radiology, Morgagni Pierantoni Hospital, Forliì, Italy
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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: 4.2] [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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Morris LF, Loh C, Ro K, Wiseman JE, Gomes AS, Asandra A, Wariri S, Yeh MW. Non–super-selective Venous Sampling for Persistent Hyperparathyroidism Using a Systemic Hypocalcemic Challenge. J Vasc Interv Radiol 2012; 23:1191-9. [DOI: 10.1016/j.jvir.2012.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Revised: 05/24/2012] [Accepted: 06/02/2012] [Indexed: 10/28/2022] Open
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Sörensen J. How Does the Patient Benefit from Clinical PET? Am J Cancer Res 2012; 2:427-36. [PMID: 22768023 PMCID: PMC3360196 DOI: 10.7150/thno.3794] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2011] [Accepted: 02/26/2012] [Indexed: 11/25/2022] Open
Abstract
Clinical molecular imaging by use of PET and PET/CT is increasingly important in routine oncological practice worldwide. A vast majority of clinical PET investigations are performed with [18F]-fluorodeoxyglucose (FDG), but there is a growing interest in novel molecular probes among scientists and clinicians. Beyond FDG, a small number of different tracers have been shown to be of clinical value. With a growing commercial interest in tracer development, many more are under investigation. This review provides some examples of clinical situations where tracers other than FDG have been found useful and an outlook towards technical and regulatory development needed to allow the full impact of clinical PET to benefit the individual patient.
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Super-selective venous sampling in conjunction with quickPTH for patients with persistent primary hyperparathyroidism: report of five cases. Surg Today 2012; 42:570-6. [DOI: 10.1007/s00595-012-0119-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 05/24/2011] [Indexed: 10/14/2022]
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Tc-99m-MIBI-Negative Parathyroid Adenoma in Primary Hyperparathyroidism Detected by C-11-Methionine PET/CT After Previous Thyroid Surgery. Clin Nucl Med 2011; 36:1153-5. [DOI: 10.1097/rlu.0b013e31823360ee] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Zarebczan B, Chen H. Influence of surgical volume on operative failures for hyperparathyroidism. Adv Surg 2011; 45:237-48. [PMID: 21954691 DOI: 10.1016/j.yasu.2011.03.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Hyperparathyroidism is a disease that is often seen in the United States. Patients may present with a wide variety of symptoms affecting multiple organs, but frequently, they are found to be hyperparathyroid on a routine blood examination. Although these patients may be asymptomatic, new consensus guidelines exist for when they should undergo surgery, and several studies have shown multiple benefits from operative intervention. Surgical cure rates can be greater than 95%, but if the initial surgery is unsuccessful, the cure rate becomes 80%. In the hands of experienced surgeons, both initial cure rates and those for reoperations are much higher, illustrating that the surgical volume does affect failure in parathyroid surgery.
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Affiliation(s)
- Barbara Zarebczan
- Department of Surgery, University of Wisconsin, 600 Highland Avenue, H4-722, Madison, WI 53792, USA
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