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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: 0] [Impact Index Per Article: 0] [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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Beck T, Burneikis T, Jin J. Parathyroidectomy trends and surgical trainee parathyroidectomy experience based on the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database. Am J Otolaryngol 2023; 44:103884. [PMID: 37058910 DOI: 10.1016/j.amjoto.2023.103884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 04/01/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND The parathyroidectomy approach has shifted over the last few decades from routine bilateral to more commonly focused exploration. The purpose of this study is to assess the operative experience in parathyroidectomy for surgical trainees as well as overall parathyroidectomy trends. METHODS Data from the Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) were analyzed between 2014 and 2019. RESULTS The overall distribution of focused versus bilateral parathyroidectomy remained stable (2014: 54 % focused and 46 % bilateral approach; 2019: 55 % focused and 45 % bilateral). Ninety three percent of procedures involved a trainee (fellow or resident) in 2014, this dropped to 74 % in 2019 (P < 0.005). Fellow involvement decreased significantly from 31 % to 17 % (P < 0.05) over the six-year period. CONCLUSIONS Resident exposure to parathyroidectomies mirrored that of practicing endocrine surgeons. This works highlights the opportunities to capture more information regarding the surgical trainee experience in endocrine surgeries.
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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) 2021. [PMID: 34927274 DOI: 10.1111/cen.14650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [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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Kuo LE, Bird SH, Lubitz CC, Pandian TK, Parangi S, Stephen AE. Four-dimensional computed tomography (4D-CT) for preoperative parathyroid localization: A good study but are we using it? Am J Surg 2021; 223:694-698. [PMID: 34579935 DOI: 10.1016/j.amjsurg.2021.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Four-dimensional computed tomography (4D-CT) scan to localize abnormal parathyroid glands is diagnostically superior to ultrasound (US) and sestamibi. The implementation of 4D-CT imaging is unknown. METHODS The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database from 2014 to 2018 was utilized. Patients with hyperparathyroidism undergoing an initial operation were included. The rate of US, sestamibi and 4D-CT performance was calculated for the entire study population, and for each institution. RESULTS 7,959 patients were included. In 311(3.9%) patients, no preoperative imaging was recorded. Of patients with imaging, US was performed in 6,872(86.3%), sestamibi in 5,094(64.0%), and 4D-CT in 1,630(20.4%). The combination of US and sestamibi was most frequent (3,855, 48.4%). Institutional rates of 4D-CT performance varied from 0.1% to 88.7%. CONCLUSIONS Of the imaging modalities, 4D-CT was utilized least frequently and with greatest variability. Given the high accuracy of 4D-CT, efforts to reduce this variation may improve overall preoperative localization in patients with hyperparathyroidism.
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Affiliation(s)
- Lindsay E Kuo
- Department of Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA.
| | - Sarah H Bird
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carrie C Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - T K Pandian
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sareh Parangi
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Antonia E Stephen
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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Li SR, McCoy KL, Levitt HE, Kelley ML, Carty SE, Yip L. Is routine 24-hour urine calcium measurement useful during the evaluation of primary hyperparathyroidism? Surgery 2021; 171:17-22. [PMID: 34325903 DOI: 10.1016/j.surg.2021.04.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/17/2021] [Accepted: 04/30/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary hyperparathyroidism and familial hypocalciuric hypercalcemia have similar biochemical profiles, and calcium-to-creatinine-clearance ratio helps distinguish the two. Additionally, 24-hour urine calcium >400 mg/day indicates surgery and guidelines recommend obtaining 24-hour urine calcium preoperatively. Our aim was to assess how 24-hour urine calcium altered care in the evaluation of suspected primary hyperparathyroidism. METHODS Consecutive patients assessed for primary hyperparathyroidism from 2018 to 2020 were reviewed. Primary hyperparathyroidism was diagnosed by 2016 American Association of Endocrine Surgeons Parathyroidectomy Guidelines criteria. 24-hour urine calcium-directed change in care was defined as familial hypocalciuric hypercalcemia diagnosis, surgical deferment for additional testing, or 24-hour urine calcium >400 mg/day as the sole surgical indication. RESULTS Of 613 patients, 565 (92%) completed 24-hour urine calcium and 477 (84%) had concurrent biochemical testing to calculate calcium-to-creatinine-clearance ratio. 24-hour urine calcium was <100 mg/day in 9% (49/565) and calcium-to-creatinine-clearance ratio was <0.01 in 17% (82/477). No patient had confirmed familial hypocalciuric hypercalcemia, although 1 had a CASR variant of undetermined significance. When calcium-to-creatinine-clearance ratio was <0.01, familial hypocalciuric hypercalcemia was excluded by 24-hour urine calcium >100 mg/day (56%), prior normal calcium (16%), renal insufficiency (11%), absence of familial hypercalcemia (3%), normal repeat 24-hour urine calcium (10%), or interfering diuretic (1%). 24-hour urine calcium-directed change in care occurred in 25 (4%), including 4 (1%) who had genetic testing. Four-gland hyperplasia was more common with calcium-to-creatinine-clearance ratio <0.01 (17% vs calcium-to-creatinine-clearance ratio ≥ 0.01, 4%, P < .001), but surgical failure rates were equivalent (P = .24). CONCLUSION 24-hour urine calcium compliance was high, and results affected management in 4%, including productive identification of hypercalciuria as the sole surgical indication in 2 patients. When calcium-to-creatinine-clearance ratio <0.01, clinical assessment was sufficient to exclude familial hypocalciuric hypercalcemia and only 1% required genetic testing. 24-hour urine calcium should be ordered judiciously during primary hyperparathyroidism assessment.
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Affiliation(s)
- Shimena R Li
- Department of Surgery, University of Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Helena E Levitt
- Department of Medicine, Division of Endocrinology and Metabolism, University of Pittsburgh, PA
| | | | - Sally E Carty
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Department of Surgery, University of Pittsburgh, PA; Division of Endocrine Surgery, University of Pittsburgh, PA.
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Di Marco A, Mechera R, Glover A, Papachristos A, Clifton-Bligh R, Delbridge L, Sywak M, Sidhu S. Focused parathyroidectomy without intraoperative parathyroid hormone measurement in primary hyperparathyroidism: Still a valid approach? Surgery 2021; 170:1383-1388. [PMID: 34144815 DOI: 10.1016/j.surg.2021.05.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/27/2021] [Accepted: 05/17/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Concern regarding suboptimal cure rates has led to some endocrine surgery units abandoning focused parathyroidectomy for primary hyperparathyroidism in favor of open bilateral neck exploration or making intraoperative parathyroid hormone estimation mandatory in focused parathyroidectomy. This study explores whether focused parathyroidectomy for radiologically localized primary hyperparathyroidism without intraoperative parathyroid hormone is still a valid approach. METHODS Retrospective review of a tertiary referral endocrine surgery unit database. All parathyroidectomies for primary hyperparathyroidism over 6 years (2013-2019) were included. Lithium-induced hyperparathyroidism, reoperations, familial disease, and concurrent thyroid surgery were excluded. Characteristics and outcomes for focused parathyroidectomy and open bilateral neck exploration were compared by intention-to-treat and treatment delivered. Persistence and recurrence, conversions and complications were analyzed as endpoints. RESULTS A total of 2,828 parathyroidectomies were performed and 2,421 analyzed. By intention to treat there were 1,409 focused parathyroidectomies and 1,012 open bilateral neck explorations. Focused parathyroidectomy patients were younger: 63 vs 66 years (P < .01); however, gender (77%, 79% female), preoperative peak serum calcium (2.72, 2.70 mmol/L [P = .23]), and serum parathyroid hormone (11.5, 11.0 pmol/L [P = .52]) did not differ. In total, 229 (16.3%) focused parathyroidectomies were converted to open bilateral neck exploration. Multiple gland disease was confirmed in 54.5% of converted patients. Median follow-up was 41 months (3-60 months). Persistence or recurrence requiring reoperation totaled 2.2% and did not differ between focused parathyroidectomy and open bilateral neck exploration in either intention to treat or final treatment analyses. Complications occurred in 1.2% of focused parathyroidectomy and 3.2% open bilateral neck exploration (P < .01). CONCLUSIONS In experienced hands and with a ready-selective approach to conversion, focused parathyroidectomy based on concordant imaging and without intraoperative parathyroid hormone may deliver equivalent cure rates to open bilateral neck exploration with significantly fewer complications. Focused parathyroidectomy without intraoperative parathyroid hormone should therefore be maintained in the endocrine surgeon's armamentarium.
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Affiliation(s)
- Aimee Di Marco
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College, London, UK. https://twitter.com/@aimeedimarco
| | - Robert Mechera
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Clarunis, University Hospital Basel, Basel, Switzerland.
| | - Anthony Glover
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia. https://twitter.com/@DrAntG
| | - Alex Papachristos
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia
| | - Roderick Clifton-Bligh
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Department of Endocrinology, Royal North Shore Hospital, University of Sydney, St Leonards, New South Wales, Australia; Cancer Genetics Unit, Kolling Institute, Sydney, New South Wales, Australia
| | - Leigh Delbridge
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Mark Sywak
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Stan Sidhu
- Endocrine Surgical Unit, University of Sydney, St Leonards, New South Wales, Australia; Sydney Medical School, Faculty of Medicine and Health, University of Sydney, New South Wales, Australia; Cancer Genetics Unit, Kolling Institute, Sydney, New South Wales, Australia
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Galani A, Morandi R, Dimko M, Molfino S, Baronchelli C, Lai S, Gheza F, Cappelli C, Casella C. Atypical parathyroid adenoma: clinical and anatomical pathologic features. World J Surg Oncol 2021; 19:19. [PMID: 33472651 PMCID: PMC7818751 DOI: 10.1186/s12957-021-02123-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/05/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Primary hyperparathyroidism is an endocrine pathology that affects calcium metabolism. Patients with primary hyperparathyroidism have high concentrations of serum calcium or high concentrations of parathyroid hormone, or incorrect parathyroid hormone levels for serum calcium values. Primary hyperparathyroidism is due to the presence of an adenoma/single-gland disease in 80-85%. Multiple gland disease or hyperplasia accounts for 10-15% of cases of primary hyperparathyroidism. Atypical parathyroid adenoma and parathyroid carcinoma are both responsible for about 1.2-1.3% and 1% or less of primary hyperparathyroidism, respectively. METHODS We performed a retrospective cohort study and enrolled 117 patients with primary hyperparathyroidism undergoing minimally invasive parathyroidectomy. Histological and immunohistochemical examination showed that 107 patients (91.5%) were diagnosed with typical adenoma (group A), while 10 patients (8.5%) were diagnosed with atypical parathyroid adenoma (group B). None of the patients were affected by parathyroid carcinoma. RESULTS Significant statistical differences were found in histological and immunohistochemical parameters as pseudocapsular invasion (p < 0.001), bands of fibrosis (p < 0.001), pronounced trabecular growth (p < 0.001), mitotic rates of > 1/10 high-power fields (HPFs) (p < 0.001), nuclear pleomorphism (p = 0.036), thick capsule (p < 0.001), Ki-67+ > 4% (p < 0.001), galectin-3 + (p = 0.002), and protein gene product (PGP) 9.5 + (p = 0.038). CONCLUSIONS Atypical parathyroid adenoma is a tumor that has characteristics both of typical adenoma and parathyroid carcinoma. The diagnosis is reached by excluding with strict methods the presence of malignancy criteria. Atypical parathyroid adenoma compared to typical adenoma showed significant clinical, hematochemical, histological, and immunohistochemical differences. We did not find any disease relapse in the 10 patients with atypical parathyroid adenoma during 60 months of follow-up time.
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Affiliation(s)
- Alessandro Galani
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy.
| | - Riccardo Morandi
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Mira Dimko
- Nephrology and Dialysis Unit, ASST Carlo Poma, Mantova, Italy
| | - Sarah Molfino
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
| | | | - Silvia Lai
- Department of Translation and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Federico Gheza
- Department of Clinical and Experimental Sciences, Surgical Clinic, University of Brescia, Brescia, Italy
| | - Carlo Cappelli
- Department of Clinical and Experimental Sciences, Unit of Endocrinology and Metabolism, University of Brescia, Brescia, Italy
| | - Claudio Casella
- Department of Molecular and Translational Medicine, Surgical Clinic, University of Brescia, Brescia, Italy
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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: 4] [Impact Index Per Article: 1.0] [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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Gimm O, Barczyński M, Mihai R, Raffaelli M. Training in endocrine surgery. Langenbecks Arch Surg 2019; 404:929-944. [PMID: 31701231 PMCID: PMC6935392 DOI: 10.1007/s00423-019-01828-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/20/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND/PURPOSE In Europe, the Division of Endocrine Surgery (DES) determines the number of operations (thyroid, neck dissection, parathyroids, adrenals, neuroendocrine tumors of the gastro-entero-pancreatic tract (GEP-NETs)) to be required for the European Board of Surgery Qualification in (neck) endocrine surgery. However, it is the national surgical boards that determine how surgical training is delivered in their respective countries. There is a lack of knowledge on the current situation concerning the training of surgical residents and fellows with regard to (neck) endocrine surgery in Europe. METHODS A survey was sent out to all 28 current national delegates of the DES. One questionnaire was addressing the training of surgical residents while the other was addressing the training of fellows in endocrine surgery. Particular focus was put on the numbers of operations considered appropriate. RESULTS For most of the operations, the overall number as defined by national surgical boards matched quite well the views of the national delegates even though differences exist between countries. In addition, the current numbers required for the EBSQ exam are well within this range for thyroid and parathyroid procedures but below for neck dissections as well as operations on the adrenals and GEP-NETs. CONCLUSIONS Training in endocrine surgery should be performed in units that perform a minimum of 100 thyroid, 50 parathyroid, 15 adrenal, and/or 10 GEP-NET operations yearly. Fellows should be expected to have been the performing surgeon of a minimum of 50 thyroid operations, 10 (central or lateral) lymph node dissections, 15 parathyroid, 5 adrenal, and 5 GEP-NET operations.
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Affiliation(s)
- Oliver Gimm
- Department of Surgery and Department of Clinical and Experimental Medicine (IKE), Linköping University, 58183 Linköping, Sweden
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202 Kraków, Poland
| | - Radu Mihai
- Department of Endocrine Surgery, Churchill Cancer Centre, Oxford University Hospital NHS Foundation Trust, Oxford, OX3 7DU United Kingdom
| | - Marco Raffaelli
- U.O. Chirurgia Endocrina e Metabolica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Semeiotica Chirurgica, Università Cattolica del Sacro Cuore, Rome, Italy
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Bhangu JS, Riss P. The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT). Best Pract Res Clin Endocrinol Metab 2019; 33:101310. [PMID: 31409538 DOI: 10.1016/j.beem.2019.101310] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed - each with their particular advantages and disadvantages, but the "perfect" criterion is still missing. Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease.
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Affiliation(s)
- Jagdeep Singh Bhangu
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Philipp Riss
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Practice Patterns in Parathyroid Surgery: A Survey of Asia-Pacific Parathyroid Surgeons. World J Surg 2019; 43:1964-1971. [PMID: 30941454 DOI: 10.1007/s00268-019-04990-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Practice variations exist amongst parathyroid surgeons depending on their expertise and resources. Our study aims to elucidate the choice of surgical techniques and adjuncts used in parathyroid surgery by surgeons in the Asia-Pacific region. METHODS A 25-question online survey was sent to members of five endocrine surgery associations. Questions covered training background, practice environment and preferred techniques in parathyroid surgery. Respondents were divided into three regions: Australia/New Zealand, South/South East Asia and East Asia, and responses were analysed according to region, specialty, case volume and years in practice. RESULTS One hundred ninety-six surgeons returned the questionnaire. Most surgeons (98%) routinely perform preoperative imaging, with 75% preferring dual imaging with 99mTcsestamibi and ultrasound. Ten per cent of surgeons use parathyroid 4DCT as first-line imaging, more commonly in East Asia (p = 0.038). Minimally invasive parathyroidectomy is the favoured technique of choice (97%). Most surgeons reporting robotic or endoscopic approaches are from East Asia. Rapid intraoperative parathyroid hormone is accessible to just under half of the surgeons but less available in Australian/New Zealand (p < 0.001). The use of intraoperative neuromonitoring is not commonly used, even less so amongst Asian surgeons (p = 0.048) and surgeons with low case load (p = 0.013). CONCLUSION Dual localisation techniques are the preferred choice of investigations in preparation for parathyroid surgery, with minimally invasive surgery without neuromonitoring the preferred approach. Use of adjuncts is sporadic and limited to certain centres.
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Kiernan CM, Wang T, Perrier ND, Grubbs EG, Solórzano CC. Bilateral Neck Exploration for Sporadic Primary Hyperparathyroidism: Use Patterns in 5,597 Patients Undergoing Parathyroidectomy in the Collaborative Endocrine Surgery Quality Improvement Program. J Am Coll Surg 2019; 228:652-659. [DOI: 10.1016/j.jamcollsurg.2018.12.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/19/2018] [Indexed: 01/12/2023]
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Thimmappa V, Smith A, Wood J, Shires CB, Langsdon S, Sebelik M. Management protocol for primary hyperparathyroidism in a single institution: utility of surgeon performed ultrasound. Gland Surg 2018; 7:S53-S58. [PMID: 30175064 DOI: 10.21037/gs.2018.07.02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background We aimed to: (I) discover preoperative diagnostic studies, intraoperative techniques, and patient factors most predictive of cure within a single hospital system; (II) establish practice guidelines for surgical treatment of primary hyperparathyroidism to maximize outcomes based on this hospital system's performance. Methods A retrospective chart review was undertaken of all parathyroid-related procedures from 01/01/02 to 7/31/15 at the Veteran's Administration Hospital. Results Seventy-one patients were eligible and charts available for analysis. Preoperative studies most predictive of cure were a combination of sestamibi parathyroid scan and surgeon performed ultrasound (S-US). When studies did not agree, S-US was most often correct. Intraoperative parathyroid hormone (PTH) rapid assay was helpful in predicting cure, but added an average of 33 minutes to operating room time. Patients who had two corroborating preoperative localizing studies, one of which was S-US, that agreed with intraoperative findings, and who did not undergo intraoperative PTH confirmation enjoyed equal cure rates and shorter operating room times. Successful achievement of normal calcium was high at 95.8%. Vitamin D deficiency was prevalent in this patient population, prompting more aggressive preoperative investigation and replacement. Conclusions A management protocol was developed based on the findings of this study: (I) obtain two preoperative localization studies, one of which is surgeon-performed ultrasound; (II) obtain preoperative vitamin D levels and supplement as indicated; and (III) in select patients who have two strongly corroborating preoperative localization studies, one of which is surgeon performed ultrasound, and intraoperative findings are consistent with the localizing studies, intraoperative PTH (IOPTH) may not be necessary.
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Affiliation(s)
- Vikrum Thimmappa
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aaron Smith
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Joshua Wood
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Courtney B Shires
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sarah Langsdon
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Merry Sebelik
- Department of Otolaryngology, Head & Neck Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.,Veteran's Affairs Medical Center, Memphis, TN, USA
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Carr AA, Yen TW, Wilson SD, Evans DB, Wang TS. Using parathyroid hormone spikes during parathyroidectomy to guide intraoperative decision-making. J Surg Res 2017; 209:162-167. [DOI: 10.1016/j.jss.2016.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 09/21/2016] [Accepted: 10/05/2016] [Indexed: 11/28/2022]
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Javid M, Callender G, Quinn C, Carling T, Donovan P, Udelsman R. Primary hyperparathyroidism with normal baseline intraoperative parathyroid hormone: A challenging population. Surgery 2017; 161:493-498. [DOI: 10.1016/j.surg.2016.08.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/20/2016] [Accepted: 08/09/2016] [Indexed: 11/29/2022]
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Trinh G, Noureldine SI, Russell JO, Agrawal N, Lopez M, Prescott JD, Zeiger MA, Tufano RP. Characterizing the operative findings and utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with normal baseline IOPTH and normohormonal primary hyperparathyroidism. Surgery 2016; 161:78-86. [PMID: 27863787 DOI: 10.1016/j.surg.2016.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 09/13/2016] [Accepted: 10/01/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND During parathyroidectomy with intraoperative parathyroid hormone monitoring, the successful removal of a hypersecreting gland(s) resulting in normocalcemia is indicated by a >50% decrease in intraoperative parathyroid hormone level, typically into the normal range. Some patients, however, will have baseline parathyroid hormone levels within the normal range. We sought to determine the utility of intraoperative parathyroid hormone testing in these patients. METHODS We retrospectively studied all patients who underwent parathyroidectomy for primary hyperparathyroidism at our institution over a 10-year period. RESULTS Overall, 317 (17%) patients had parathyroid hormone within the normal range at the onset of operation (baseline intraoperative parathyroid hormone), and 1,544 (83%) had classic primary hyperparathyroidism. The intraoperative parathyroid hormone degradation was slower in normal baseline intraoperative parathyroid hormone patients than classic primary hyperparathyroidism patients, though this did not reach statistical significance (P < .254). A >50% intraoperative parathyroid hormone decrease predicted cure in 98.7% of normal baseline patients and 98.8% of classic primary hyperparathyroidism patients (P = .810). Normal baseline patients had a lesser cure rate the longer it took to achieve a 50% decrease intraoperatively; however, the cure rate was constant at any time point the 50% decrease occurred in patients with classic primary hyperparathyroidism (P < .05). CONCLUSION The 50% rule delineating operative cure can be applied with equal confidence to patients with normal range, baseline intraoperative parathyroid hormone. Moreover, the time at which the 50% drop is achieved impacts operative success rates in these patients.
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Affiliation(s)
- Gina Trinh
- Queen's University School of Medicine, Kingston, Ontario, Canada
| | - Salem I Noureldine
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jonathon O Russell
- Division of Head and Neck Endocrine Surgery, Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Nishant Agrawal
- Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago, IL
| | - Michael Lopez
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Jason D Prescott
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martha A Zeiger
- Endocrine Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ralph P Tufano
- Department of Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC.
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Ambulatory bilateral neck exploration for primary hyperparathyroidism: is it safe? Am J Surg 2016; 212:722-727. [DOI: 10.1016/j.amjsurg.2016.06.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 06/07/2016] [Accepted: 06/23/2016] [Indexed: 11/18/2022]
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Laird AM, Libutti SK. Minimally Invasive Parathyroidectomy Versus Bilateral Neck Exploration for Primary Hyperparathyroidism. Surg Oncol Clin N Am 2016; 25:103-18. [PMID: 26610777 DOI: 10.1016/j.soc.2015.08.012] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Primary hyperparathyroidism is a disease that is caused by excess parathyroid hormone (PTH) secretion from 1 or more of the parathyroid glands. Surgery is the only cure. Traditional surgical management consists of a 4-gland cervical exploration. Development of imaging specific to identification of parathyroid glands and application of the rapid PTH assay to operative management have made more minimal exploration possible. There are distinct advantages and disadvantages of minimally invasive parathyroidectomy (MIP) and bilateral neck exploration (BNE). The advantages of MIP seem to outweigh those of BNE, and MIP has replaced BNE as the operation of choice by many surgeons.
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Affiliation(s)
- Amanda M Laird
- Montefiore Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 3400 Bainbridge Avenue, 4th Floor, Bronx, NY 10467, USA.
| | - Steven K Libutti
- Montefiore Medical Center/Albert Einstein College of Medicine, Greene Medical Arts Pavilion, 3400 Bainbridge Avenue, 4th Floor, Bronx, NY 10467, USA
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Oltmann SC, Alhefdhi AY, Rajaei MH, Schneider DF, Sippel RS, Chen H. Antiplatelet and Anticoagulant Medications Significantly Increase the Risk of Postoperative Hematoma: Review of over 4500 Thyroid and Parathyroid Procedures. Ann Surg Oncol 2016; 23:2874-82. [PMID: 27138383 DOI: 10.1245/s10434-016-5241-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE Antiplatelet and/or anticoagulant medication use is common. Abstinence a week before surgery may still result in altered hemostasis. The study aim was to report on perioperative antiplatelet and anticoagulant use in thyroidectomy and parathyroidectomy patients, and to determine the association with postoperative hematoma (POH) rates. METHODS Retrospective review of a prospective endocrine surgery database was performed. Procedure extent was defined as unilateral, bilateral, or extensive. Antiplatelets were categorized as none, 325 mg aspirin (ASA), <325 mg ASA, clopidogrel, or other. Anticoagulants were categorized as none, oral, or injectable. RESULTS A total of 4514 patients were identified. POH developed in 22 patients (0.5 %). Rates were similar between age, gender, and reoperative status. POH were seven times more common after thyroidectomy (0.8 vs. 0.1 %, p < 0.01). Unilateral procedures had lower POH rates than bilateral or extensive (0.1 vs. 0.9 vs. 0.8 %, p < 0.01). POH rates in patients receiving 325 mg ASA (0.8 %) or clopidogrel (2.2 %) were much higher than patients not receiving antiplatelets (0.5 %) or receiving <325 mg ASA (0.1 %, p = 0.04). Oral anticoagulants (2.2 %) and injectable anticoagulants (10.7 %) had much higher POH rates than patients not receiving anticoagulants (0.4 %, p < 0.01). Target organ, patient gender, procedure extent, antiplatelet use, and anticoagulant use were included on logistic regression to determine association with POH. Bilateral procedures, thyroidectomy, clopidogrel, oral, and injectable anticoagulants were all independently associated with POH. CONCLUSIONS POH occur more frequently after thyroidectomy and during bilateral procedures. Patients requiring clopidogrel or any anticoagulant coverage are at much higher risk for POH. These higher-risk patients should be considered for observation to ensure prompt POH recognition and intervention.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Amal Y Alhefdhi
- Department of Surgery, The King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | | | | | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, Madison, WI, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
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Lai V, Yen TWF, Doffek K, Carr AA, Carroll TB, Fareau GG, Evans DB, Wang TS. Delayed Calcium Normalization After Presumed Curative Parathyroidectomy is Not Associated with the Development of Persistent or Recurrent Primary Hyperparathyroidism. Ann Surg Oncol 2016; 23:2310-4. [PMID: 27006125 DOI: 10.1245/s10434-016-5190-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Following parathyroidectomy for primary hyperparathyroidism (pHPT), serum calcium levels typically normalize relatively quickly. The purpose of this study was to identify potential factors associated with delayed normalization of calcium levels despite meeting intraoperative parathyroid hormone (IOPTH) criteria and to determine whether this phenomenon is associated with higher rates of persistent pHPT. METHODS This was a retrospective review of 554 patients who underwent parathyroidectomy for sporadic pHPT from January 2009 to July 2013. Patients who underwent presumed curative parathyroidectomy and had elevated POD0 calcium levels (>10.2 mg/dL) were matched 1:2 for age and gender to control patients with normal POD0 calcium levels. RESULTS Of the 554 patients, 52 (9 %) had an elevated POD0 Ca (median 10.7, range 10.3-12.2). Compared with the control group, these patients had higher preoperative calcium (12 vs. 11.1, p < 0.001) and PTH (144 vs. 110 pg/mL, p = 0.004) levels and lower 25OH vitamin D levels (26 vs. 31 pg/mL; p = 0.024). Calcium normalization occurred in 64, 90, and 96 % of patients by postoperative days (POD) 1, 14, and 30, respectively. There was no difference in rates of single-gland disease or cure rates between the groups. CONCLUSIONS After presumed curative parathyroidectomy, nearly 10 % of patients had transiently persistent hypercalcemia. Most of these patients had normal serum calcium levels within the first 2 weeks and did not have increased rates of persistent pHPT. Immediate postoperative calcium levels do not predict the presence of persistent pHPT, and these patients may not require more stringent follow-up.
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Affiliation(s)
| | - Tina W F Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Azadeh A Carr
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ty B Carroll
- Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Gilbert G Fareau
- Division of Clinical Endocrinology, Metabolism, and Nutrition, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
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Oltmann SC, Sippel RS. Surgical management of the patient with primary hyperparathyroidism. INTERNATIONAL JOURNAL OF ENDOCRINE ONCOLOGY 2015. [DOI: 10.2217/ije.14.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract: The successful surgical management of primary hyperparathyroidism requires a surgeon with a clear understanding of both the embryology and anatomy of the parathyroid glands. While the majority of patients may only have a single diseased gland, there is no 100% confirmation that can be attained in the preoperative period. For this reason, even when imaging is suggestive of a single diseased gland, additional intraoperative adjuncts should be used. Intraoperative parathyroid hormone monitoring is the most commonly used adjunct. When preoperative localization is not possible, or intraoperative parathyroid hormone levels fail to meet criteria for successful resection, the patient requires a four gland exploration. Cure is not confirmed until normocalcemia is documented for at least 6 months after surgery.
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Affiliation(s)
- Sarah C Oltmann
- Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-9092, USA
| | - Rebecca S Sippel
- Department of Surgery, University of Wisconsin, 600 Highland Ave, K3/704, Madison, WI, 53792-7375, USA
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Carty SE. 2014 American Association of Endocrine Surgeons presidential address: evolution. Surgery 2014; 156:1289-96. [PMID: 25456898 DOI: 10.1016/j.surg.2014.08.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 08/21/2014] [Indexed: 11/29/2022]
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Oltmann SC, Holt SA. How do we improve patient access to high-volume thyroid surgeons? Surgery 2014; 156:1450-2. [DOI: 10.1016/j.surg.2014.08.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 08/22/2014] [Indexed: 11/24/2022]
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Rajaei MH, Oltmann SC, Adkisson CD, Elfenbein DM, Chen H, Carty SE, McCoy KL. Is intraoperative parathyroid hormone monitoring necessary with ipsilateral parathyroid gland visualization during anticipated unilateral exploration for primary hyperparathyroidism: a two-institution analysis of more than 2,000 patients. Surgery 2014; 156:760-6. [PMID: 25239313 DOI: 10.1016/j.surg.2014.06.060] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 06/24/2014] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Intraoperative parathyroid hormone (ioPTH) monitoring during focused parathyroidectomy for primary hyperparathyroidism (PHPT) is used commonly, but some argue that ioPTH adds little if a normal ipsilateral parathyroid gland (IPG) is visualized. This hypothesis was tested for validity. METHODS The prospective databases of consecutive patients with PHPT undergoing initial parathyroidectomy with ioPTH at two academic institutions were queried. Patients with ectopic adenoma, familial PHPT, previous parathyroidectomy, planned bilateral exploration, or <6 months follow-up were excluded. Persistence was defined as hypercalcemia at <6 months. RESULTS From 1998 to 2013, 2,162 patients met inclusion criteria, and the rate of persistent disease was 1.5%. Most (n = 1,353; 63.5%) underwent single-gland resection with ioPTH and no IPG visualization, with 1% persistence. Among patients with a single adenoma resected and a normal IPG visualized, 15.2% had contralateral disease. Resection based on IPG appearance alone would have resulted in 13% persistent disease. CONCLUSION In PHPT, the cure rate for initial unilateral exploration guided by ioPTH is 98.5% versus a predicted rate of 87% when decision making is based on IPG appearance alone. Routine visualization of IPG is not necessary during exploration for suspected single adenoma guided by ioPTH. ioPTH remains useful in optimizing outcomes.
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Affiliation(s)
| | - Sarah C Oltmann
- Department of Surgery, University of Wisconsin, Madison, WI.
| | | | | | - Herbert Chen
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Sally E Carty
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Kelly L McCoy
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Wharry LI, Yip L, Armstrong MJ, Virji MA, Stang MT, Carty SE, McCoy KL. The final intraoperative parathyroid hormone level: how low should it go? World J Surg 2014; 38:558-63. [PMID: 24253106 DOI: 10.1007/s00268-013-2329-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In minimally invasive surgery for primary hyperparathyroidism (HPT), intraoperative parathyroid hormone (IOPTH) monitoring assists in obtaining demonstrably better outcomes, but optimal criteria are controversial. METHODS The outcomes of 1,108 initial parathyroid operations for sporadic HPT using IOPTH monitoring from 1997 to 2011 were stratified by final post-resection IOPTH level. All patients had adequate follow-up to verify cure. RESULTS With mean follow-up of 1.8 years (range 0.5-14.3 years), parathyroidectomy using IOPTH monitoring failed in 1.2 % of cases, with an additional 0.5 % incidence of long-term recurrence at a mean of 3.2 years (range 0.8-6.8 years) postoperatively. Operative success was equally likely with a final IOPTH drop to 41-65 pg/mL vs ≤40 pg/mL (p = 1). In the 76 patients with an elevated baseline IOPTH level that did not drop to ≤65 pg/mL, surgical failure was 43 times more likely than with a drop into normal range (13 vs. 0.3 %; p < 0.001). When the final IOPTH level dropped by >50 % but not into the normal range, surgical failure was 19 times more likely (3.8 vs. 0.2 %; p = 0.015). Long-term recurrence was more likely in patients with a final IOPTH level of 41-65 pg/mL than with a level ≤40 pg/mL (1.2 vs. 0; p = 0.016). CONCLUSIONS Adjunctive intraoperative PTH monitoring facilitates a high cure rate for initial surgery of sporadic primary hyperparathyroidism. A final IOPTH level that is within the normal range and drops by >50 % from baseline is a strong predictor of operative success. Patients with a final IOPTH level between 41-65 pg/mL should be followed beyond 6 months for long-term recurrence.
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Affiliation(s)
- Laura I Wharry
- Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, Pittsburgh, PA, 15213, USA
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Rajaei MH, Bentz AM, Schneider DF, Sippel RS, Chen H, Oltmann SC. Justified follow-up: a final intraoperative parathyroid hormone (ioPTH) Over 40 pg/mL is associated with an increased risk of persistence and recurrence in primary hyperparathyroidism. Ann Surg Oncol 2014; 22:454-9. [PMID: 25192677 DOI: 10.1245/s10434-014-4006-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Indexed: 11/18/2022]
Abstract
INTRODUCTION After parathyroidectomy for sporadic primary hyperparathyroidism (PHPT), overall rates of persistence/recurrence are extremely low. A marker of increased risk for persistence/recurrence is needed. We hypothesized that final intraoperative parathyroid hormone (FioPTH) ≥40 pg/mL is indicative of increased risk for disease persistence/recurrence, and can be used to selectively determine the degree of follow-up. METHOD A retrospective review of PHPT patients undergoing parathyroidectomy with ioPTH monitoring was performed. An ioPTH decline of 50 % was the only criteria for operation termination. Patients were grouped based on FioPTH of <40, 40-59, and >60 pg/mL. RESULTS Between 2001 and 2012, 1,371 patients were included. Mean age was 61 ± 0.4 years, and 78°% were female. Overall persistence rate was 1.4°%, with a 2.9°% recurrence rate. Overall, 976 (71°%) patients had FioPTH < 40, 228 (16.6°%) had FioPTH 40-59, and 167 (12.2°%) had FioPTH ≥60. Mean follow-up was 21 ± 0.6 months. Patients with FioPTH <40 were younger, with lower preoperative serum calcium, PTH, and creatinine (all p ≤ 0.001). Patients with FioPTH <40 had the lowest persistence rate (0.2 %) versus patients with FioPTH 40-59 (3.5 %) or FioPTH ≥60 (5.4 %; p < 0.001). Recurrence rate was also lowest in patients with FioPTH <40 (1.3 vs. 5.9 vs. 8.2 %, respectively; p < 0.001). Disease-free status was greatest in patients with FioPTH <40 at 2 years (98.5 vs. 96.8 vs. 90.5 %, respectively) and 5 years (95.7 vs. 72.3 vs. 74.8 %, respectively; p < 0.01). CONCLUSIONS Patients with FioPTH < 40 pg/mL had lower rates of persistence and recurrence, than patients with FioPTH 40-59, or ≥60. Differences became more apparent after 2 years of follow-up. Patients with FioPTH ≥40 pg/mL warrant close and prolonged follow-up.
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Affiliation(s)
- Mohammad H Rajaei
- Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA
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Oltmann SC, Brekke AV, Macatangay JD, Schneider DF, Chen H, Sippel RS. Surgeon and Staff Radiation Exposure During Radioguided Parathyroidectomy at a High-Volume Institution. Ann Surg Oncol 2014; 21:3853-8. [DOI: 10.1245/s10434-014-3822-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Indexed: 11/18/2022]
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McCoy KL, Chen NH, Armstrong MJ, Howell GM, Stang MT, Yip L, Carty SE. The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity. World J Surg 2014; 38:1274-81. [DOI: 10.1007/s00268-014-2450-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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