[Reoperation for persistent or recurrent primary hyperparathyroidism. Seventy-seven cases among 1888 operated patients]

Cystic parathyroid lesion: case report of rare entity

Introduction and importance

Parathyroid cysts are rarely encountered in neck surgery and often misdiagnosed. We review the case incidence and treatment of parathyroid cystic lesions among all neck procedure in two single institutions operated on by a single surgeon.

Case presentation

We report two female patients presenting with neck swallowing, dysphagia, choking and occasional dysphonia. Ultrasound US (ultrasound) imaging revealed two neck masses of 66 × 44 mm and 44 × 25 × 23 mm; serum iPTH (intact Parathyroid Hormone) levels were 238 and 699 ng/mL respectively and sestamibi scintiscan results were negative for both masses. Intra-cystic fluid evaluation of PTH showed elevated value (>5000 ng/ml). Both patients underwent parathyroidectomy along with total thyroidectomy and thyroid lobectomy. Post-operatively I-PTH and serum calcium levels became normal. Final histology confirmed a benign parathyroid cystic adenoma with concomitant benign thyroid disease.

Clinical discussion

Parathyroid cyst is of rare entity and a diagnostic challenge.

Conclusions

This case report demonstrates that fine needle aspiration (FNA) fluid with intra-cystic parathyroid analysis shows to be fundamental and supports surgery for hyperparathyroidism resolution.

Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery

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.

Monocentric experience of primary hyperparathyroidism surgery in Algeria

Introduction

Primary hyperparathyroidism (PHPT) remains a relatively underdiagnosed disease in developing countries. The aim of this study was to assess the demographic, pathological, biochemical, and surgical characteristics of patients with primary hyperparathyroidism in a university hospital department of otolaryngology in eastern Algeria.

Materials and method

We performed a retrospective analysis of the records of 62 patients operated in our department for primary hyperparathyroidism between January 2002 and December 2013.

Results

The mean age was 47.7 ± 15 years with a female preponderance (88.7%). The mode of discovery was during a biological assessment for bone syndrome in 42% of cases. The mean calcemia was 2.92 ± 0.6 mmol/L, and the intact serum parathyroid hormone was 867.78 ± 954.50 pmol/L. A total of 54.8% of patients had bilateral neck exploration, and 45.2% had minimally invasive open parathyroidectomy. Postoperative complications were dominated by severe hypocalcemia and hungry bone syndrome.

Conclusion

The diagnosis of primary hyperparathyroidism in our country is late, and management is often performed after the appearance of bone and renal complications.

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Primary hyperparathyroidism is an underdiagnosed disease in developing countries.

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The diagnosis is made after the appearance of bone and renal complications.

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Bone manifestations are the most common presenting symptoms.

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Biochemical profile is dominated by hypercalcemia and elevated serum parathyroid hormone levels.

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Average adenoma weight is very high, correlating with severe hyperparathyroidism.

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Hypocalcemia and hungry bone syndrome are the most common postoperative complications.

Aortopulmonary ectopic parathyroid gland and concurrent thymolipoma

Ectopic parathyroid adenomas are considered the main cause of primary hyperparathyroidism. However, concurrent parathyroid and thymic pathologies are rarely diagnosed in the same patient. A 47-year-old man with history of diabetes mellitus, hypertension, and myasthenia gravis presented with persistent hypercalcemia. Laboratory investigations, computed tomography, and technetium-99 m sestamibi scintigraphy revealed ectopic parathyroid glands, a mediastinal mass, and an enlarged thymus. The patient underwent thymectomy and mass excision via a median sternotomy. Histopathology was consistent with ectopic parathyroid adenoma and thymolipoma. The serum calcium and parathormone concentrations normalized within 48 hours after surgery.

[Localization of parathyroid adenomas with C11-methionine PET-CT]

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.

Surgical approach in patients with hyperparathyroidism in multiple endocrine neoplasia type 1: total versus partial parathyroidectomy

Usually, primary hyperparathyroidism is the first endocrinopathy to be diagnosed in patients with multiple endocrine neoplasia type 1, and is also the most common one. The timing of the surgery and strategy in multiple endocrine neoplasia type 1/hyperparathyroidism are still under debate. The aims of surgery are to: 1) correct hypercalcemia, thus preventing persistent or recurrent hyperparathyroidism; 2) avoid persistent hypoparathyroidism; and 3) facilitate the surgical treatment of possible recurrences. Currently, two types of surgical approach are indicated: 1) subtotal parathyroidectomy with removal of at least 3-3 K glands; and 2) total parathyroidectomy with grafting of autologous parathyroid tissue. Transcervical thymectomy must be performed with both of these procedures. Unsuccessful surgical treatment of hyperparathyroidism is more frequently observed in multiple endocrine neoplasia type 1 than in sporadic hyperparathyroidism. The recurrence rate is strongly influenced by: 1) the lack of a pre-operative multiple endocrine neoplasia type 1 diagnosis; 2) the surgeon's experience; 3) the timing of surgery; 4) the possibility of performing intra-operative confirmation (histologic examination, rapid parathyroid hormone assay) of the curative potential of the surgical procedure; and, 5) the surgical strategy. Persistent hyperparathyroidism seems to be more frequent after subtotal parathyroidectomy than after total parathyroidectomy with autologous graft of parathyroid tissue. Conversely, recurrent hyperparathyroidism has a similar frequency in the two surgical strategies. To plan further operations, it is very helpful to know all the available data about previous surgery and to undertake accurate identification of the site of recurrence.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

PURPOSE

Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration.

MATERIALS AND METHODS

Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence.

RESULTS

Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia.

CONCLUSIONS

Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.

Virtual neck exploration in patients with hyperparathyroidism and former cervical operations

BACKGROUND

In surgery for primary hyperparathyroidism, preoperative localization together with intraoperative parathyroid hormone assay is important when minimal invasive operations of the parathyroid glands are intended. In cases of reoperation, correct localization of the abnormal parathyroid glands is extremely instrumental. Computed tomography (CT)-(99m)Tc-sestamibi (MIBI)-single photon emission computed tomography (SPECT) image fusion allows for a virtual exploration of the neck by showing the suspected gland three-dimensionally with all the anatomic landmarks in correct position. The aim of this study was to evaluate whether CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in detecting abnormal parathyroid glands in patients with previous neck surgery.

PATIENTS AND METHODS

In a prospective study, CT-MIBI-SPECT image fusion for preoperative localization was performed in 28 patients with hyperparathyroidism and previous neck surgery. Twenty-one patients had thyroidectomy and seven patients had surgery for hyperparathyroidism. The results of MIBI-SPECT alone and CT-MIBI-SPECT image fusion were compared in these patients. The outcome and the exact predicted position, not just the predicted side, were correlated with intraoperative findings.

RESULTS

CT-MIBI-SPECT image fusion was able to predict the exact position of the abnormal gland in 24 of 28 patients (86%), whereas MIBI-SPECT alone was successful in 12 of 28 cases (43%, p < 0.004) only. CT-MIBI-SPECT image fusion detected all three pathologic glands in their ectopic position. With MIBI-SPECT alone, just one ectopic pathologic gland was found.

CONCLUSION

This study provides evidence that CT-MIBI-SPECT image fusion is superior to MIBI-SPECT alone in preoperative localization of enlarged parathyroid glands in patients with hyperparathyroidism and previous neck surgery. This should be kept in mind if the results are compared to earlier studies concerning CT-MIBI-SPECT image fusion.

Mediastinal hyperfunctioning parathyroids: incidence, evolving treatment, and outcome

BACKGROUND

The evaluation and treatment of hyperfunctioning mediastinal parathyroid gland(s) (MPG) is evolving. This study reports our overall experience with MPG in a tertiary referral center.

METHODS

A prospective database of 922 patients undergoing parathyroidectomy by 2 surgeons from 1982 to 2005 was reviewed.

RESULTS

Thirty-two of 922 (3.5%) patients had MPG. Nine (28%) patients had a prior failed parathyroidectomy. Sestamibi and computed tomography scans were correctly positive in 24/28 (86%) and 6/7 (86%) patients, respectively. MPGs were removed via cervical approach in 22 (69%). Eleven of 22 patients had a focused cervical approach. Nine MPGs required a limited sternotomy (n = 3) or a successful radioguided video-assisted thoracoscopic approach (VATS, n = 4) for removal. Two VATS were converted to a full sternotomy. One patient refused surgery. All patients who required sternotomy/VATS had MPGs caudal to the innominate vein. Twenty-nine of 31 (94%) patients were cured. Two are stable on calcimimetics. One patient has permanent hypoparathyroidism.

CONCLUSIONS

Most MPGs can be removed through a cervical approach. Preoperative Sestamibi and computed tomography scans can help the surgeon plan the best initial surgical approach. Those below the innominate vein require a thoracic procedure, preferably a radioguided probe-assisted thoracoscopic resection with intraoperative parathyroid hormone (ioPTH). An alternative to surgical removal is medical treatment.

REOPERATIVE PARATHYROID SURGERY: THE IMPORTANCE OF ECTOPIC LOCATION AND MULTIGLAND DISEASE

BACKGROUND

Despite the availability of expert surgeons and preoperative imaging investigations, some patients require reoperation for persistent or recurrent hyperparathyroidisms.

METHOD

Fifty consecutive patients were reviewed.

RESULTS

There were 28 persistent cases (24 primary, 4 secondary) and 22 recurrent cases (15 primary, 7 secondary) and 98% had successful surgical treatment. Multigland disease was present in 24 of 39 (62%) of primary cases, 11 of 24 persistent and 13 of 15 recurrent (P < 0.02). Four patients in the recurrent primary group had multiple endocrine neoplasia type 1, whereas the other 20 primary patients had sporadic multigland disease. Multigland disease was present in all secondary cases and was a very important factor in this entire series of patients (70%). Regrowth of a remnant of a gland biopsied or partially resected at an earlier operation was the cause of recurrence in 12 of 15 primary and 2 of 7 secondary cases (P < 0.05). The site of missed glands in persistent disease was ectopic in 60%. Ectopic glands were found in the following sites: intrathyroidal 10 (8 inferior and 2 superior), intrathymic 9, posterior mediastinum 4, base of skull 2, carotid sheath 1 and supernumerary 5. Investigations to locate missing glands were positive in 28 of 43 sestamibi scans (65%), 14 of 34 ultrasound scans (41%), 10 of 24 computed tomography scans (42%) and 11 of 13 selective venous sampling tests (85%).

CONCLUSION

Some persistent cases are unavoidable because of ectopic locations and some recurrences are inevitable because of multigland disease.