Does Routine Use of Ultrasound Result in Additional Thyroid Procedures in Patients with Primary Hyperparathyroidism?

Significance of incidental thyroid 18 F-fluorocholine uptake in patients with hyperparathyroidism imaged for localizing hyperfunctioning parathyroid glands

OBJECTIVE

18 F-fluorocholine PET/CT is considered the imaging gold standard for detection of hyperfunctioning parathyroid glands . However, increased uptake might also occur in the thyroid gland. The aim of our study was to assess the incidence and significance of 18 F-fluorocholine uptake in the thyroid gland in patients with hyperparathyroidism.

MATERIALS AND METHODS

This retrospective study includes 195 consecutive patients with hyperparathyroidism, who underwent 18 F-fluorocholine PET/CT, for detection of hyperfunctioning parathyroid glands. PET/CT images were reviewed by two nuclear medicine physicians for the presence of focal or diffuse thyroid uptake. PET/CT results were compared with laboratory parameters, ultrasonography, EU-TIRADS classification in the presence of thyroid nodules, cytology, and final histology.

RESULTS

25 patients (13%) showed 18 F-fluorocholine uptake in the thyroid gland: focal thyroid uptake (FTU) in 7 patients (4%), diffuse thyroid uptake (DTU) in 8 patients (4%), and combined uptake (FTU + DTU) in 10 patients (5%), with a total of 20 active thyroid nodules. There was no correlation between EU-TIRADS classification and PET parameters. One highly 18 F-fluorocholine active thyroid nodule and one isoactive thyroid nodule turned out to be papillary thyroid cancers in the final histology; 50% of the patients with DTU had Hashimoto's thyroiditis.

CONCLUSION

Incidental 18 F-fluorocholine uptake in the thyroid gland was observed in 13% of patients. As reported for 18 F-FDG, focal 18 F-fluorocholine uptake might represent thyroid cancer and should be evaluated with ultrasound and, if indicated, with fine-needle aspiration cytology. Diffuse 18 F-fluorocholine uptake most likely represents multinodular goiter or Hashimoto's thyroiditis.

Reducing disparities in the treatment of hyperparathyroidism

Background

Hyperparathyroidism is common with African American patients historically experiencing disparate outcomes. With a comprehensive outreach program and systematic treatment plans, we sought to evaluate our institution's ability to reduce disparities in hyperparathyroidism.

Methods

We performed a retrospective review of prospectively collected data at a single medical center for all patients undergoing parathyroidectomy by endocrine surgeons from 2015 to 2021 for primary (PHPT) and tertiary (THPT) hyperparathyroidism. Patient demographics, pre-and post-operative clinical and biochemical data were collected and analyzed by race.

Results

Of the 757 patients included, 675 patients had PHPT with 135 (20 %) African-American (AA) and 528(78 %) female. Of 82 patients with THPT, 44 (53 %) were AA and 34 (32 %) were female. AA patients were younger than Caucasian (CA) patients with a mean age (±SD) of 56 ± 15 vs 60 ± 14 years in PHPT (p < 0.01) and 50 ± 10 vs 55 ± 10 years in THPT (p = 0.02).Median (IQR) preoperative PTH was higher in AA with PHPT 134 (97-190) vs 102 (75-144) pg/mL (p < 0.01) and in AA with THPT 285 (189-544) vs 218 (145-293) (p = 0.01) pg/mL. AA PHPT patients had significantly higher preoperative mean (±SD) calcium levels 10.9 ± 0.8 vs 10.6 ± 0.8 mg/dL(p < 0.001). Biochemical cure rates at 6 months and complication rates were not different between races.

Conclusions

AA patients with PHPT and THPT disease experienced similar cure rates to their CA counterparts despite having a more severe biochemical disease. Health care disparities may be ameliorated with treatment by high volume surgeons embedded in a comprehensive health care system.

Esophageal schwannoma mimicking non-functional parathyroid adenoma on 99mTc-sestamibi imaging: a case report

Technetium-99m sestamibi single-photon emission computed tomography/computed tomography (99mTc-sestamibi SPECT/CT) is a mainstay of the pre-operative localization of parathyroid lesions. We report here the case of a 30 year-old woman with a fortuitously discovered 2 cm cervical mass for which a parathyroid origin was originally suspected due to its retro-thyroidal localization and a personal history of nephrolithiasis. Normal serum calcium and parathyroid hormone (PTH) levels excluded primary hyperparathyroidism, raising suspicion of a non-functional parathyroid adenoma, and SPECT/CT imaging showed that the mass was 99mTc-sestamibi-avid. Fine-needle aspiration (FNA) was performed; cytology was non-diagnostic but the needle washout was negative for thyroglobulin, calcitonin and PTH, arguing against a thyroidal or parathyroidal origin of the mass. Core needle biopsy revealed a schwannoma, ostensibly originating from the recurrent laryngeal nerve; upon surgical resection, it was finally found to arise from the esophageal submucosa. This case illustrates the fact that endocrinologists, radiologists, nuclear medicine, head and neck, and other specialists investigating patients with cervical masses should be aware that schwannomas need to be considered in the differential diagnosis of focal 99mTc-sestamibi uptake in the neck region.

The Diagnostic Value of Contrast Enhanced Ultrasound for Localization of Parathyroid Lesions in Primary Hyperparathyroidism: Comparison With Color Doppler Ultrasound: Comparison With Color Doppler Ultrasound

OBJECTIVES

Preoperative localization of pathological parathyroid glands with imaging is essential for focused unilateral neck exploration and minimally invasive techniques. Recently published studies suggested that contrast-enhanced ultrasonography (CEUS) had high accuracy in the localization of hyperfunctioning parathyroid glands, with a general increase in the sensitivity as compared to conventional sonography. The purpose of this study was to determine the usefulness of CEUS in the localization of parathyroid lesions relating to surgical and histopathological data, in comparison to color Doppler ultrasound (CDUS), in the same series of patients.

METHODS

Records of 142 patients who underwent parathyroidectomy were retrospectively examined comparing imaging and intraoperative/histopathologic findings.

RESULTS

The overall sensitivity of CEUS was 77.6% compared with 74.6% for CDUS, although no significative differences were found (P = .516). Conversely, CDUS has shown higher sensitivity than CEUS in the group of patients with associated thyroid pathology but there was no statistical difference (P = .529). The sensitivity for detection of multiple adenomas was the same for both procedures.

CONCLUSIONS

We found no significative superior sensitivity of CEUS also in case of concomitant thyroid pathology and multiple glands disease.

Clinical application of 18F-FCH PET/CT in the diagnosis and treatment of hyperparathyroidism

Objective

We evaluated the difference in parathyroid visualization on ¹⁸F-FCH PET/CT images obtained at 5 and 60 min, and quantitatively analyzed the mode of FCH uptake at different time points, to determine the best imaging time for FCH PET/CT.

Methods

This retrospective study included 73 patients with hyperparathyroidism (HPT) who underwent ¹⁸F-FCH PET/CT imaging between December 2017 and December 2021. The diagnostic efficiency of 5- and 60-min dual time point imaging for the diagnosis of hyperparathyroidism and parathyroid adenoma and hyperplasia, were compared using visual and quantitative analyses.

Results

Dual-time ¹⁸F-FCH PET/CT imaging visual analysis had diagnostic value for HPT. The receiver operating characteristic curve of PET/CT quantitative parameters for the diagnosis of HPT and lesions showed that the parathyroid/thyroid SUVmax ratio for 60-min imaging had a higher sensitivity and specificity (based on patient, sensitivity: 90.90% and specificity: 85.71%; based on focus, sensitivity: 83.06% and specificity: 85.71%) compared to that for 5-min imaging. PET/CT quantitative parameters can distinguish parathyroid adenoma and hyperplasia. The 60-min parathyroid SUVmax value had the highest diagnostic value (cutoff: 3.945; area under the curve: 0.783).

Conclusion

The quantitative parameters of 60min ¹⁸F-FCH PET/CT have more advantages in aiding in the pathologica diagnosis and clinical treatment of HPT.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Pre-operative imaging workup for surgical intervention in primary hyperparathyroidism: A tertiary referral center experience

PURPOSE

Preoperative imaging in patients with primary hyperparathyroidism provides important localization information, allowing the surgeon to perform a focused surgery. However there are no evidence-based guidelines suggesting which preoperative imaging should be used, resulting in a risk of excessive prescription of exams and waste of economic resources. The main purpose of this study was to describe our experience on the performance of various imaging techniques for the preoperative localization of abnormal parathyroid gland/s, with a focus on the sensitivity and specificity of each technique. Secondly, we carried out an analysis of the cost utility of each technique in order to determine the most clinical and cost-effective combination of localization studies.

MATERIALS AND METHODS

Records of 336 patients who underwent parathyroidectomy were retrospectively examined comparing imaging and intraoperative/histopathologic findings to evaluate the accuracy in parathyroid detection of each imaging technique. Costs were determined by regional health system reimbursement.

RESULTS

We found that the sensitivity of color Doppler US was significantly higher than SPECT (p 0,023), while the sensitivity of 4D-CT was significantly better than US (p 0,029) and SPECT (p 0,0002).

CONCLUSIONS

In experienced hands color Doppler US is a highly sensitive technique especially in patients with no thyroid diseases. In patients with concomitant thyroid pathology, the combination of US and 4D-CT represents a reliable localization technique.

Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role?

BACKGROUND

Persistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared.

METHODS

This retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia.

RESULTS

Of 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46).

CONCLUSIONS

Recurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.

Discordant findings on preoperative imaging for primary hyperparathyroidism and thyroid disease: Choosing the path to follow

BACKGROUND

Preoperative localization of abnormal parathyroid glands in primary hyperparathyroidism is often obtained by sestamibi, and ultrasonography. We aimed to identify which modality is most accurate when laterality of abnormal glands on preoperative imaging is discordant.

METHODS

A single institution retrospective review identified 112 consecutive patients with primary hyperparathyroidism who underwent successful parathyroidectomy and sestamibi with pertechnetate.

RESULTS

Sestamibi with pertechnetate had a sensitivity of 72% and positive predictive value of 90%; ultrasonography had sensitivity of 50% and positive predictive value 80%. Patients with thyroiditis had lesser sensitivity and positive predictive value on sestamibi with pertechnetate (53% and 77%, respectively), in contrast to ultrasonography (54%, 88%, respectively). The sensitivity and positive predictive value of sestamibi with pertechnetate and ultrasonography did not differ in patients with thyroid nodules. Seventeen patients (15%) had discordant laterality on preoperative imaging. In discordant cases, sestamibi with pertechnetate was correct in 53% overall but in only 17% of those with thyroiditis (P = .01), whereas ultrasonography was correct in 26% overall but in 50% of those with thyroiditis (P = .01).

CONCLUSION

Thyroiditis decreased the sensitivity and positive predictive value of sestamibi with pertechnetate in primary hyperparathyroidism. In patients with discordant laterality on preoperative imaging, sestamibi with pertechnetate is the more accurate choice to guide operative planning, although ultrasonography may be a better guide in those with thyroiditis.

Concomitant thyroid disease and primary hyperparathyroidism in patients undergoing parathyroidectomy or thyroidectomy

BACKGROUND

Thyroid abnormalities have been found intraoperatively during parathyroidectomy and have resulted in concomitant thyroidectomy. The identification of concomitant disease is important prior to primary operation in order to minimize reoperations. This study investigates the incidence of concomitant primary hyperparathyroidism (PHPT) and thyroid nodular disease in patients undergoing thyroidectomy or parathyroidectomy.

METHODS

We performed a retrospective review of prospectively gathered data for 621 patients who underwent thyroidectomy, parathyroidectomy, or both at Tulane Medical Center. Information obtained included initial referral, initial thyroid stimulating hormone (TSH), initial parathyroid hormone (PTH), fine needle aspiration (FNA) results, ultrasound results, type of operation performed, final diagnosis, and final pathology.

RESULTS

Among the 400 patients referred primarily for thyroid disease, 13.50% underwent a thyroidectomy and parathyroidectomy (PTX) simultaneously and 10.75% received a final diagnosis of thyroid and concomitant parathyroid disease. Among the 103 patients referred primarily for parathyroid disease, 26.21% underwent a PTX and thyroidectomy and 24.27% received a final diagnosis of both thyroid and parathyroid disease. Patients referred primarily for parathyroid disease were more likely to receive a final diagnosis of both parathyroid and thyroid disease and were more likely to undergo a combined operation.

CONCLUSIONS

Concomitant thyroid and parathyroid disease occur and preoperative analysis is important to avoid increased complications from reoperations.

The Incidental Thyroid Lesion in Parathyroid Disease Management

Objective

The incidental thyroid lesion is a common finding during general imaging studies. Their management has been the subject of numerous studies and recommendations. Parathyroid disease workup necessitates imaging investigation of the adjacent thyroid gland and therefore provides a unique window to the perioperative management of thyroid incidentaloma. The specific prevalence of incidental thyroid lesions in the context of parathyroid disease is unknown. We seek to investigate its prevalence during parathyroid workup and surgery and to ascertain if there was a change in management of these patients.

Study Design

Five-year retrospective database review.

Setting

Tertiary care medical center.

Subjects and Methods

The source and indication for referral, preoperative investigation findings, and management of the incidental thyroid lesions were examined. The actual procedure performed and final pathology results were assessed.

Results

A total of 98 patients and 106 operations, including revision surgeries, were identified. There were 21 incidental thyroid lesions (21.4%) detected, whereby 15 patients underwent fine-needle aspirations and 12 subsequently had diagnostic hemithyroidectomies. This decision was made preoperatively in 5 patients and intraoperatively in 7 patients at the time of parathyroid surgery. Along with other pathologies, there were 7 patients with micropapillary thyroid carcinoma identified.

Conclusions

In our series, the prevalence of incidental thyroid lesion and thyroid malignancy is comparable to the general population. The management of the initial parathyroid disease in our patients was altered by the imaging and cytological findings of these thyroid lesions. This has implications on perioperative counseling of the thyroid and parathyroid disease.

Benign and Malignant Thyroid Gland Diseases in the Patients with Primary Hyperparathyroidism

Introduction:

This study aimed to evaluate concurrently detected thyroid pathologies in the patients who underwent surgery for primary hyperparathyroidism (PHPT).

Materials and Methods:

In this study, we retrospectively analyzed the files of the patients who underwent surgery for PHPT between 2012 and 2015. Pre- and post-operative laboratory examination results and preoperative radiological and nuclear medicine findings of the patients were retrospectively recorded.

Results:

A total number of 41 patients with PHPT were divided into two groups as the Group 1 with PHPT and benign thyroid pathology (21 patients) and the Group 2 with PHPT and malignant thyroid pathology (20 patients). In Group 1, 18 and 3 of 21 patients were females and males, respectively. Group 2 included 15 male and 5 female patients. The mean age of the patients was found to be 55.6 and 53.9 years in Group 1 and Group 2, respectively. Both groups were matched for age and gender. In terms of thyroid pathology, 20 of 41 patients (48.7%) who underwent total thyroidectomy for PHPT were found to have thyroid papillary carcinoma while benign pathologic conditions were detected in 21 (51.3%) individuals.

Conclusions:

Cooccurrence of thyroid diseases and PHPT is common. Therefore, all the patients should preoperatively be evaluated for the presence of thyroid pathology to determine the technique of parathyroid surgery.

Thyroid cancer incidence in simultaneous thyroidectomy with parathyroid surgery

OBJECTIVE

Primary hyperparathyroidism (PHPT) is often seen in conjunction with an underlying thyroid disorder. Imaging methods that are used to localize the parathyroid adenoma also detect associated thyroid nodules and thyroid cancer. The aim of this study was to detect the rate of thyroid cancer identified while performing parathyroidectomy and thyroidectomy in patients with PHPT.

MATERIAL AND METHODS

Files of all patients who were operated for PHPT and who underwent simultaneous thyroidectomy were analyzed. Data regarding parathyroid pathology, surgical procedures, indications of thyroid surgery, and pathology results were retrospectively recorded. The indications for thyroid surgery included presence of suspicious thyroid nodules in ultrasonography, increase in size of thyroid nodules in follow-up ultrasound, or presence of suspicious thyroid fine needle aspiration biopsy (FNAB) findings. Rates of thyroid cancer detection were investigated according to definite pathology reports.

RESULTS

Eighty-three patients who underwent parathyroidectomy with a diagnosis of PHPT with concurrent thyroidectomy in Department of General Surgery, İstanbul University İstanbul Faculty of Medicine were included in the study. Eighteen patients were male (22%) and 65 were female (78%). The median age was 53 (18-70) years. The primary indication for parathyroidectomy was primary hyperparathyroidism in all patients. The thyroid procedures applied in addition to parathyroidectomy were lobectomy + isthmusectomy in 29 patients (35%), bilateral subtotal thyroidectomy in 20 patients (24%), bilateral total thyroidectomy in 23 patients (28%), and total thyroidectomy on one side and near total thyroidectomy to the other side in 11 patients (13%). The only indication for thyroidectomy was the presence of thyroid nodules until 2000 (20 patients, 24%). Indications in the remaining 63 patients included the presence of multiple nodules that cannot be followed up by ultrasonography in 25 patients (30%), presence of a suspicious nodule on ultrasonography in 33 patients (40%), growth in nodule size in 2 patients (2%), and detection of suspicious findings on FNAB in 3 patients (4%). Five patients (6%) were diagnosed with papillary thyroid cancer, four of whom were micropapillary cancer.

CONCLUSION

Imaging methods performed to localize the pathological parathyroid gland for a diagnosis of PHPT are useful in estimating other accompanying pathologies. Presence of thyroid nodules should be evaluated before all parathyroid procedures, and if the nodule has an indication for surgery, thyroid surgery should be considered at the same operation with parathyroid surgery.

Incidentalomas during imaging for primary hyperparathyroidism--incidence and clinical outcomes

Background

Imaging for pre-operative localisation of parathyroid glands in primary hyperparathyroidism is now routine. This has led to the detection of incidental lesions (incidentalomas) in other organs, the nature of which is not well characterised.

The aim of this study was to determine the incidence, characteristics and outcomes in patients who had incidental findings on parathyroid imaging.

Methods

Records of patients who underwent imaging for primary hyperparathyroidism over 2 years were reviewed to identify incidental lesions detected on parathyroid imaging. Patients with persistent or renal hyperparathyroidism were excluded. Details on the management of detected incidentalomas were obtained from patient records.

Results

Incidentalomas were identified in 17 of 170 patients (10 %) undergoing parathyroid imaging. Incidentalomas included thyroid (n = 11), breast (n = 3), lateral compartment of the neck (n = 1), lung (n = 1) and clavicle (n = 1). However, no disease of clinical significance needing treatment was detected on further investigation.

Conclusions

Although a significant proportion of patients undergoing parathyroid imaging had incidental lesions detected, these seem to be of little clinical significance. The morbidity and cost of further interventions on these incidentalomas need to be weighed against the benefits of routine imaging in improving outcomes of first-time surgery in patients with primary hyperparathyroidism.

Incidental thyroid nodules in patients with primary hyperparathyroidism

BACKGROUND

It is desirable to detect neoplastic thyroid disease before proceeding with surgical therapy for hyperparathyroidism so that both conditions can be treated with a single operation.

METHODS

Between March 1998 and June 2009, 227 patients with primary hyperparathyroidism were treated with surgical therapy. Of these, 217 were evaluated preoperatively with a modified 4-dimensional CT and ultrasonography. The medical records of these patients were reviewed in order to document the incidence and significance of thyroid pathology in this cohort of patients.

RESULTS

Thyroid nodules were identified in 159 of the 217 patients (73.3%). Nine of 217 patients (4.1%) were treated with either a partial or a total thyroidectomy at the time of parathyroidectomy. Three of these patients had papillary thyroid carcinoma, 1 had a Hurthle cell carcinoma, and 1 had an incidental micropapillary thyroid carcinoma.

CONCLUSION

The rate of clinically significant thyroid malignancy in patients undergoing surgical treatment of primary hyperparathyroidism was 1.8%.

Surgical management of primary hyperparathyroidism in older adults

OBJECTIVES

To compare the feasibility, safety, and outcome of parathyroidectomy in the management of primary hyperparathyroidism (PHPT) in individuals aged 75 and older with that of those younger than 50.

DESIGN

Retrospective chart review.

SETTING

Department of Endocrine Surgery, Hospital Paul Desbief (Marseille, France).

PARTICIPANTS

Individuals who underwent surgery from June 2005 to February 2013 (N = 526) had a clinical examination and laboratory and imaging assessments to diagnose PHPT.

MEASUREMENTS

The clinical and biochemical characteristics and surgery outcomes of individuals younger than 50 (n = 80) were compared with the characteristics and outcomes of those aged 75 and older (n = 89).

RESULTS

Most of the participants did not have any specific signs of PHPT, and the diagnosis of PHPT was established in some participants during routine clinical and laboratory examination. Nephrolithiasis and osteitis fibrosa cystica were observed only in the younger group. Urinary calcium decreased with age. Nine participants aged 75 and older did not undergo surgery (four declined, five had medical contraindications). Conventional surgery through transverse cervicotomy was used in the majority of participants. Cure rate was excellent (158/160), with few and reversible minor complications. The coexistence of thyroid lesions was significantly higher in the older (47.5%) than in the younger group (32.3%). Nodules and multinodular goiters were removed in the majority of participants during the parathyroidectomy procedure.

CONCLUSION

With the exception of a few cases with severe associated comorbidities, parathyroidectomy is safe and curative and should be considered as first-line choice for older adult with PHPT.

Evaluation of thyroid incidentaloma

Thyroid nodules are an extremely common endocrine disorder with a generally accepted prevalence of around 4% to 7%. Incidental thyroid nodules are typically nonpalpable thyroid nodules found during radiographic evaluation for a non-thyroid-related issue (eg, computed tomographic scan, positron emission tomography scan, carotid duplex). Incidental thyroid nodules are contributing to but are not the sole reason for the rising incidence of thyroid cancer in the Unites States and other developed nations.

Surgeon-driven thyroid interrogation of patients presenting with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (pHPT) is an increasingly prevalent disease affecting all age groups. The authors sought to determine the impact of a "thyroid interrogation" practice protocol on the surgical treatment of patients with the diagnosis of pHPT referred to a single surgeon.

STUDY DESIGN

We performed a retrospective review of prospectively gathered data on parathyroidectomy (PTX) patients undergoing both a prospective clinical thyroid evaluation and thyroid ultrasound between January 2008 and October 2012.

RESULTS

Only 5.6% of 468 PTX patients were referred to a single surgeon for both parathyroid and thyroid surgical evaluation; 31% of patients had known pre-existing thyroid disease (hypothyroidism most commonly), and 22% of patients had palpable thyroid abnormalities unrecognized in 67% of cases by the referring physician. Of the 468 patients, 2.6% had a history of classic head and neck radiation exposure, 2.6% a history of radio-iodine treatment, and 3% a family history of thyroid cancer. Thyroid abnormalities were found on ultrasound in 61% of patients, and 26% of patients underwent thyroid biopsies. Parathyroid and thyroid surgery was combined for 18.4% of patients; indications included obstructive symptoms (3.2%), hyperthyroidism (0.9%), intraoperative findings (5.1%), and concern for malignancy (9.2%). Malignancy was diagnosed in 23 patients (4.9%), only 8 of whom had been referred for thyroid evaluation.

CONCLUSIONS

The majority of patients referred for PTX had evidence of thyroid pathology. For an important minority of these patients, benign and malignant disease was identified that merited surgical treatment at the time of PTX. We recommend comprehensive thyroid evaluation of patients referred for PTX.

Factors in conversion from minimally invasive parathyroidectomy to bilateral parathyroid exploration for primary hyperparathyroidism

BACKGROUND

Ongoing experience has documented equivalence of minimally invasive parathyroidectomy (MIP) and standard bilateral parathyroid exploration (BPE) for primary hyperparathyroidism in most patients; however, intraoperative conversion of MIP to BPE is required for multiple indications. This study analyzes the factors, predictors, and cure rates in converted MIP.

METHODS

We retrospectively analyzed a database of 1,002 patients undergoing initial parathyroidectomy for primary hyperparathyroidism from 2008 to 2011 for rate of successful MIP, converted MIP, planned BPE, and factors leading to conversion from MIP to BPE.

RESULTS

Of 989 included parathyroidectomies, 647 (65%) were successful MIP, 186 (19%) were converted MIP, and 156 (16%) were planned BPE. The most common indication for conversion included intraoperative parathyroid hormone (IOPTH) criteria not met (46%), localization incorrect (36%), and evidence of multigland disease (17%). Converted MIP had lower preoperative calcium and PTH and lower baseline IOPTH compared with successful MIP. Complication rates were similar; however, rates of persistent hyperparathyroidism were highest in converted MIPs (6%) versus planned BPEs (3%) and successful MIPs (2%; P < .01).

CONCLUSION

Patients requiring conversion of MIP to BPE have lower preoperative serum calcium and PTH levels, a less dramatic decrease in IOPTH, and a greater rate of persistent disease than successful MIP.

Clinical review: Parathyroid localization and implications for clinical management

CLINICAL CONTEXT

The prevalence of hyperparathyroidism, especially primary hyperparathyroidism, has increased in recent decades due to improvements in diagnostic techniques with a corresponding surge in parathyroid surgery, leading to the development of focused, minimally invasive surgical approaches. Focused parathyroidectomy is predicated on preoperative localization of suspected parathyroid pathology. As a result, there has been a proliferation of parathyroid imaging modalities and protocols, resulting in confusion about their indications and applications.

EVIDENCE ACQUISITION

Bibliographies from clinical trials and review articles published since 2000 were reviewed and supplemented with targeted searches using biomedical databases. We also employed our extensive clinical experience.

EVIDENCE SYNTHESIS

The best-studied modalities for parathyroid localization are nuclear scintigraphy and sonography and are widely applied as initial studies. Multiple variations exist, and several additional noninvasive imaging techniques, such as computed tomography and magnetic resonance, are described. The exquisite anatomical detail of 4-dimensional computed tomography must be balanced with significant radiation exposure to the thyroid gland. Invasive venous PTH sampling and parathyroid arteriography have important roles in remedial cases. Due to considerable heterogeneity in imaging, multidisciplinary collaboration between endocrinologists, surgeons, and radiologists is beneficial.

CONCLUSIONS

Parathyroid localization is indicated in surgical candidates. Crucial considerations when selecting an imaging study include availability, cost, radiation exposure, local expertise, and accuracy. Additional factors include the patient's anticipated pathology and whether it is de novo or refractory disease. An approach to imaging for patients with primary hyperparathyroidism is presented.

Algorithm for Estimation of Thyroid Gland Size in Ultrasonography Images for Extracting Abnormal Thyroid in Medical Practice

Measurement algorithm for the size of the thyroid gland in ultrasonography (US) images has been proposed on the basis of the position of the neighboring regions in order to objectively evaluate target organs for medical screening and secondary use. The measurement algorithm extracts the operator’s notion about the setting information on the basis of a drawn mark in the US images for decreasing computational costs. The measurement experiments for real US images performed in Kochi Medical School Hospital showed that the proposed algorithm detects the neighboring regions for the all target US images and that the enlarged thyroid glands evaluated by the proposed algorithm have relation with other blood test results. The proposed algorithmcan assist the evaluation of US screening and medical data analysis on the basis of the quantitative value of the US images.

Preoperative thyroid ultrasound is indicated in patients undergoing parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Primary hyperaparathyroidism (pHPT) is often accompanied by underlying thyroid pathology that can confound preoperative parathyroid localization studies and complicate intra-operative decision making. The aim of this study was to examine the utility of preoperative thyroid ultrasonography (US) in patients prior to undergoing parathyroidectomy for pHPT.

METHODS

An Institutional Review Board approved prospective study was undertaken from January 2005 through July 2008. All patients with pHPT meeting inclusion criteria (n=94) underwent preoperative thyroid ultrasound in addition to standard (99m)Tc-sestamibi scintigraphy for parathyroid localization. Demographics, operative management and final pathology were examined in all cases.

RESULTS

Fifty-four of the 94 patients (57%) were noted to have a thyroid nodule on preoperative US, of which 30 (56%) underwent further examination with fine needle aspiration biopsy. Alteration of the operative plan attributable to underlying thyroid pathology occurred in 16 patients (17%), with patients undergoing either total thyroidectomy (n=9) or thyroid lobectomy (n=7). Thyroid cancer was noted in 33% of patients undergoing thyroid resection, and 6% of all patients with HPT.

CONCLUSIONS

The routine utilization of preoperative thyroid ultrasound in patients prior to undergoing parathyroid surgery for pHPT is indicated. The added information from this non-invasive modality facilitates timely management of co-incidental, and sometimes malignant, thyroid pathology.