How and when is multiglandular disease diagnosed in sporadic primary hyperparathyroidism?

Persistence and Recurrence of Primary Hyperparathyroidism

Persistent and recurrent primary hyperparathyroidism (PHPT) represent significant challenges in the management of PHPT. Persistent PHPT is defined as persistence of hypercalcemia following parathyroidectomy (PTX) or the recurrence of hypercalcemia within the first 6 months following surgery. Recurrent PHPT is defined as recurrence of hypercalcemia after 6 months following PTX and requires normalization of serum calcium prior to the recurrence. These conditions are often attributed to missed or ectopic glands, multiglandular disease, surgeon inexperience, or rare causes such as parathyromatosis and parathyroid carcinoma. Diagnosis requires a detailed biochemical evaluation, imaging studies, and exclusion of other causes of hypercalcemia as well as secondary causes of hyperparathyroidism. Preoperative imaging modalities, including neck ultrasound, SPECT-CT with 99m Tc-sestamibi scan, 4D-CT, 18F-Fluorocholine PET/CT, and PET/MRI are helpful in localizing abnormal parathyroid glands in cases requiring repeat surgery. Repeat surgery is associated with higher risk and requires an experienced surgeon. When surgery is not indicated or possible, medical management with cinacalcet and antiresorptive therapies may be considered. This review highlights the etiology, diagnostic approaches, and management strategies for persistent and recurrent PHPT, emphasizing the importance of multidisciplinary care in order to optimize outcomes.

Intraoperative parathyroid hormone assay benefits surgery for primary hyperparathyroidism when preoperative localisation is negative or not performed

INTRODUCTION

Parathyroid localisation is now routine before first-time surgery for patients with primary hyperparathyroidism (PHPT). The aim of this study was to investigate the contribution of intraoperative parathyroid hormone (PTH) (ioPTH) in patients in whom localisation was either not undertaken or negative for a tumour.

METHODS

This was a retrospective study of patients undergoing first-time parathyroidectomy for PHPT in a regional endocrine centre. Data were collected prospectively (Microsoft Excel) and the all-Wales electronic patient record portal was used to retrieve missing data. Statistical analysis appropriate for nonparametric data was undertaken, with statistical significance reached when p<0.05.

RESULTS

Between 1 July 2002 and 31 December 2022, 1,490 patients underwent a first-time parathyroidectomy for PHPT. Of this cohort, 1,133 patients had at least one positive imaging modality; the study group consisted of 343 patients that had negative imaging, and 13 that had no preoperative localisation. Patients with MEN-1 (n=26), an incorrect diagnosis (n=4), or less than six months follow-up (n=6) were excluded. Of the remaining 321, 106 patients underwent surgery without ioPTH (Group A), 215 cases with ioPTH (Group B). In Group B there were more women (170 female/45 male; 79% vs 67 female/37 male; 63% p=0.002, chi-squared), lower calcium (median [range] 2.77 [2.63-3.24] mmol/l; vs 2.85 [2.60-4.52] p=0.001) and lower PTH (12.0pmol/l [3.4-39.5] vs 14.4 [3.9-97.0] p=0.001) and smaller weights of resected tissue (320mg [50-9,000] vs 454 [46-8,280] p=0.02) (Student's t-test). The rate of multiple gland disease was similar (Group A 29%; Group B 27%). The rate of normocalcaemia at 6 months was significantly higher when ioPTH was used (Group B 202/215; 94% vs Group A 90/106; 85%) (p=0.014, chi-square test). The sensitivity and specificity of ioPTH was 98.5% [confidence interval (CI) 96.2-99.6] and 91.2% [80.7-97.0] (positive predictive value 99.9%, CI 93.6-100.0).

CONCLUSION

Despite milder hyperparathyroidism and smaller tumour weight, the outcome in patients in whom ioPTH was used was superior, with failure rates 2.5-fold higher in the cohort where ioPTH was not utilised. The results of this study demonstrate that ioPTH is a valuable adjunct for the surgeon in cases where localisation has failed or not been undertaken.

Primary Hyperparathyroidism: Part Two: Surgical Management

Primary hyperparathyroidism (PHPT) is caused by the overproduction of parathyroid hormone by 1 or more parathyroid glands resulting in hypercalcemia and its downstream clinical consequences. The definitive management of PHPT is surgery. Approaches to successful surgery include bilateral exploration or focused parathyroidectomy with intraoperative parathyroid hormone monitoring, which in experienced hands are both associated with a low risk of complications.

A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease

BACKGROUND

Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity.

METHODS

We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy.

CONCLUSION

Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.

Persistence of primary hyperparathyroidism: a single-center experience

BACKGROUND

Parathyroidectomy is the only definitive treatment for primary hyperparathyroidism (PHPT). Precise localization of abnormal glands is a key to a successful surgery. Most patients are expected to be successfully treated with focused parathyroidectomy. However, this approach is associated with a risk of existing multiglandular disease which may lead to the postoperative persistence of PHPT.

METHODS

Eight hundred ten patients who underwent an initial surgery for PHPT at SPBU Hospital in 2017-2018 were included in the study. Preoperative imaging results were evaluated. Multivariate logistic regressions were calculated to estimate predictive values of preoperative data for the risk of postoperative persistence and risk of MGD.

RESULTS

Multiglandular disease was found to be a leading cause of persistent hyperparathyroidism. An anamnesis of thyroid surgery was found to be a significant risk factor for the persistence of hyperparathyroidism. The rate of persistence did not differ significantly between groups with bilateral neck exploration and focused parathyroidectomy. Age, sex, body mass index as well as negative results of preoperative US, MIBI, and 4D CT were not independently associated with a higher risk of MGD. All preoperative imaging modalities showed from low to moderate sensitivity for the detection of MGD. The frequency of cases of a missed second adenoma did not differ significantly between patients with concordant and discordant preoperative data. There were 7 cases with previously unsuspected second adenomas found solely due to bilateral neck exploration.

CONCLUSIONS

None of the combination of preoperative visualization modalities was able to rule out the MGD and reliably identify patients for focused parathyroidectomy. Additional preoperative visualization failed to improve overall results. Bilateral neck exploration appeared to have a slight benefit for the patients with concordant preoperative imaging results.

Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy

Background

The contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients.

Methods

The data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2).

Results

There were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%–97.6% according to the 20 min intraoperative parathyroid hormone value.

Conclusion

The cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.

[Role of preoperative visualization in the choice of surgery for primary hyperparathyroidism]

BACKGROUND

Precise localization of abnormal parathyroid glands is important for a successful surgery for primary hyperparathyroidism (PHPT). While a large number of patients can be successfully treated with the focused parathyroidectomy, there is a considerable rate of the persistent PHPT mostly because of undetected multiglandular disease (MGD).

AIM

The aim of the study was to evaluate the meaning of preoperative visualization data for planning the surgery for patients with PHPT.

MATERIALS AND METHODS

The study was conducted at SPBU Hospital in 2017-2018. 810 patients who underwent a primary surgery for PHPT were included in the study. Preoperative imaging results were investigated and multivariative logistic regressions were calculated to assess the predictive values of preoperative data. The rate of cases with persistent disease and cases with MGD were compared between patients with different results of preoperative data.

RESULTS

Age, sex, body mass index, negative results of preoperative US, MIBI and 4D CT were not independently associated with the higher risk of multiglandular disease. The larger number of performed preoperative visualization studies were associated with the higher risk of persistence. 37% cases of MGD were not identified preoperatively. There were 7 cases with previously unsuspected second adenomas found only due to bilateral neck exploration.

CONCLUSION

Any combination of preoperative visualization modalities was not able to rule out the MGD reliably. Efficacy of surgical treatment was not associated with the higher number of preoperative studies. Bilateral neck exploration may decrease the rate of the persistent hyperparathyroidism improving the identification of multiglandular disease.