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Gazivoda V, Prioli KM, Li AC, Pizzi L, Laird AM, Beninato T. Which Localizing Strategy is the Most Cost-Effective in Reoperative Primary Hyperparathyroidism? J Surg Res 2024; 296:547-555. [PMID: 38340488 DOI: 10.1016/j.jss.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 12/03/2023] [Accepted: 01/07/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION 2%-10% of patients with primary hyperparathyroidism (PHPT) who undergo parathyroidectomy develop persistent/recurrent disease. The aim of this study was to determine which preoperative localization method is most cost-effective in reoperative PHPT. METHODS Clinical decision analytic models comparing cost-effectiveness of localizing studies in reoperative PHPT were constructed using TreeAge Pro. Cost and probability assumptions were varied via Probabilistic Sensitivity Analysis (PSA) to test the robustness of the base case models. RESULTS Base case analysis of model 1 revealed ultrasound (US)-guided fine-needle aspiration with PTH assay as most cost-effective after localizing US. This was confirmed on PSA of model 1. Model 2 showed four-dimensional computed tomography (4D-CT) as most cost-effective after negative US. If not localized by US, on PSA, 4D-CT was the next most cost-effective test. CONCLUSIONS US-guided FNA with PTH is the most cost-effective confirmatory test after US localization. 4D-CT should be considered as the next best test after negative US.
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Affiliation(s)
- Victor Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Katherine M Prioli
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Albert C Li
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Laura Pizzi
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Amanda M Laird
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Toni Beninato
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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2
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Michaelsen SH, Bay M, Gerke O, Vestergaard S, Graumann O, Nielsen VE, Madsen AR, Bonnema SJ, Godballe C. Evaluation of Surgeon-Performed Ultrasonography With or Without Contrast Enhancement vs Scintigraphy in Patients With Primary Hyperparathyroidism. JAMA Otolaryngol Head Neck Surg 2023; 149:531-539. [PMID: 37052913 PMCID: PMC10102920 DOI: 10.1001/jamaoto.2023.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/12/2023] [Indexed: 04/14/2023]
Abstract
Importance Scintigraphy and ultrasonography are common imaging modalities for the preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism. When comparing the 2 modalities, the benefits of ultrasonography in terms of convenience, patient comfort, duration, cost, and lack of radiation should be taken into account. Objective To investigate whether surgeon-performed ultrasonography, with or without contrast-enhanced ultrasonography (CEUS), is noninferior to scintigraphy for localizing pathological parathyroid glands in patients with primary hyperparathyroidism. Design, Setting, and Participants Prospective, paired, noninferiority cohort study performed at a high-volume tertiary referral center for parathyroidectomy with blinded examiners and a 6-month follow-up. Participants were adults (age ≥18 years) referred for parathyroidectomy due to primary hyperparathyroidism. Of 207 eligible patients, 35 were excluded, leaving 172 enrolled in the study. Inclusion lasted from September 2019 until February 2021. Follow-up ended in December 2021. Exposures 99mTechnetium-pertechnetate/99mtechnetium-sestamibi subtraction scintigraphy with 99mtechnetium-sestamibi single-photon emission computed tomography/computed tomography, followed by surgeon-performed ultrasonography and CEUS. Main Outcomes and Measures The sensitivity of each imaging modality in localizing pathological parathyroid glands, calculated on a per-quadrant and a per-patient basis, respectively. The a priori noninferiority margin was a lower 95% confidence limit for the difference in sensitivity not falling below -10%. Results Out of 172 participants, 139 (80.8%) were women, the median (range) age was 65 (24-87) years, and the median (IQR) follow-up was 200.5 (181-280.25) days. Quadrant sensitivity (95% CI) was 70.9% (63.2%-78.5%) for ultrasonography, 68.4% (60.4%-76.5%) for ultrasonography plus CEUS, and 67.0% (60.0%-74.0%) for scintigraphy. The sensitivity difference (95% CI) compared with scintigraphy was 3.9% (-4.1% to 11.8%) for ultrasonography and 1.5% (-6.4% to 9.3%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Per-patient sensitivity was 81.4% (74.8%-86.9%) for ultrasonography and 79.1% (72.2%-84.9%) for both scintigraphy and ultrasonography plus CEUS. The sensitivity difference compared with scintigraphy was 2.3% (-6.8% to 11.4%) for ultrasonography and 0.0% (-9.1% to 9.1%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Conclusions and Relevance In this cohort study, conventional ultrasonography by an experienced parathyroid surgeon-sonographer was noninferior to scintigraphy and may constitute a valid first-line imaging modality in patients with primary hyperparathyroidism, even without the addition of CEUS. Further imaging should be reserved for cases that are equivocal or nonlocalizing on ultrasonography.
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Affiliation(s)
- Sanne Høxbroe Michaelsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette Bay
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Sys Vestergaard
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Ole Graumann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Viveque Egsgaard Nielsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Rørbæk Madsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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3
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Piccin O, D'Alessio P, Serra C, Felicani C, Vicennati V, Repaci A, Pagotto U, Cavicchi O. 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. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:91-98. [PMID: 35357028 DOI: 10.1002/jum.15984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 01/18/2022] [Accepted: 03/21/2022] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Ottavio Piccin
- Department of Otolaryngology Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pasquale D'Alessio
- Department of Otolaryngology Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Carla Serra
- Department of Organ Insufficiency and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Cristina Felicani
- Department of Organ Insufficiency and Transplantation, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valentina Vicennati
- Department of Endocrinology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andrea Repaci
- Department of Endocrinology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Uberto Pagotto
- Department of Endocrinology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ottavio Cavicchi
- Department of Otolaryngology Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Advances in Endocrine Surgery. Surg Oncol Clin N Am 2023; 32:199-220. [PMID: 36410918 DOI: 10.1016/j.soc.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Recent changes in the landscape of endocrine surgery include a shift from total thyroidectomy for almost all patients with papillary thyroid cancer to the incorporation of thyroid lobectomy for well-selected patients with low-risk disease; minimally invasive parathyroidectomy with, and potentially without, intraoperative parathyroid hormone monitoring for patients with well-localized primary hyperparathyroidism; improvement in the management of parathyroid cancer with the incorporation of immune checkpoint blockade and/or targeted therapies; and the incorporation of minimally invasive techniques in the management of patients with benign tumors and selected secondary malignancies of the adrenal gland.
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5
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Invited Commentary: Can Imaging Alone Predict the Number of Abnormal Parathyroid Glands in Primary Hyperparathyroidism? J Am Coll Surg 2022; 235:340-341. [PMID: 35839412 DOI: 10.1097/xcs.0000000000000237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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6
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Colmer SF, Wulster K, Johnson AL, Levine DG, Underwood C, Watkins TW, Van Eps AW. Treatment of primary hyperparathyroidism in a Miniature Horse using chemical ablation of abnormal parathyroid tissue localized by 3-phase computed tomography. J Vet Intern Med 2022; 36:798-804. [PMID: 35150016 PMCID: PMC8965272 DOI: 10.1111/jvim.16390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 02/03/2022] [Accepted: 02/03/2022] [Indexed: 11/28/2022] Open
Abstract
A 15‐year‐old Miniature Horse mare with persistently increased plasma calcium (total and ionized) and serum parathyroid hormone concentrations was presented for suspected primary hyperparathyroidism. Ultrasonography of the thyroid region identified an enlarged heterogeneous mass axial to the right thyroid lobe suggestive of an enlarged parathyroid gland, which was further confirmed using sestamibi nuclear scintigraphy and 3‐phase computed tomography. Percutaneous ultrasound‐guided ethanol ablation of the mass, a method not previously described in the horse, was performed under general anesthesia resulting in rapid normalization of plasma ionized calcium and serum parathyroid hormone concentrations. Ablation of abnormal parathyroid gland tissue may be a suitable alternative to surgical resection in certain cases of primary hyperparathyroidism in the horse.
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Affiliation(s)
- Sarah F Colmer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - Kathryn Wulster
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - Amy L Johnson
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - David G Levine
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - Claire Underwood
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - Trevor W Watkins
- Department of Medical Imaging, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Andrew W Van Eps
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, Pennsylvania, USA
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Dimitroukas CP, Metaxas VI, Efthymiou FO, Zampakis PE, Kalogeropoulou CP, Panayiotakis GS. DOSIMETRIC EVALUATION OF THE TWO-PHASE COMPUTED TOMOGRAPHY IN PARATHYROID GLANDS IMAGING. RADIATION PROTECTION DOSIMETRY 2021; 196:207-219. [PMID: 34635914 DOI: 10.1093/rpd/ncab137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 07/03/2021] [Accepted: 08/30/2021] [Indexed: 06/13/2023]
Abstract
This study evaluates the patient radiation dose from the two-phase protocols of two different computed tomography (CT) systems and compares this with that delivered by the other similar protocols previously published. Two hundred and fourteen patients with primary hyperparathyroidism were included in the study with a two-phase CT scan between 2008 and 2020 by using a Toshiba Aquilion Prime 80 and a GE Light Speed 16. The standard 'neck' or a modified 'parathyroid' protocol was used. The patient dose was evaluated in terms of volumetric computed tomography dose index (CTDIvol), dose length product (DLP) and effective dose (ED) per acquisition protocol and CT system. CTDIvol and DLP were recorded retrospectively, while the ED was calculated based on DLP and an appropriate conversion coefficient. Comparisons of patient dose between the two protocols and two CT systems and the corresponding published values were established. A significantly lower patient dose (40.2-43.2%) than the GE system (p < 0.0001) resulted from the Toshiba system. The 'parathyroid' protocol resulted in a 6.5-9.6% lower patient dose than the standard 'neck' protocol. Compared with the literature, the lowest ED value (3.6 mSv) was observed since this protocol consists of a lowered tube voltage of 100 kVp, a reduced scan length for the pre-contrast phase and implementation of an iterative reconstruction algorithm.
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Affiliation(s)
- Christos P Dimitroukas
- Department of Medical Physics, School of Medicine, University of Patras, Patras 265 04, Greece
- Department of Medical Physics, University Hospital of Patras, Patras 265 04, Greece
| | - Vasileios I Metaxas
- Department of Medical Physics, School of Medicine, University of Patras, Patras 265 04, Greece
| | - Fotios O Efthymiou
- Department of Medical Physics, School of Medicine, University of Patras, Patras 265 04, Greece
| | - Petros E Zampakis
- Department of Radiology, School of Medicine, University of Patras, Patras 265 04, Greece
- Department of Radiology, University Hospital of Patras, Patras 265 04, Greece
| | - Christina P Kalogeropoulou
- Department of Radiology, School of Medicine, University of Patras, Patras 265 04, Greece
- Department of Radiology, University Hospital of Patras, Patras 265 04, Greece
| | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, Patras 265 04, Greece
- Department of Medical Physics, University Hospital of Patras, Patras 265 04, Greece
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Hanba C, Khariwala SS. What Is the Optimal Imaging Modality for Parathyroid Adenoma? Laryngoscope 2021; 132:1508-1509. [PMID: 34751975 DOI: 10.1002/lary.29937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/05/2021] [Accepted: 10/26/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Curtis Hanba
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
| | - Samir S Khariwala
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis, Minnesota, U.S.A
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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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10
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Yap A, Hope TA, Graves CE, Kluijfhout W, Shen WT, Gosnell JE, Sosa JA, Roman SA, Duh QY, Suh I. A cost-utility analysis of 18F-fluorocholine-positron emission tomography imaging for localizing primary hyperparathyroidism in the United States. Surgery 2021; 171:55-62. [PMID: 34340823 DOI: 10.1016/j.surg.2021.03.075] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States. METHODS A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed. RESULTS Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy. CONCLUSION Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations.
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Affiliation(s)
- Ava Yap
- Department of Surgery, University of California San Francisco, CA.
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, CA
| | | | | | - Wen T Shen
- Department of Surgery, University of California San Francisco, CA
| | | | - Julie A Sosa
- Department of Surgery, University of California San Francisco, CA
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, CA
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, CA
| | - Insoo Suh
- Department of Surgery, New York University Langone Health, NY
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11
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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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12
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Implementation of a 4-dimensional computed tomography protocol for parathyroid adenoma localization. Am J Otolaryngol 2021; 42:102907. [PMID: 33460975 DOI: 10.1016/j.amjoto.2021.102907] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 12/29/2020] [Indexed: 01/13/2023]
Abstract
PURPOSE To present the results of our implementation of a four-dimensional computed tomography- (4DCT) based parathyroid localization protocol for primary hyperparathyroidism at a safety net hospital. METHODS We performed a retrospective review of all patients who underwent parathyroidectomy for primary hyperparathyroidism at Elmhurst Hospital Center from June 2016 - September 2019. Patients treated prior to the implementation of 4DCT during October 2018 served as historical controls for comparison. Imaging-related costs and hospital charges were obtained from the Radiology Department for each patient. RESULTS Forty-two patients underwent parathyroid surgery during the study period. Twenty patients had undergone 4DCT while 22 had nuclear medicine studies with or without ultrasonography. The sensitivity and specificity of 4DCT was 90.4% and 100% respectively, compared to 63% and 93.7% for nuclear imaging studies and 41% and 95% for ultrasound. The mean number of glands explored was significantly less in the 4DCT group, 1.8 ± 1.19 versus 2.77 ± 1.26 (p = 0.01). There was no increase in infrastructure or personnel costs associated with 4DCT implementation. CONCLUSIONS 4DCT represents an increasingly common imaging modality for pre-operative parathyroid localization. Here we demonstrate that 4DCT is associated with a reduction in the number of glands explored and enables minimally invasive parathyroid surgery. 4DCT is a cost-effective and clinically sound localization study for parathyroid localization in an urban safety-net hospital.
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Abstract
OBJECTIVE. The purpose of this article is to review the clinical manifestations, endocrine tumors types, and multimodality diagnostic tools available to physicians involved in the management of patients with multiple endocrine neoplasia (MEN) syndrome, in addition to discussing relevant imaging findings and appropriate imaging follow-up. CONCLUSION. Thorough knowledge of the spectrum of tumors associated with MEN gene mutations aids in the screening, diagnostic workup, and posttreatment monitoring of patients with MEN-related gene mutations.
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Smaxwil C, Aschoff P, Reischl G, Busch M, Wagner J, Altmeier J, Ploner O, Zielke A. [ 18F]fluoro-ethylcholine-PET Plus 4D-CT (FEC-PET-CT): A Break-Through Tool to Localize the "Negative" Parathyroid Adenoma. One Year Follow Up Results Involving 170 Patients. J Clin Med 2021; 10:jcm10081648. [PMID: 33924371 PMCID: PMC8068905 DOI: 10.3390/jcm10081648] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/16/2021] [Accepted: 03/25/2021] [Indexed: 12/18/2022] Open
Abstract
Background: The diagnostic performance of [18F]fluoro-ethylcholine-PET-CT&4D-CT (FEC-PET&4D-CT) to identify parathyroid adenomas (PA) was analyzed when ultrasound (US) or MIBI-Scan (MS) failed to localize. Postsurgical one year follow-up data are presented. Methods: Patients in whom US and MS delivered either incongruent or entirely negative findings were subjected to FEC-PET&4D-CT and cases from July 2017 to June 2020 were analyzed, retrospectively. Cervical exploration with intraoperative PTH-monitoring (IO-PTH) was performed. Imaging results were correlated to intraoperative findings, and short term and one year postoperative follow-up data. Results: From July 2017 to June 2020 in 171 FEC-PET&4D-CTs 159 (92.9%) PAs were suggested. 147 patients already had surgery, FEC-PET&4D-CT accurately localized in 141; false neg. 4, false pos. 2, global sensitivity 0.97; accuracy 0.96, PPV 0.99. All of the 117 patients that already have completed their 12-month postoperative follow up had normal biochemical parameter, i.e., no signs of persisting disease. However, two cases may have a potential for recurrent disease, for a cure rate of at least 98.3%. Conclusion: FEC-PET&4D-CT shows unprecedented results regarding the accuracy localizing PAs. The one-year-follow-up data demonstrate a high cure rate. We, therefore, suggest FEC-PET-CT as the relevant diagnostic tool for the localization of PAs when US fails to localize PA, especially after previous surgery to the neck.
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Affiliation(s)
- Constantin Smaxwil
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
- Correspondence: ; Tel.: +49-711-9913301; Fax: +49-711-9913309
| | - Philip Aschoff
- Department of Nuclear Medicine and PET-CT Centre, Institute of Diagnostic and Interventional Radiology, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany;
| | - Gerald Reischl
- Department of Preclinical Imaging and Radiopharmacy, Werner Siemens Imaging Center, Eberhard Karls University of Tuebingen, 72076 Tuebingen, Germany;
- Cluster of Excellence iFIT (EXC 2180) Image Guided and Functionally Instructed Tumor Therapies, University of Tuebingen, 72076 Tuebingen, Germany
| | - Mirjam Busch
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Joachim Wagner
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Julia Altmeier
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
| | - Oswald Ploner
- Department of Internal Medicine, Endocrinology, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany;
| | - Andreas Zielke
- Department of Endocrine Surgery, Endokrines Zentrum Stuttgart, Diakonie-Klinikum Stuttgart, 70176 Stuttgart, Germany; (M.B.); (J.W.); (J.A.); (A.Z.)
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Tay D, Das JP, Yeh R. Preoperative Localization for Primary Hyperparathyroidism: A Clinical Review. Biomedicines 2021; 9:biomedicines9040390. [PMID: 33917470 PMCID: PMC8067482 DOI: 10.3390/biomedicines9040390] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 01/02/2023] Open
Abstract
With increasing use of minimally invasive parathyroidectomy (PTx) over traditional bilateral neck exploration in patients with primary hyperparathyroidism (PHPT), accurate preoperative localization has become more important to enable a successful surgical outcome. Traditional imaging techniques such as ultrasound (US) and sestamibi scintigraphy (MIBI) and newer techniques such as parathyroid four-dimension computed tomography (4D-CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) are available for the clinician to detect the diseased gland(s) in the preoperative workup. Invasive parathyroid venous sampling may be useful in certain circumstances such as persistent or recurrent PHPT. We review the diagnostic performance of these imaging modalities in preoperative localization and discuss the advantages and weaknesses of these techniques. US and MIBI are established techniques commonly utilized as first-line modalities. 4D-CT has excellent diagnostic performance and is increasingly performed in first-line setting and as an adjunct to US and MIBI. PET and MRI are emerging adjunct modalities when localization has been equivocal or failed. Since no evidence-based guidelines are yet available for the optimal imaging strategy, clinicians should be familiar with the range and advancement of these techniques. Choice of imaging modality should be individualized to the patient with consideration for efficacy, expertise, and availability of such techniques in clinical practice.
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Affiliation(s)
- Donovan Tay
- Department of Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore;
| | - Jeeban P. Das
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Randy Yeh
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
- Correspondence:
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Soylu L, Aydın OU, Ilgan S, Özbaş S, Bilezikçi B, Gürsoy A, Koçak S. Radioguided occult lesion localization for minimally-invasive parathyroidectomy without quick PTH monitoring and frozen section: impact of the learning curve. Turk J Surg 2021; 36:297-302. [PMID: 33778386 DOI: 10.47717/turkjsurg.2020.4470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 04/24/2020] [Indexed: 11/23/2022]
Abstract
Objectives Minimally-invasive parathyroidectomy (MIP) is a surgical procedure that reduces the duration of operation, hospital costs, and hypocalcemia, and shortens the length of hospital stay. This study addressed the important procedural details of the radioguided occult lesion localization (ROLL)-MIP technique and evaluated the consequences of the learning curve from a series of patients. Patients and Methods A total of 80 patients who underwent ROLL-MIP for a single parathyroid adenoma were included into this retrospective study. In order to analyze the effect of the learning curve, these subjects were then divided into 2 groups per time period and the operative times were compared. Group A consisted of 22 previously reported patients who served as the control group. Group B consisted of 58 consecutive patients. Results Serum calcium and parathyroid hormone (PTH) levels were normalized in all of the patients within 2 days and remained normal during the follow-up period (31 ± 18.5 months). None of the patients who underwent ROLL-guided parathyroidectomy suffered temporary or permanent recurrent laryngeal nerve injuries. Mean operation time (time from incision to excision of the adenoma) was 23 ± 6 min in Group A and 18 ± 7 min in Group B. Mean operative times were significantly shorter in group B. Conclusion The success of MIP administered with the ROLL technique in a single adenomatous patient was quite high. This method seems especially valuable in patients with atypically located or small adenomas.
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Affiliation(s)
- Lütfi Soylu
- Ankara Güven Hastanesi , Endokrin Cerrahi , Ankara, Turkey
| | | | | | - Serdar Özbaş
- Ankara Güven Hastanesi , Endokrin Cerrahi , Ankara, Turkey
| | | | | | - Savaş Koçak
- Ankara Güven Hastanesi , Endokrin Cerrahi , Ankara, Turkey
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Giovanella L, Bacigalupo L, Treglia G, Piccardo A. Will 18F-fluorocholine PET/CT replace other methods of preoperative parathyroid imaging? Endocrine 2021; 71:285-297. [PMID: 32892309 DOI: 10.1007/s12020-020-02487-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a common endocrine disorder usually due to hyperfunctioning parathyroid glands (HPs). Surgical removal of the HPs is the main treatment for PHPT, making the correct detection and localization of HPs crucial to guiding targeted and minimally invasive surgical treatment in patients with PHPT. To date, different imaging methods have been used to detect and localize HPs, including radiology, nuclear medicine, and hybrid techniques. METHODS The present work discusses the role and value of different imaging methods in PHPT and, particularly, evaluates the potential role of 18F-fluorcholine PET/CT as a "one-stop-shop" method for preoperative parathyroid localization in patients with PHPT. DISCUSSION Cervical ultrasound (US) and parathyroid scintigraphy using 99mTc-MIBI are the most commonly employed methods in clinical practice. More recently, four-dimensional computed tomography (4D CT) and positron emission tomography (PET) with radiolabeled choline have emerged as useful alternatives in cases of negative or discordant findings from first-line imaging methods. CONCLUSIONS Due to the excellent diagnostic performance of radiolabeled choline PET/CT and the low radiation burden, this technique seems to be an ideal candidate to substitute current imaging procedures including US, MIBI scintigraphy, 4D CT and MRI and perform a fast and reliable "one-stop-shop" preoperative localization of HP in patients with PHPT, including challenging cases of postoperative persistent/recurrent disease.
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Affiliation(s)
- Luca Giovanella
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland.
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Lorenzo Bacigalupo
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Ente Ospedaliero Galliera, Genova, Italy
| | - Giorgio Treglia
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Research and Innovation Service, Academic Education, Research and Innovation Area, General Directorate, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arnoldo Piccardo
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Ente Ospedaliero Galliera, Genova, Italy
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Broome DT, Naples R, Bailey R, Tekin Z, Hamidi M, Bena JF, Morrison SL, Berber E, Siperstein AE, Scharpf J, Skugor M. Use of Preoperative Imaging in Primary Hyperparathyroidism. J Clin Endocrinol Metab 2021; 106:e328-e337. [PMID: 33119066 DOI: 10.1210/clinem/dgaa779] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Indexed: 12/12/2022]
Abstract
CONTEXT Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. OBJECTIVE Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. DESIGN, SETTING, AND PATIENTS This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. MAIN OUTCOME MEASURES Surgical cure rate, concordance of imaging with operative findings, and imaging performance. RESULTS The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. CONCLUSIONS Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.
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Affiliation(s)
- David T Broome
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Robert Naples
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Richard Bailey
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Zehra Tekin
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Moska Hamidi
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - James F Bena
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Shannon L Morrison
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Allan E Siperstein
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mario Skugor
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
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Piccin O, D'Alessio P, Cioccoloni E, Burgio L, Poggi C, Altieri P, Vicennati V, Repaci A, Pagotto U, Cavicchi O. Pre-operative imaging workup for surgical intervention in primary hyperparathyroidism: A tertiary referral center experience. Am J Otolaryngol 2021; 42:102819. [PMID: 33157312 DOI: 10.1016/j.amjoto.2020.102819] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 10/26/2020] [Accepted: 10/26/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Ottavio Piccin
- Department of Otolaryngology Head and Neck Surgery, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy.
| | - Pasquale D'Alessio
- Department of Otolaryngology Head and Neck Surgery, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Eleonora Cioccoloni
- Department of Otolaryngology Head and Neck Surgery, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Luca Burgio
- Department of Otolaryngology Head and Neck Surgery, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Cristina Poggi
- Department of Radiology, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Paola Altieri
- Division of Endocrinology, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Valentina Vicennati
- Division of Endocrinology, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Andrea Repaci
- Division of Endocrinology, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Uberto Pagotto
- Division of Endocrinology, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
| | - Ottavio Cavicchi
- Department of Otolaryngology Head and Neck Surgery, IRCSS-Azienda Ospedaliero Universitaria di Bologna, Policlinico Sant'Orsola, via Massarenti 9, 40138 Bologna, Italy
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Abstract
The role of preoperative parathyroid imaging continues to evolve. This study evaluated whether surgeon-performed ultrasound (U/S) obviates the need for other imaging studies and leads to a focused exploration with a high degree of surgical success. From July 2010 to February 2012, 200 patients presenting with nonfamilial primary hyperparathyroidism underwent neck U/S in the surgeon's office. The U/S interpretation was classified as Class 1 if an adenoma was identified with high confidence, Class 2 if a possible but not definite enlarged gland was imaged, and Class 0 (zero) if no adenoma was identified. The findings were correlated with subsequent intra-operative findings. There were 144 Class 1 U/Ss (72%); of 132 patients coming to surgery, 96.2 per cent had surgical findings concordant with preoperative U/S and all had apparent surgical cure. Twenty-nine patients (14.5%) had Class 2 U/S; the 31 per cent confirmed false-positives in this group were usually colloid nodules. Fourteen of 27 with Class 0 U/S underwent surgery after being offered dynamically enhanced computed tomography scan. All 200 patients were apparent surgical cures. Surgeon-performed U/S is expedient, convenient, inexpensive, and accurate. A clearly identified adenoma can safely lead to a focused limited exploration and avoid additional imaging 93 per cent of the time.
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Affiliation(s)
| | - John B. Hanks
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Philip W. Smith
- Department of Surgery, University of Virginia, Charlottesville, Virginia
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21
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Frank E, Watson W, Fujimoto S, De Andrade Filho P, Inman J, Simental A. Surgery versus Imaging in Non-Localizing Primary Hyperparathyroidism: A Cost-Effectiveness Model. Laryngoscope 2020; 130:E963-E969. [PMID: 32065406 DOI: 10.1002/lary.28566] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/05/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether advanced imaging is cost-effective compared to primary bilateral neck exploration in the management of non-localizing primary hyperparathyroidism. STUDY DESIGN Cost-effectiveness analysis. METHODS Cost-effectiveness analysis based on decision tree model and available Medicare financial data using data from 347 consecutive patients having parathyroidectomy for primary hyperparathyroidism with either 1) positive, concordant ultrasound and sestamibi or 2) negative sestamibi and negative ultrasound. RESULTS Bilateral neck exploration (BNE) costs $9578 and has a success rate of 97.3%. Single photon emission computed tomography (SPECT) + minimally invasive parathyroidectomy (MIP) was modeled to have a total cost of $8197 with a success rate of 98.6%. SPECT/computed tomography (CT) + MIP was modeled to have a total cost of $8271 and a 98.9% success rate. Four-dimensional (4D)-CT + MIP was modeled to cost $8146 with a success rate of 99%. Incremental cost-effectiveness ratios (IECR) (as compared to BNE) were -536.1, -605.5, and -701.6 ($/percent cure rate) for SPECT, SPECT/CT, and 4D-CT respectively. One-way sensitivity analyses demonstrate the change in IECR and cut-off points (IECR = 0) for four major variables. CONCLUSIONS In patients with non-localizing primary hyperparathyroidism, advanced imaging is associated with cost-savings compared to routine bilateral neck exploration. Increased cost-savings were predicted with increased imaging accuracy and decreased imaging costs. Increasing time for BNE or decreasing time for MIP were associated with increased cost savings. LEVEL OF EVIDENCE III Laryngoscope, 2020.
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Affiliation(s)
- Ethan Frank
- Department of Otolaryngology, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - WayAnne Watson
- Loma Linda University School of Medicine, Loma Linda, California, U.S.A
| | - Shannon Fujimoto
- Loma Linda University School of Medicine, Loma Linda, California, U.S.A
| | - Pedro De Andrade Filho
- Department of Otolaryngology, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Jared Inman
- Department of Otolaryngology, Loma Linda University Medical Center, Loma Linda, California, U.S.A
| | - Alfred Simental
- Department of Otolaryngology, Loma Linda University Medical Center, Loma Linda, California, U.S.A
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22
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Acar N, Haciyanli M, Coskun M, Erdogan NK, Celik SC, Haciyanli SG, Gur EO. Diagnostic value of four-dimensional computed tomography and four-dimensional magnetic resonance imaging in primary hyperparathyroidism when first-line imaging was inadequate. Ann R Coll Surg Engl 2020; 102:294-299. [PMID: 31918555 DOI: 10.1308/rcsann.2019.0182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Accurate localisation of the abnormal hyperfunctioning gland with preoperative imaging has a critical role in parathyroid surgery to obtain a successful outcome. This study aimed to evaluate the diagnostic performance of second-line imaging and their contribution to the treatment success in primary hyperparathyroidism when the first-line methods were negative or discordant. METHODS Among the patients who underwent parathyroidectomy due to primary hyperparathyroidism, 33 who underwent four-dimensional computed tomography and/or four-dimensional magnetic resonance imaging because of negative or discordant first-line imaging results were included. Persistent and recurrent cases were excluded. RESULTS The majority of the patients were female (84.8%) and the mean age was 59.2 years. Seventeen patients had four-dimensional computed tomography and 25 had four-dimensional magnetic resonance imaging, respectively. Four-dimensional computed tomography and four-dimensional magnetic resonance imaging localised the culprit gland successfully in 52.9% and 84%, respectively. Twenty-five patients in whom single adenoma was detected underwent focused parathyroidectomy. The culprit gland was solitary in 32 cases and one patient had double adenoma. Normocalcaemia was achieved in all cases. Among the 29 patients who completed their postoperative sixth month success rate was 100%. CONCLUSION Four-dimensional magnetic resonance imaging had high accuracy with fast dynamic imaging in detecting parathyroid adenomas. When the first-line imaging methods were negative or inconclusive, four-dimensional magnetic resonance imaging should be considered primarily since it is cost effective in Turkey and emits no radiation.
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Affiliation(s)
- N Acar
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - M Haciyanli
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - M Coskun
- Department of Radiology, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - N K Erdogan
- Department of Radiology, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - S C Celik
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - S G Haciyanli
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
| | - E O Gur
- Department of General Surgery, İzmir Katip Çelebi University Atatürk Training and Research Hospital, İzmir, Turkey
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23
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Parikh AM, Grogan RH, Morón FE. Localization of Parathyroid Disease in Reoperative Patients with Primary Hyperparathyroidism. Int J Endocrinol 2020; 2020:9649564. [PMID: 32454822 PMCID: PMC7212332 DOI: 10.1155/2020/9649564] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
The localization of persistent or recurrent disease in reoperative patients with primary hyperparathyroidism presents challenges for radiologists and surgeons alike. In this article, we summarize the relevant imaging modalities, compare their accuracy in identifying reoperative disease, and outline their advantages and disadvantages. Accurate localization by preoperative imaging is a predictor of operative success, whereas negative or discordant preoperative imaging is a risk factor for operative failure. Ultrasound is a common first-line modality because it is inexpensive, accessible, and radiation-free. However, it is highly operator-dependent and less accurate in the reoperative setting than in the primary setting. Sestamibi scintigraphy is superior to ultrasound in localizing reoperative disease but requires radiation, prolonged imaging times, and reader experience for accurate interpretation. Like ultrasound, sestamibi scintigraphy is less accurate in the reoperative setting because reoperative patients can exhibit distorted anatomy, altered perfusion of remaining glands, and interference of radiotracer uptake. Meanwhile, four-dimensional computed tomography (4DCT) is superior to ultrasound and sestamibi scintigraphy in localizing reoperative disease but requires the use of radiation and intravenous contrast. Both 4DCT and magnetic resonance imaging (MRI) do not significantly differ in accuracy between unexplored and reoperative patients. However, MRI is more costly, inaccessible, and time-consuming than 4DCT and is inappropriate as a first-line modality. Hybrid imaging with positron emission tomography and computed tomography (PET/CT) may be a promising second-line modality in the reoperative setting, particularly when first-line modalities are discordant or inconclusive. Lastly, selective venous sampling should be reserved for challenging cases in which noninvasive modalities are negative or discordant. In the challenging population of reoperative patients with PHPT, a multimodality approach that utilizes the expertise of high-volume centers can accurately localize persistent or recurrent disease and enable curative parathyroidectomy.
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Affiliation(s)
- Aaroh M. Parikh
- School of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
| | - Raymon H. Grogan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Fanny E. Morón
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA
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Vitetta GM, Ravera A, Mensa G, Fuso L, Neri P, Carriero A, Cirillo S. Actual role of color-doppler high-resolution neck ultrasonography in primary hyperparathyroidism: a clinical review and an observational study with a comparison of 99mTc-sestamibi parathyroid scintigraphy. J Ultrasound 2019; 22:291-308. [PMID: 30357759 PMCID: PMC6704209 DOI: 10.1007/s40477-018-0332-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Accepted: 10/11/2018] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Primary hyperparathyroidism (PHPT) is a frequent endocrine pathology that has surgical treatment as its only decisive measure. High-Resolution Neck Ultrasonography with color-Doppler (CDHR-NUS) and 99mTechnetium-SestaMIBI Parathyroid Scintigraphy (99mTc-MIBI PS) are the two instrumental exams more commonly used in the preoperatory localization of pathologic parathyroids. The aim of this observational study was to outline-in accordance with the latest scientific literature-the precise role of CDHR-NUS in the environment of PHPT, comparing it with that of Parathyroid Scintigraphy. METHODS 136 patients operated on for PHPT and underwent CDHR-NUS and 99mTc-MIBI PS preoperatively. The CDHR-NUS was carried out by an expert medical sonographer. The results of the two methods were compared between each other and with the results of the operative act for the evaluation of accordance and diagnostic performances. RESULTS PHPT is prevalently due to monoglandular pathology (SGD). The parallel use of CDHR-NUS and of 99mTc-MIBI PS does not determine a significant increase in diagnostic accuracy. The preoperative accordance evaluation between the two methods does not exclude the presence of multiglandular pathology (MGD) with certainty. CONCLUSIONS CDHR-NUS is an accurate as well as cost-effective method; its role as a main and eventual unique preoperative localization method in patients affected by PHPT is confirmed. In the presence of expert medical sonographers, the sequential use of the two methods is retained correct and their use in parallel is neither justified nor cost-effective. The preoperative accordance evaluation between the two methods is neither necessary nor indispensable.
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Affiliation(s)
- Giovanni Mariano Vitetta
- S.C. Radiodiagnostica, Azienda Ospedaliera Ordine Mauriziano di Torino, Largo Turati, 62-10128, Turin, Italy.
| | - Alberto Ravera
- S.S. Chirurgia della Tiroide, Azienda Ospedaliera Ordine Mauriziano di Torino, Turin, Italy
| | - Giovanni Mensa
- S.S. Chirurgia della Tiroide, Azienda Ospedaliera Ordine Mauriziano di Torino, Turin, Italy
| | - Luca Fuso
- Dipartimento di Scienze Chirurgiche, Università di Torino, Turin, Italy
| | - Pierluigi Neri
- S.C.D.U. di Radiodiagnostica e Interventistica, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Alessandro Carriero
- S.C.D.U. di Radiodiagnostica e Interventistica, Azienda Ospedaliero-Universitaria Maggiore della Carità di Novara, Novara, Italy
| | - Stefano Cirillo
- S.C. Radiodiagnostica, Azienda Ospedaliera Ordine Mauriziano di Torino, Largo Turati, 62-10128, Turin, Italy
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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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Zafereo M, Yu J, Angelos P, Brumund K, Chuang HH, Goldenberg D, Lango M, Perrier N, Randolph G, Shindo ML, Singer M, Smith R, Stack BC, Steward D, Terris DJ, Vu T, Yao M, Tufano RP. American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism. Head Neck 2019; 41:2398-2409. [PMID: 31002214 DOI: 10.1002/hed.25781] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 04/08/2019] [Indexed: 12/13/2022] Open
Abstract
Health care consumer organizations and insurance companies increasingly are scrutinizing value when considering reimbursement policies for medical interventions. Recently, members of several American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) committees worked closely with one insurance company to refine reimbursement policies for preoperative localization imaging in patients undergoing surgery for primary hyperparathyroidism. This endeavor led to an AAO-HNS parathyroid imaging consensus statement (https://www.entnet.org/content/parathyroid-imaging). The American Head and Neck Society Endocrine Surgery Section gathered an expert panel of authors to delineate imaging options for preoperative evaluation of surgical candidates with primary hyperparathyroidism. We review herein the current literature for preoperative parathyroid localization imaging, with discussion of efficacy, cost, and overall value. We recommend that planar sestamibi imaging, single photon emission computed tomography (SPECT), SPECT/CT, CT neck/mediastinum with contrast, MRI, and four dimensional CT (4D-CT) may be used in conjunction with high-resolution neck ultrasound to preoperatively localize pathologic parathyroid glands. PubMed literature on parathyroid imaging was reviewed through February 1, 2019.
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Affiliation(s)
- Mark Zafereo
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Justin Yu
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas
| | - Peter Angelos
- Section of Endocrine Surgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Kevin Brumund
- Section of Head and Neck Surgery, UC San Diego Health System, San Diego, California
| | - Hubert H Chuang
- Department of Nuclear Medicine, MD Anderson Cancer Center, Houston, Texas
| | - David Goldenberg
- Otolaryngology - Head and Neck Surgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Miriam Lango
- Division of Head & Neck Surgery, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Nancy Perrier
- Department of Surgical Oncology, MD Anderson Cancer Center, Houston, Texas
| | - Gregory Randolph
- Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Maisie L Shindo
- Department of Otolaryngology - Head and Neck Surgery, Oregon Health & Science University School of Medicine, Portland, Oregon
| | - Michael Singer
- Department of Otolaryngology - Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
| | - Russell Smith
- Head and Neck Surgical Oncology, Baptist MD Anderson Cancer Center, Jacksonville, Florida
| | - Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David Steward
- Division of Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - David J Terris
- Department of Otolaryngology, Medical College of Georgia, Augusta, Georgia
| | - Thinh Vu
- Department of Diagnostic Radiology, MD Anderson Cancer Center, Houston, Texas
| | - Mike Yao
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Ralph P Tufano
- Division of Head and Neck Endocrine Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
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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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Memeh KO, Palacios JE, Khan R, Guerrero MA. PRE-OPERATIVE LOCALIZATION OF PARATHYROID ADENOMA: PERFORMANCE OF 4D MRI PARATHYROID PROTOCOL. Endocr Pract 2019; 25:361-365. [PMID: 30720353 DOI: 10.4158/ep-2018-0424] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Accurate pre-operative image localization is critical in the selection of minimally invasive parathyroidectomy as a surgical treatment approach in patients with primary hyperparathyroidism (PHPT). Sestamibi scan, ultrasound, computed tomography, and conventional magnetic resonance imaging (MRI) has varying accuracy in localizing parathyroid adenoma (PTA). Our group has previously shown that four-dimensional (4D) MRI is more accurate than conventional imaging in identifying single adenomas. In this study, we set out to determine if it is possible to accurately localize the quadrant of the adenoma using 4D MRI. Methods: We analyzed and matched the quadrants of PTA identified by pre-operative 4D-MRI with the operative findings during parathyroidectomy for PHPT at our institution during the study period. All resections were confirmed to be successful with an adequate decrease in intraoperative parathyroid hormone as defined by the Miami criterion. Results: A total of 26 patients with PHPT underwent pre-operative localization with the 4D MRI parathyroid protocol. Fourteen patients had true single-gland adenoma (SGA) and 12 patients had multi-gland disease (MGD). 4D MRI accurately identified all the SGA. Using this method, we were also able to localize the adenoma in the correct quadrant in 14 of the 18 patients with SGA. All 3 double adenomas were accurately identified using 4D MRI; however, MGD was only accurately identified 67% of the time. The 4D MRI had an overall 85% accuracy in distinguishing SGA from MGD. Conclusion: 4D MRI accurately identified single and double adenomas in their respective quadrants. However, accuracy was lower with MGD. Abbreviations: BNE = bilateral neck exploration; CT = computed tomography; IOPTH = intra-operative parathyroid hormone; MGD = multi-gland disease; MIBI = sestamibi; MIP = minimally invasive parathyroidectomy; MRI = magnetic resonance imaging; PHPT = primary hyperparathyroidism; PTA = parathyroid adenoma; PTH = parathyroid hormone; SGA = single-gland adenoma; SPECT = single photon emission computed tomography; 4D = four-dimensional.
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Bunch PM, Kelly HR. Preoperative Imaging Techniques in Primary Hyperparathyroidism. JAMA Otolaryngol Head Neck Surg 2018; 144:929-937. [DOI: 10.1001/jamaoto.2018.1671] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Paul M. Bunch
- Division of Diagnostic Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Hillary R. Kelly
- Division of Diagnostic Neuroradiology, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
- Department of Radiology, Massachusetts Eye and Ear, Harvard Medical School, Boston
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Yan S, Zhao W, Wang B, Zhang L. A Novel Technology for Localization of Parathyroid Adenoma: Ultrasound-Guided Fine Needle Aspiration Combined With Rapid Parathyroid Hormone Detection and Nano-Carbon Technology. Surg Innov 2018; 25:357-363. [PMID: 29890904 DOI: 10.1177/1553350618779703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. The study aims to evaluate the clinic feasibility of rapid parathyroid hormone (PTH) detection and nano-carbon technology in preoperative diagnosis and localization of parathyroid adenoma. Methods. With the guidance of ultrasound, the operator performed the parathyroid puncture and tested the PTH value by using a PTH test kit, and then injected nano-carbon into parathyroid adenoma as a marker to observe whether the parathyroid adenoma was stained black during the final operation. Meanwhile, a part of excised specimen was made into homogenate and detected rapidly again by using the PTH test kit. The remaining was confirmed by intraoperative frozen pathological examination. Result. The sensitivity (12/12) of preoperative diagnosis was significantly higher than that of ultrasound (6/12), magnetic resonance imaging (7/12), and MIBI (9/12). During the operation, we found that the inner part of the parathyroid adenoma was stained black, and the PTH value of the specimen homogenate confirmed as parathyroid adenoma was more than 3000 pg/mL. Conclusion. This novel technology, as a very positive method for localization of parathyroid adenoma, plays an important role in guaranteeing the surgical reliability of parathyroid adenoma with help of nano-carbon technology.
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Affiliation(s)
- Shouyi Yan
- Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Wenxin Zhao
- Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Bo Wang
- Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
| | - Liyong Zhang
- Fujian Medical University Union Hospital, Fuzhou, Fujian Province, China
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Diagnostic accuracy of 3T magnetic resonance imaging in the preoperative localisation of parathyroid adenomas: comparison with ultrasound and 99mTc-sestamibi scans. Eur Radiol 2018; 28:4900-4908. [DOI: 10.1007/s00330-018-5437-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 03/08/2018] [Accepted: 03/19/2018] [Indexed: 12/14/2022]
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Cunha-Bezerra P, Vieira R, Amaral F, Cartaxo H, Lima T, Montarroyos U, Bandeira F. Better performance of four-dimension computed tomography as a localization procedure in normocalcemic primary hyperparathyroidism. J Med Imaging Radiat Oncol 2018; 62:493-498. [PMID: 29656552 DOI: 10.1111/1754-9485.12728] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 02/24/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The multi-phase or four-dimensional computed tomography (4D CT) has emerged as a promising technique for preoperative localization of parathyroid lesions in patients with primary hyperparathyroidism (PHPT), but little is known about its accuracy in patients with normocalcemic primary hyperparathyroidism (NPHPT). METHODS A total of 18 patients diagnosed with PHPT underwent three methods of preoperative localization (4D CT, TC-99-Sestamibi scintigraphy and ultrasonography). After surgery, the results of imaging were compared with operative findings, pathological and biochemical data to evaluate the sensitivity and of each localization procedure. RESULTS In NPHPT the sensitivity for identifying the parathyroid lesion, according to presentation of PHPT (hypercalcemic or normocalcemic), was better with 4DCT in comparison to USG and scintigraphy. In these patients, the sensitivity for lateralization was as follows: USG: 22% (95% CI 0-44.9), scintigraphy: 11.1% (95% CI 0-31.6), 4DCT: 55.6% (95% CI 23.1-88). In hypercalcemic patients the results were as follows: USG: 58.3% (95% CI 30.4-86.2), scintigraphy: 75% (95% CI 50.5-99.5), 4DCT: 75% (95% CI 50.5-99.5). There was a poor agreement between the three procedures in the identification of the parathyroid lesions, with Kappa coeficients of 0.292 and 0.01 for scintigraphy and 4DCT, respectively, in comparison to USG. CONCLUSION Our data showed that 4DCT had a better performance as a preoperative localization procedure of the parathyroid lesion in patients with NPHPT.
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Affiliation(s)
- Phelipe Cunha-Bezerra
- Head and Neck Unit, Department of Surgery, Oswaldo Cruz Hospital, University of Pernambuco Medical School, Recife, Brazil
| | - Ricardo Vieira
- Head and Neck Unit, Department of Surgery, Oswaldo Cruz Hospital, University of Pernambuco Medical School, Recife, Brazil
| | - Fernando Amaral
- Radiology Department, Hospital Barão de Lucena (SUS/PE), Recife, Brazil
| | | | - Túlio Lima
- Pathology Division, Instituto de Medicina Integral Prof. Fernando Figueira (Imip), Recife, Brazil
| | | | - Francisco Bandeira
- Division of Endocrinology, Diabetes and Metabolic Bone Diseases, Hospital Agamenon Magalhães, University of Pernambuco Medical School, Recife, Brazil
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Sho S, Yuen AD, Yeh MW, Livhits MJ, Sepahdari AR. Factors Associated With Discordance Between Preoperative Parathyroid 4-Dimensional Computed Tomographic Scans and Intraoperative Findings During Parathyroidectomy. JAMA Surg 2018; 152:1141-1147. [PMID: 28793141 DOI: 10.1001/jamasurg.2017.2649] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Parathyroid 4-dimensional computed tomographic scans (4D-CTs) have emerged as an accurate and cost-effective initial localization study for patients with primary hyperparathyroidism. However, potential limitations and factors affecting the accuracy of preoperative 4D-CTs remain poorly defined. Objectives To characterize factors associated with missed parathyroid lesions on preoperative 4D-CTs and to investigate patterns of commonly observed errors. Design, Setting, and Participants A prospectively accrued patient database was analyzed from September 1, 2011, through October 31, 2016. The study was performed in a tertiary referral center. Consecutive patients with primary hyperparathyroidism undergoing preoperative 4D-CTs and subsequent parathyroidectomy were included in the study. Main Outcomes and Measures Discordance between preoperative 4D-CTs and intraoperative findings in the number and location of abnormal parathyroid lesions. Results Of 411 patients studied (mean [SD] age, 59 [14] years; 325 [79.1%] female), 123 (29.9%) had discordance between preoperative 4D-CTs and intraoperative findings. Among the 411 patients, 75 (18.2%) had major discordance, including incorrectly localized adenoma on the contralateral side of the neck, missed double adenoma, and absence of any abnormal lesion detected on 4D-CTs. Compared with concordant cases, discordant cases had higher frequencies of multigland disease (66.7% [82 of 123] vs 24.3% [70 of 288], P < .001) and multinodular goiter or thyroid nodule (40.7% [50 of 123] vs 29.2% [84 of 288], P = .02). Missed parathyroid lesions were smaller (mean [SD], 0.86 [0.29] vs 1.24 [0.50] cm; P < .001) and were more likely to be in the inferior position (65.4% [87 of 133] vs 38.1% [177 of 465], P < .001). Parathyroid lesion size of 10 mm or less (odds ratio [OR], 4.37; 95% CI, 2.24-8.54), multigland disease (OR, 7.63; 95% CI, 3.49-16.69), multinodular goiter or thyroid nodule (OR, 1.82; 95% CI, 1.01-3.28), and parathyroid lesion in the inferior position (OR, 6.82; 95% CI, 3.10-14.99) were independently associated with discordant 4D-CT results. Conclusions and Relevance Multigland disease was most strongly associated with discordance between preoperative 4D-CTs and intraoperative findings, followed by parathyroid lesion in the inferior position and parathyroid lesion size of 10 mm or less. Awareness of these potential pitfalls may allow surgeons to better leverage this new localization technique in preoperative planning and intraoperative troubleshooting.
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Affiliation(s)
- Shonan Sho
- Section of Endocrine Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Alexander D Yuen
- Section of Endocrine Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Michael W Yeh
- Section of Endocrine Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Masha J Livhits
- Section of Endocrine Surgery, David Geffen School of Medicine, University of California, Los Angeles
| | - Ali R Sepahdari
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles
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Abstract
Primary hyperparathyroidism (PHPT) is characterized by excessive, dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Minimally invasive surgical techniques have created a need for more precise localization of the parathyroid lesion by imaging. A variety of imaging protocols and techniques have been used for this purpose, but no one modality is clearly superior. Nuclear medicine scintigraphy and ultrasound imaging are established modalities, although multiphase or 4-dimensional computed tomography is an emerging modality with several advantages. This review provides a background regarding PHPT and key anatomy, and discusses these alternative parathyroid imaging modalities with updates.
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Affiliation(s)
- Samuel J Kuzminski
- Department of Radiological Sciences, University of Oklahoma Health Sciences Center, College of Medicine, PO Box 2690, Garrison Tower, Suite 4G4250, Oklahoma City, OK 73126, USA
| | - Julie A Sosa
- Department of Surgery, Duke University, Duke University Medical Center, Box 2945, Durham, NC 27710, USA
| | - Jenny K Hoang
- Department of Radiology, Duke University, Duke University Medical Center, Box 3808, Erwin Road, Durham, NC 27710, USA.
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Silver E, Sadeghi N, Knoll S, Taheri MR. Utility of Single-Phase Computed Tomography in Identifying Parathyroid Adenomas: A Feasibility Study. Curr Probl Diagn Radiol 2017; 47:90-93. [PMID: 28705526 DOI: 10.1067/j.cpradiol.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We tested the hypothesis that a single-phase neck computed tomography (CT) is not inferior to multiphase neck CT (MPNCT), ultrasound, or nuclear medicine sestamibi scan in identifying parathyroid adenomas (PAs). METHODS A total of 29 patients who had an MPNCT for the evaluation of a PA were identified; 11 patients met the inclusion criteria. During the 30-second arterial phase CT (APNCT), a normalized Hounsfield unit of suspected PA was compared to Hounsfield unit of a normal-appearing level I and a level II lymph node. A PA was defined as a lesion with a ratio of greater than 1.4 when compared to the level I and level II lymph node. This cutoff was determined based on the normalized ratios between level II and level I lymph nodes. Results of intraoperative parathyroid hormone assays and surgical pathology were used to validate the accuracy of this technique. RESULTS The sensitivity of this method in APNCT is 90.9% whereas positive predictive value is 100%. The sensitivity or positive predictive value of ultrasound and nuclear medicine are 60% or 100% and 90% or 100%, respectively. CONCLUSION The sensitivity of APNCT is equivalent to that of MPNCT in identifying PA.
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Affiliation(s)
- Ethan Silver
- Department of Radiology, The George Washington University Hospital, Washington, DC.
| | - Nader Sadeghi
- Department of Otolaryngology, The George Washington University Hospital, Washington, DC
| | - Stanley Knoll
- Department of General Surgery, The George Washington University Hospital, Washington, DC
| | - M Reza Taheri
- Department of Radiology, The George Washington University Hospital, Washington, DC
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Liddy S, Worsley D, Torreggiani W, Feeney J. Preoperative Imaging in Primary Hyperparathyroidism: Literature Review and Recommendations. Can Assoc Radiol J 2017; 68:47-55. [DOI: 10.1016/j.carj.2016.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/20/2016] [Accepted: 07/06/2016] [Indexed: 12/17/2022] Open
Affiliation(s)
- Stephen Liddy
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin, Ireland
| | - Daniel Worsley
- Division of Nuclear Medicine, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - John Feeney
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin, Ireland
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4D-CT for Detection of Parathyroid Adenomas and Hyperplasia: State of the Art Imaging. CURRENT RADIOLOGY REPORTS 2017. [DOI: 10.1007/s40134-017-0198-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Kluijfhout WP, Pasternak JD, Beninato T, Drake FT, Gosnell JE, Shen WT, Duh QY, Allen IE, Vriens MR, de Keizer B, Hope TA, Suh I. Diagnostic performance of computed tomography for parathyroid adenoma localization; a systematic review and meta-analysis. Eur J Radiol 2017; 88:117-128. [PMID: 28189196 DOI: 10.1016/j.ejrad.2017.01.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 11/02/2016] [Accepted: 01/03/2017] [Indexed: 01/02/2023]
Abstract
PURPOSE To perform a systematic review and meta-analysis of the sensitivity and positive predictive value (PPV) of CT for preoperative parathyroid localization in patients with primary hyperparathyroidism (pHPT), and subsequently compare the different protocols and their performance in different patient groups. MATERIALS AND METHODS We performed a search of the Embase, Pubmed and Cochrane Library databases to identify studies published between January 1, 2000 and March 31, 2016 investigating the diagnostic value of CT for parathyroid localization in patients with biochemical diagnosis of pHPT. Performance of CT was expressed in sensitivity and PPV with pooled proportion using a random-effects model. Factors that could have affected the diagnostic performance were investigated by subgroup analysis. RESULTS Thirty-four studies evaluating a total of 2563 patients with non-familial pHPT who underwent CT localization and surgical resection were included. Overall pooled sensitivity of CT for localization of the pathological parathyroid(s) to the correct quadrant was 73% (95% CI: 69-78%), which increased to 81% (95% CI: 75-87%) for lateralization to the correct side. Subgroup analysis based on the number of contrast phases showed that adding a second contrast phase raises sensitivity from 71% (95% CI: 61-80%) to 76% (95% CI: 71-87%), and that adding a third phase resulted in a more modest additional increase in performance with a sensitivity of 80% (95% CI: 74-86%). CONCLUSION CT performs well in localizing pathological glands in patients with pHPT. A protocol with two contrast phases seems to offer a good balance of acceptable performance with limitation of radiation exposure.
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Affiliation(s)
- Wouter P Kluijfhout
- Department of Surgery, University of California San Francisco, United States; Department of Surgery, University Medical Center Utrecht, The Netherlands.
| | | | - Toni Beninato
- Department of Surgery, University of California San Francisco, United States
| | | | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, United States
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, United States
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, United States
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, University of California San Francisco, USA
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, The Netherlands
| | - Bart de Keizer
- Department of Radiology, University Medical Center Utrecht, The Netherlands
| | - Thomas A Hope
- Department of Radiology, University of California San Francisco, USA
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, United States
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Bann DV, Zacharia T, Goldenberg D, Goyal N. Parathyroid localization using 4D-computed tomography. EAR, NOSE & THROAT JOURNAL 2016; 94:E55-7. [PMID: 25923289 DOI: 10.1177/014556131509404-506] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Darrin V Bann
- MD/PhD Program, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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41
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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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Rameau A, Eng S, Vu J, Saket R, Jun P, Friduss M. Four-dimensional computed tomography scan utility in parathyroidectomy for primary hyperparathyroidism with low baseline intact parathyroid hormone. Laryngoscope 2016; 127:1476-1482. [DOI: 10.1002/lary.26201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 05/17/2016] [Accepted: 06/28/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Anaïs Rameau
- Otolaryngology-Head and Neck Surgery Department; Stanford University; Stanford California U.S.A
| | - Soo Eng
- Endocrinology Department; Kaiser Permanente Hospital; Santa Clara California U.S.A
| | - Joseph Vu
- Endocrinology Department; Kaiser Permanente Hospital; Santa Clara California U.S.A
| | - Ramin Saket
- Neuroradiology Division; Kaiser Permanente Hospital; Santa Clara California U.S.A
| | - Peter Jun
- Neuroradiology Division; Kaiser Permanente Hospital; Santa Clara California U.S.A
| | - Michael Friduss
- Otolaryngology-Head and Neck Surgery Department; Stanford University; Stanford California U.S.A
- Department of Otolaryngology-Head and Neck Surgery; Kaiser Permanente Hospital; Santa Clara California U.S.A
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Melfa GI, Raspanti C, Attard M, Cocorullo G, Attard A, Mazzola S, Salamone G, Gulotta G, Scerrino G. Comparison of minimally invasive parathyroidectomy under local anaesthesia and minimally invasive video-assisted parathyroidectomy for primary hyperparathyroidism: a cost analysis. G Chir 2016; 37:61-7. [PMID: 27381690 DOI: 10.11138/gchir/2016.37.2.061] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) origins from a solitary adenoma in 70- 95% of cases. Moreover, the advances in methods for localizing an abnormal parathyroid gland made minimally invasive techniques more prominent. This study presents a micro-cost analysis of two parathyroidectomy techniques. PATIENTS AND METHODS 72 consecutive patients who underwent minimally invasive parathyroidectomy, video-assisted (MIVAP, group A, 52 patients) or "open" under local anaesthesia (OMIP, group B, 20 patients) for PHPT were reviewed. Operating room, consumable, anaesthesia, maintenance costs, equipment depreciation and surgeons/anaesthesiologists fees were evaluated. The patient's satisfaction and the rate of conversion to conventional parathyroidectomy were investigated. T-Student's, Kolmogorov-Smirnov tests and Odds Ratio were used for statistical analysis. RESULTS 1 patient of the group A and 2 of the group B were excluded from the cost analysis because of the conversion to the conventional technique. Concerning the remnant patients, the overall average costs were: for Operative Room, 1186,69 € for the MIVAP group (51 patients) and 836,11 € for the OMIP group (p<0,001); for the Team, 122,93 € (group A) and 90,02 € (group B) (p<0,001); the other operative costs were 1388,32 € (group A) and 928,23 € (group B) (p<0,001). The patient's satisfaction was very strongly in favour of the group B (Odds Ratio 20,5 with a 95% confidence interval). CONCLUSIONS MIVAP is more expensive compared to the "open" parathyroidectomy under local anaesthesia due to the costs of general anaesthesia and the longer operative time. Moreover, the patients generally prefer the local anaesthesia. Nevertheless, the rate of conversion to the conventional parathyroidectomy was relevant in the group of the local anaesthesia compared to the MIVAP, since the latter allows a four-gland exploration.
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Ramirez AG, Shada AL, Martin AN, Raghavan P, Durst CR, Mukherjee S, Gaughen JR, Ornan DA, Hanks JB, Smith PW. Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism. Surgery 2016; 160:731-7. [PMID: 27302106 DOI: 10.1016/j.surg.2016.04.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/20/2016] [Accepted: 04/08/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. METHODS A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. RESULTS Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14 mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240 g compared with 1,300 g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6 months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. CONCLUSION With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be considered to avoid unnecessary radiation exposure.
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Affiliation(s)
| | - Amber L Shada
- Department of Surgery, University of Wisconsin, Madison, WI
| | - Allison N Martin
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Prashant Raghavan
- Department of Diagnostic Radiology, University of Maryland, College Park, MD
| | - Christopher R Durst
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - Sugoto Mukherjee
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - John R Gaughen
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - David A Ornan
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA
| | - John B Hanks
- Department of Surgery, University of Virginia, Charlottesville, VA
| | - Philip W Smith
- Department of Surgery, University of Virginia, Charlottesville, VA.
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Use of PET tracers for parathyroid localization: a systematic review and meta-analysis. Langenbecks Arch Surg 2016; 401:925-935. [PMID: 27086309 PMCID: PMC5086346 DOI: 10.1007/s00423-016-1425-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 04/03/2016] [Indexed: 01/15/2023]
Abstract
Purpose The great spatial and temporal resolution of positron emission tomography might provide the answer for patients with primary hyperparathyroidism (pHPT) and non-localized parathyroid glands. We performed a systematic review of the evidence regarding all investigated tracers. Methods A study was considered eligible when the following criteria were met: (1) adults ≥17 years old with non-familial pHPT, (2) evaluation of at least one PET isotope, and (3) post-surgical and pathological diagnosis as the gold standard. Performance was expressed in sensitivity and PPV. Results Twenty-four papers were included subdivided by radiopharmaceutical: 14 studies investigated l-[11C]Methionine (11C-MET), one [11C]2-hydroxy-N,N,N-trimethylethanamium (11C-CH), six 2-deoxy-2-[18F]fluoro-d-glucose (18F-FDG), one 6-[18F] fluoro-l-DOPA (18F-DOPA), and three N-[(18F)Fluoromethyl]-2-hydroxy-N,N-dimethylethanaminium (18F-FCH). The 14 studies investigating MET included a total of 327 patients with 364 lesions. Sensitivity for the detection of a lesion in the correct quadrant had a pooled estimate of 69 % (95 % CI 60–78 %). Heterogeneity was overall high with I2 of 51 % (p = 0.01) for all 14 studies. Pooled PPV ranged from 91 to 100 % with a pooled estimate of 98 % (95 % CI 96–100 %). Of the other investigated tracers, 18-FCH seems the most promising with high diagnostic performance. Conclusions The results of our meta-analysis show that 11C-MET PET has an overall good sensitivity and PPV and may be considered a reliable second-line imaging modality to enable minimally invasive parathyroidectomy. Our literature review suggests that 18F-FCH PET may produce even greater accuracy and should be further investigated using both low-dose CT and MRI for anatomical correlation.
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47
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Parathyroid 4D CT and Scintigraphy. Otolaryngol Head Neck Surg 2016; 154:847-53. [DOI: 10.1177/0194599816630711] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 01/14/2016] [Indexed: 11/15/2022]
Abstract
Objective To determine the prevalence of missed lesions for parathyroid 4-dimensional computed tomography (4D CT) and scintigraphy and to describe the factors leading to missed lesions for both modalities. Study Design Case series with chart review. Setting Single center, hospital based. Subjects and Methods Forty patients undergoing 4D CT and scintigraphy before parathyroidectomy between July 2009 and October 2013 were included. Radiology reports and imaging were reviewed and correlated with operative notes to identify cases with missed lesions and the reasons for those misses. All lesions were then classified according to the following factors: multigland disease, lesion size, patient body weight, and multinodular goiter. Results Of the 40 patients, 6 had multigland disease, resulting in 51 lesions; 12 and 29 lesions were missed on 4D CT and scintigraphy, respectively. The sensitivity for detection of all lesions was 76% for 4D CT and 43% for scintigraphy. Sensitivities for single-gland disease were 88% for 4D CT and 50% for scintigraphy. Sensitivities for multigland disease were 53% for 4D CT and 24% for scintigraphy. Rates of multigland disease in patients with missed lesions were 75% on 4D CT and 48% on scintigraphy, as compared with patients with detected lesions, 23% and 18%, respectively ( P ≤ .04). Mean weight of lesions missed on 4D CT was 0.3 and 0.6 g in detected lesions ( P = .15). Mean weight of lesions missed on scintigraphy was 0.4 and 0.8 g in detected lesions ( P = .03). Conclusion 4D CT has higher sensitivity than scintigraphy. Missed lesions are more likely to occur with multigland disease for both modalities and in smaller lesions for scintigraphy.
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Minisola S, Cipriani C, Diacinti D, Tartaglia F, Scillitani A, Pepe J, Scott-Coombes D. Imaging of the parathyroid glands in primary hyperparathyroidism. Eur J Endocrinol 2016; 174:D1-8. [PMID: 26340967 DOI: 10.1530/eje-15-0565] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 09/03/2015] [Indexed: 01/21/2023]
Abstract
Primary hyperparathyroidism (PHPT) is one of the most frequent endocrine diseases worldwide. Surgery is the only potentially curable option for patients with this disorder, even though in asymptomatic patients 50 years of age or older without end organ complications, a conservative treatment may be a possible alternative. Bilateral neck exploration under general anaesthesia has been the standard for the definitive treatment. However, significant improvements in preoperative imaging, together with the implementation of rapid parathyroid hormone determination, have determined an increased implementation of focused, minimally invasive surgical approach. Surgeons prefer to have a localization study before an operation (both in the classical scenario and in the minimally invasive procedure). They are not satisfied by having been referred a patient with just a biochemical diagnosis of PHPT. Imaging studies must not be utilized to make the diagnosis of PHPT. They should be obtained to both assist in determining disease etiology and to guide operative procedures together with the nuclear medicine doctor and, most importantly, with the surgeon. On the contrary, apart from minimally invasive procedures in which localization procedures are an obligate choice, some surgeons believe that literature on parathyroidectomy over the past two decades reveals a bias towards localization. Therefore, surgical expertise is more important than the search for abnormal parathyroid glands.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Daniele Diacinti
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Francesco Tartaglia
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Alfredo Scillitani
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Jessica Pepe
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - David Scott-Coombes
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
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Gandini G, Marchisio F, Isolato G, Sargiotto A, Zotta M, Bisi G. Preoperative Localization for Parathyroid Surgery in Primary and Secondary Hyperparathyroidism. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Affiliation(s)
- Paul Lee
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia.
- Diabetes and Metabolism Branch, Garvan Institute of Medical Research, Sydney, NSW, Australia.
| | - Jerry R Greenfield
- Department of Endocrinology, St Vincent's Hospital, Sydney, NSW, Australia
- Diabetes and Metabolism Branch, Garvan Institute of Medical Research, Sydney, NSW, Australia
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