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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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McClean A, England RJA. Revision parathyroid surgery - challenges and considerations in comparison to primary surgery. J Laryngol Otol 2023; 137:1233-1236. [PMID: 36938821 DOI: 10.1017/s002221512300049x] [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] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Revision parathyroidectomy is made necessary by recurrent or persistent parathyroid disease. This study aimed to identify challenges in revision surgery compared to primary parathyroid surgery. METHODS All revision parathyroidectomies performed by one surgeon over a 17-year period were assessed for demographics, imaging, histology, biochemistry, cure rate, gland weight, gland location and gland ectopia, and compared to a series of 100 primary parathyroidectomies. RESULTS Twenty-eight revision surgical procedures were identified. Sestamibi scanning for gland localisation was superior to ultrasound in both primary and revision surgery. Pre-operative calcium and gland weight were significantly higher in revision cases. There were no significant differences in post-operative calcium levels, pre- or post-operative parathyroid hormone levels, or gland location. 36 per cent of glands excised in revision surgery were ectopic, compared to 25 per cent in primary procedures. The cure rate was significantly lower in revision surgery. CONCLUSION Revision parathyroidectomy patients present with higher pre-operative calcium and larger adenomas; the cure rate is significantly lower in these patients.
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Affiliation(s)
- A McClean
- Plastic and Reconstructive Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - R J A England
- ENT, Hull University Teaching Hospitals NHS Trust, Hull, UK
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Pavlidis ET, Pavlidis TE. Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy. World J Clin Cases 2023; 11:2213-2225. [PMID: 37122518 PMCID: PMC10131017 DOI: 10.12998/wjcc.v11.i10.2213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 02/01/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.
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Affiliation(s)
- Efstathios T Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- The Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University, Thessaloniki 54642, Greece
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The difficult parathyroid: advice to find elusive gland(s) and avoid or navigate reoperation. Curr Probl Surg 2023; 60:101262. [PMID: 36894218 DOI: 10.1016/j.cpsurg.2022.101262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Uludag M, Unlu MT, Kostek M, Caliskan O, Aygun N, Isgor A. Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:1-17. [PMID: 37064844 PMCID: PMC10098391 DOI: 10.14744/semb.2023.39260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/18/2023]
Abstract
Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.
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Affiliation(s)
- Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
- Address for correspondence: Mehmet Taner Unlu, MD. Türkiye Sağlık Bilimleri Üniversitesi, Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Türkiye Phone: +90 539 211 32 36 E-mail:
| | - Mehmet Kostek
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Adnan Isgor
- Deparment of General Surgery, Sisli Memorial Hospital, Istanbul, Türkiye
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Giant Ectopic Parathyroid Adenoma Arising in the Posterior Mediastinum. Report of Case and a Review. Case Rep Surg 2022; 2022:6473197. [PMID: 36407056 PMCID: PMC9668461 DOI: 10.1155/2022/6473197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 10/08/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
We present a case of a greatly enlarged giant ectopic parathyroid adenoma that weighed 43 grams, which was located in the posterior mediastinum of a 74-year-old man. The patient presented with generalized weakness and decreased level of consciousness. He was found to have elevated level of serum calcium (19.9 mg/dl), and a subsequent assay of parathyroid hormone (PTH) was greatly elevated (2234 pg/ml). We report the course of management and outcome of the patient and present a review of the literature on giant ectopic parathyroid adenomas in the posterior mediastinum.
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Latgé A, Averous G, Helali M, Bachellier P, Imperiale A. Parathyromatosis: a challenging cause of recurrent primary hyperparathyroidism. QJM 2022; 115:235-236. [PMID: 35166836 DOI: 10.1093/qjmed/hcac042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- A Latgé
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France
| | - G Averous
- Pathology, University Hospitals of Strasbourg, University of Strasbourg, 1, Avenue Molière, 67200 Strasbourg, France
- Pathology, University Hospitals of Strasbourg, University of Strasbourg, 1, Avenue Molière, 67200 Strasbourg, France
| | - M Helali
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France
| | - P Bachellier
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, University Hospitals of Strasbourg, University of Strasbourg, 1, Avenue Molière, 67200 Strasbourg, France
- Hepato-Pancreato-Biliary Surgery and Liver transplantation, University Hospitals of Strasbourg, University of Strasbourg, 1, Avenue Molière, 67200 Strasbourg, France
| | - A Imperiale
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France and Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Université de Strasbourg, 17, rue Albert Calmette, 67093 Strasbourg, France and Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS/Unistra, Strasbourg, France
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Bollerslev J, Rejnmark L, Zahn A, Heck A, Appelman-Dijkstra NM, Cardoso L, Hannan FM, Cetani F, Sikjaer T, Formenti AM, Björnsdottir S, Schalin-Jäntti C, Belaya Z, Gibb F, Lapauw B, Amrein K, Wicke C, Grasemann C, Krebs M, Ryhänen E, Makay Ö, Minisola S, Gaujoux S, Bertocchio JP, Hassan-Smith Z, Linglart A, Winter EM, Kollmann M, Zmierczak HG, Tsourdi E, Pilz S, Siggelkow H, Gittoes N, Marcocci C, Kamenický P. European Expert Consensus on Practical Management of Specific Aspects of Parathyroid Disorders in Adults and in Pregnancy: Recommendations of the ESE Educational Program of Parathyroid Disorders. Eur J Endocrinol 2022; 186:R33-R63. [PMID: 34863037 PMCID: PMC8789028 DOI: 10.1530/eje-21-1044] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 12/03/2021] [Indexed: 11/17/2022]
Abstract
This European expert consensus statement provides recommendations for the diagnosis and management of primary hyperparathyroidism (PHPT), chronic hypoparathyroidism in adults (HypoPT), and parathyroid disorders in relation to pregnancy and lactation. Specified areas of interest and unmet needs identified by experts at the second ESE Educational Program of Parathyroid Disorders (PARAT) in 2019, were discussed during two virtual workshops in 2021, and subsequently developed by working groups with interest in the specified areas. PHPT is a common endocrine disease. However, its differential diagnosing to familial hypocalciuric hypercalcemia (FHH), the definition and clinical course of normocalcemic PHPT, and the optimal management of its recurrence after surgery represent areas of uncertainty requiring clarifications. HypoPT is an orphan disease characterized by low calcium concentrations due to insufficient PTH secretion, most often secondary to neck surgery. Prevention and prediction of surgical injury to the parathyroid glands are essential to limit the disease-related burden. Long-term treatment modalities including the place for PTH replacement therapy and the optimal biochemical monitoring and imaging surveillance for complications to treatment in chronic HypoPT, need to be refined. The physiological changes in calcium metabolism occurring during pregnancy and lactation modify the clinical presentation and management of parathyroid disorders in these periods of life. Modern interdisciplinary approaches to PHPT and HypoPT in pregnant and lactating women and their newborns children are proposed. The recommendations on clinical management presented here will serve as background for further educational material aimed for a broader clinical audience, and were developed with focus on endocrinologists in training.
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Affiliation(s)
- Jens Bollerslev
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Specialized Endocrinology, Department of Endocrinology, Medical Clinic, Oslo University Hospital, Oslo, Norway
- Correspondence should be addressed to J Bollerslev Email
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Alexandra Zahn
- Schön-Klinik Hamburg, Department of Endocrine Surgery, Hamburg, Germany
| | - Ansgar Heck
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Section of Specialized Endocrinology, Department of Endocrinology, Medical Clinic, Oslo University Hospital, Oslo, Norway
| | - Natasha M Appelman-Dijkstra
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Luis Cardoso
- Centro Hospitalar e Universitário de Coimbra, i3S – Instituto de Investigação e Inovação em Saúde da Universidade do Porto, Porto, Portugal
| | - Fadil M Hannan
- Nuffield Department of Women’s and Reproductive Health, University of Oxford, Oxford, UK
| | - Filomena Cetani
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Tanja Sikjaer
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, Vita-Salute San Raffaele University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Sigridur Björnsdottir
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
| | - Camilla Schalin-Jäntti
- Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Zhanna Belaya
- The National Medical Research Centre for Endocrinology, Moscow, Russia
| | - Fraser Gibb
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Corinna Wicke
- Thyroid Center, Luzerner Kantonsspital, Luzern, Switzerland
| | - Corinna Grasemann
- Division of Rare Diseases, Department of Pediatrics, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael Krebs
- Division of Endocrinology and Metabolism, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Eeva Ryhänen
- Endocrinology, Abdominal Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Özer Makay
- Division of Endocrine Surgery, Department of General Surgery, Ege University Hospital, Izmir, Turkey
| | - Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, Sapienza University of Rome, Rome, Italy
| | - Sébastien Gaujoux
- Department of Digestive, Hepatobiliary and Endocrine Surgery, Paris Descartes University, Cochin Hospital, Paris, France
| | - Jean-Philippe Bertocchio
- Assistance Publique-Hôpitaux de Paris (AP-HP), Pitié-Salpêtrière Hospital, Nephrology Department, Boulevard de l’Hôpital, Paris, France
| | - Zaki Hassan-Smith
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Agnès Linglart
- Université de Paris Saclay, AP-HP, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Filière OSCAR, Service d’Endocrinologie et Diabète de l’Enfant, Hôpital Bicêtre Paris Saclay, Le Kremlin Bicêtre, France
| | - Elizabeth M Winter
- Division of Endocrinology, Department of Medicine, Leiden University Medical Center (LUMC), Leiden, the Netherlands
| | - Martina Kollmann
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Hans-Georg Zmierczak
- Reference Centre for Rare Bone, Calcium and Phosphate Disorders – University Hospital Ghent, Ghent, Belgium
| | - Elena Tsourdi
- Center for Healthy Aging, Department of Medicine III, Technische Universität Dresden Medical Center, Dresden, Germany
| | - Stefan Pilz
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Heide Siggelkow
- Endokrinologikum Göttingen, Georg-August-University Göttingen, Göttingen, Germany
| | - Neil Gittoes
- Department of Endocrinology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Peter Kamenický
- Université Paris-Saclay, Inserm, Physiologie et Physiopathologie Endocriniennes, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service d’Endocrinologie et des Maladies de la Reproduction, Centre de Référence des Maladies Rares du Métabolisme du Calcium et du Phosphate, Le Kremlin-Bicêtre, France
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18F-Fluorocholine PET and 4D-CT in Patients with Persistent and Recurrent Primary Hyperparathyroidism. Diagnostics (Basel) 2021; 11:diagnostics11122384. [PMID: 34943620 PMCID: PMC8700343 DOI: 10.3390/diagnostics11122384] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with primary hyperparathyroidism (pHPT) can develop persistent (P-pHPT) or recurrent (R-pHPT) disease after parathyroidectomy. Before recommending reoperation, recurrence must be accurately identified because of the high risk of complications. Our study evaluates 18F-fluorocholine (18F-FCH) PET/CT and 4D-CT integrated in PET/4D-CT in patients with P-pHPT/R-pHPT. Patients with P-pHPT/R-pHPT investigated by 18F-FCH PET/4D-CT between May 2018 and March 2021 were retrospectively included. Forty-two patients were included, 37 of whom underwent 4D-CT. The sensitivity and detection rate (DR%) were 95% and 88% for 18F-FCH PET/CT and 70% and 63% for 4D-CT, respectively. PET/CT and 4D-CT were concordant in 18/24 glands and concordant and positive in 15/24 (63%) glands. Discordant results were obtained for 6/24 glands. The surgical success rate was 65%. PET/CT showed significantly higher sensitivity than 4D-CT. Dynamic CT allowed the identification of no additional glands missed by PET/CT, and the combination of the 2 techniques did not improve the sensitivity or DR%. 18F-FCH PET/CT appears to be a valuable technique to accurately detect hyperfunctioning parathyroid tissue in patients with P-pHPT/R-pHPT and is better than 4D-CT. Except for cases with doubtful locations of PET targets that may require 4D-CT for surgical guidance, standard nonenhanced 18F-FCH PET/CT can be effectively recommended in patients with P-pHPT/R-pHPT before reoperation.
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10
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Steinl GK, Yeh R, McManus CM, Lee JA, Kuo JH. Variations in the Course of the Carotid Arteries in Patients with Retropharyngeal Parathyroid Adenomas. AJNR Am J Neuroradiol 2021; 42:749-752. [PMID: 33602744 DOI: 10.3174/ajnr.a6995] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022]
Abstract
The carotid arteries, classically described as taking a relatively straight course through the neck, deviate medially in a minority of patients. At the extreme, the internal carotid arteries may "kiss" in the midline, coming extremely close to the pharyngeal wall. In this clinical report, we describe 5 patients with primary hyperparathyroidism, all with ectopic retropharyngeal parathyroid adenomas but all with varying carotid artery anatomy. We describe these variations using a previously developed clinical grading system that highlights 1) the relationship between carotid artery location and risk of injury during pharyngeal procedures and 2) the importance of universal, objective criteria to classify carotid anatomy. Radiologists should be familiar with variations in carotid anatomy and communicate them to the operative team.
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Affiliation(s)
- G K Steinl
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - R Yeh
- Department of Radiology (R.Y.), Memorial Sloan Kettering Cancer Center, New York, New York
| | - C M McManus
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - J A Lee
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - J H Kuo
- From the Department of Surgery, Division of GI/Endocrine Surgery (G.K.S., C.M.M., J.A.L., J.H.K.), Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
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11
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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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12
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Camenzuli C, DiMarco AN, Isaacs KE, Grant Y, Jackson J, Alsafi A, Harvey C, Barwick TD, Tolley N, Palazzo FF. The changing face of reoperative parathyroidectomy: a single-centre comparison of 147 parathyroid reoperations. Ann R Coll Surg Engl 2020; 103:29-34. [PMID: 32829647 DOI: 10.1308/rcsann.2020.0185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Reoperative parathyroidectomy for persistent and recurrent primary hyperparathyroidism is dependent on radiology. This study aimed to compare outcomes in reoperative parathyroidectomy at a single centre using a combination of traditional and newer imaging studies. MATERIALS AND METHODS Retrospective case note review of all reoperative parathyroidectomies for persistent and recurrent primary hyperparathyroidism over five years (June 2014 to June 2019; group A). Imaging modalities used and their positive predictive value, complications and cure rates were compared with a published dataset spanning the preceding nine years (group B). RESULTS From over 2000 parathyroidectomies, 147 were reoperations (101 in group A and 46 in group B). Age and sex ratios were similar (56 vs 62 years; 77% vs 72% female). Ultrasound use remains high and shows better positive predictive value (76% vs 57 %). 99mTc-sestamibi use has declined (79% vs 91%) but the positive predictive value has improved (74% vs 53%). 4DCT use has almost doubled (61% vs 37%) with better positive predictive value (88% vs 75%). 18F-fluorocholine positron emission tomography-computed tomography and ultrasound-guided fine-needle aspiration for parathyroid hormone are novel modalities only available for group A. Both carried a positive predictive value of 100%. Venous sampling with or without angiography use has decreased (35% vs 39%) but maintains a high positive predictive value (86% vs 91%). Cure rates were similar (96% vs 100%). Group A had 5% permanent hypoparathyroidism, 1% permanent vocal cord palsy and 1% haematoma requiring reoperation. No complications for group B. CONCLUSION Optimal imaging is key to good cure rates in reoperative parathyroidectomy. High-quality, non-interventional imaging techniques have produced a shift in the preoperative algorithm without compromising outcomes.
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Affiliation(s)
- C Camenzuli
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A N DiMarco
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - K E Isaacs
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Y Grant
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - J Jackson
- Department of Endocrine and Thyroid Radiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - A Alsafi
- Department of Endocrine and Thyroid Radiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - C Harvey
- Department of Endocrine and Thyroid Radiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - T D Barwick
- Department of Endocrine and Thyroid Radiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - N Tolley
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - F F Palazzo
- Department of Endocrine and Thyroid Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
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13
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Di Marco AN, Palazzo FF. Near-infrared autofluorescence in thyroid and parathyroid surgery. Gland Surg 2020; 9:S136-S146. [PMID: 32175254 DOI: 10.21037/gs.2020.01.04] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contrast-free autofluorescence (AF) of the parathyroid glands (PTGs) and thyroid tissue occurs in the near-infrared (NIR) spectrum on excitation by light in the upper range of the visible spectrum or lower NIR spectrum. In vivo, PTGs autofluoresce more brightly than thyroid (by a factor of 2-20 times) and appear as a bright spot against surrounding thyroid, muscle or fat on a processed image which is generated in real-time. NIR-AF of PTGs was first described in 2009 although NIR-AF had previously been used in several other clinical applications. Since then there has been a great amount of interest in the use of NIR-AF in thyroid and parathyroid surgery with over 25 published reports of the utilisation of both self-built and proprietary NIR-AF devices in neck endocrine surgery. All of these reports have confirmed the feasibility of NIR-AF intraoperatively and its ability to detect PTGs, although the reported accuracy varies from 90-100%. Reports of the effect of NIR-AF on relevant clinical endpoints i.e., post-operative hypoparathyroidism in thyroidectomy and persistent disease in parathyroidectomy are however scant. There has been one multicentre clinical trial of NIR-AF in thyroidectomy but this did not report clinical outcomes and two single-centre, non-randomised studies which did report post-operative hypoparathyroidism but with differing results: one showing no benefit in 106 NIR-AF vs. 163 controls and one, a reduction of early hypocalcaemia from 20% to 5% in 93 NIR-AF patients vs. 420 controls. There were only 2 cases of permanent hypoparathyroidism across both studies and therefore no significant observable difference in this key outcome variable. In parathyroidectomy, possible variability of the AF signal due to composition of a PTG adenoma, secondary/tertiary disease and MEN1 as well as depth-penetration preventing detection of sub-surface PTGs would imply that NIR-AF in its current form is not well-placed to improve cure-rates in hyperparathyroidism, which may already be as high as 98%. Thus far, no study has addressed this. Despite the promising results of NIR-AF, the absence of data demonstrating an improvement in outcomes and the cost of its use currently limit its use in routine clinical practice, especially in a publicly funded healthcare system with budgetary constraints. However, it can be utilised in research settings and this should be undertaken within the context of well-designed and conducted randomised, multi-centre, appropriately powered studies, which will assist in establishing its role in neck endocrine surgery.
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Affiliation(s)
- Aimee N Di Marco
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
| | - Fausto F Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.,Department of Surgery & Cancer, Imperial College, London, UK
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14
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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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15
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Mazotas IG, Yen TWF, Doffek K, Shaker JL, Carr AA, Evans DB, Wang TS. Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role? J Surg Res 2019; 246:335-341. [PMID: 31635835 DOI: 10.1016/j.jss.2019.08.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 06/07/2019] [Accepted: 08/15/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Persistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared. METHODS This retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia. RESULTS Of 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46). CONCLUSIONS Recurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.
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Affiliation(s)
- Ioanna G Mazotas
- Department of Surgery, Mission Hospital, Asheville, North Carolina.
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kara Doffek
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Joseph L Shaker
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Azadeh A Carr
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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16
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Iacobone M, Scerrino G, Palazzo FF. Parathyroid surgery: an evidence-based volume-outcomes analysis : European Society of Endocrine Surgeons (ESES) positional statement. Langenbecks Arch Surg 2019; 404:919-927. [PMID: 31595330 DOI: 10.1007/s00423-019-01823-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/02/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The interest in correlation between hospital and surgeon practice volume and postoperative outcomes has grown considerably over the last decades; it has been suggested that surgery is likely to be associated with higher cure rates, lower morbidity and more favourable results in cost-effectiveness when performed in a high-volume setting. The aim of this paper is to undertake an evidence-based literature review of the relationship between surgical volume and clinical outcomes in parathyroidectomy for primary hyperparathyroidism. We used accepted quality markers to identify the relationship between volume and outcome with a view to defining a reproducible minimal surgical volume-related standard of care in parathyroid surgery. METHODS A peer review literature analysis of volume and outcomes in parathyroid surgery was carried out and assessed from an evidence-based perspective. Results were discussed at the 2019 Conference of the European Society of Endocrine Surgeons devoted to "Volumes, Outcomes and Quality Standards in Endocrine Surgery". RESULTS Literature reports no prospective randomised studies; thus, a low level of evidence may be achieved. CONCLUSIONS Parathyroid surgery is at increased risk of failures, morbidity and need for reoperations and cost when performed in low-volume settings; thus, it should be concentrated in dedicated settings, with adequate annual volume and expertise. Acceptable results may be achieved moving parathyroid surgery cases away from low-volume settings (< 15 parathyroidectomies/year). Challenging procedures (primary hyperparathyroidism without unequivocal preoperative localization, hereditary variants, paediatric patients, reoperations) should be confined to high-volume settings (> 40 parathyroidectomies/year).
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Affiliation(s)
- Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
| | - Gregorio Scerrino
- General and Emergency Surgery Unit, Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - F Fausto Palazzo
- Department of Endocrine Surgery, Hammersmith Hospital, London, UK
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17
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Purkiss S, Keegel T, Vally H, Wollersheim D. Cervical re-explorations and proxy survival following parathyroidectomy for primary hyperparathyroidism using Australian administrative data. ANZ J Surg 2019; 90:872-876. [PMID: 31067607 DOI: 10.1111/ans.15238] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 03/19/2019] [Accepted: 03/21/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Administrative data may have utility in the impartial assessment of surgical outcomes and rare events. We have used a publicly available sample of the Australian pharmaceutical and health service provision (medical benefits scheme) databases to assess outcomes following parathyroidectomy for primary hyperparathyroidism (PHP). METHODS A cohort study using linked pharmaceutical and medical benefits schemes data was performed covering the period 1993-2014. Procedure codes identified participants undergoing parathyroidectomy for PHP and subsequent cervical re-exploration surgery (CRX), and the last service date used as a proxy for survival. Time to CRX and survival were modelled using Kaplan-Meier analysis. Demographic data and the era of parathyroid surgery were managed as covariates for Cox regression survival analyses. RESULTS A total of 2165 persons undergoing parathyroidectomy for PHP were identified. Median follow-up was 5.3 years (range 0.2-22). The annual number of parathyroidectomies for PHP increased gradually; 72 individuals underwent CRX (3.3%). The median time to CRX was 152 days (confidence interval 0-396) in 2000-2004 reducing to 47 days (confidence interval 15-78) for the period 2010-2014 (log-rank P = 0.027). The proportion of persons requiring CRX reduced over time from 6.1% in 1997 to 2.1% in 2012 (r2 = 0.5817, P = 0.023). Overall median survival (24.6 years) was poorer when compared with age matched controls (log-rank P = 0.025) but was not associated with CRX or gender. CONCLUSION Administrative data can be used for the assessment of surgical outcomes and may be useful for comparisons of surgical performance, and the appraisal of infrequent events. CRX rates following parathyroidectomy for PHP are improving in Australia.
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Affiliation(s)
- Shaun Purkiss
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Tessa Keegel
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia.,Monash Centre for Occupational Health, Monash University, Melbourne, Victoria, Australia
| | - Hassan Vally
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Dennis Wollersheim
- Department of Public Health, La Trobe University, Melbourne, Victoria, Australia
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18
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Abstract
Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or pre-operative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15–65 pg/mL) can be considered cured and may need less frequent follow-up.
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Affiliation(s)
- Anatoliy V. Rudin
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Travis J. McKenzie
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Roberta Wermer
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Department of Medicine, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Geoffrey B. Thompson
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
| | - Melanie L. Lyden
- Division of Breast, Endocrine, Metabolic and Gastrointestinal Surgery, Mayo Clinic-Rochester, Rochester, Minnesota
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19
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Abstract
Sporadic primary hyperparathyroidism (pHPT) is the commonest cause of hypercalcaemia in the ambulatory population. It has a female preponderance and its incidence is increasing. In 85% of cases it is caused by a single parathyroid adenoma, with four gland hyperplasia in up to 20%. Parathyroidectomy is the only cure and bilateral neck exploration remains the gold standard to achieve this. Several adjuncts have been developed to improve success rates or limit the extent of surgery. Pre-operative localisation permits planned targeted surgery. Ultrasound scanning and scintigraphy are the most commonly employed, although 4DCT has become a useful modality in complex cases. However, excellent rates of biochemical cure can be achieved in specialist centres when pre-operative imaging is negative. Pre-operative prediction models and intra-operative parathyroid hormone (ioPTH) assist, with high sensitivity, to predict single gland disease. Reoperations present a major challenge to the endocrine surgeon.
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Affiliation(s)
- Richard J Egan
- Morriston Hospital, Heol Maes Eglwys, Swansea, SA6 6NL, UK.
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20
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Affiliation(s)
- Reema Mallick
- Department of Surgery, University of Alabama-Birmingham, 1808 7th Avenue South, Suite 502, Birmingham, AL 35233, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama-Birmingham, 1808 7th Avenue South, Suite 502, Birmingham, AL 35233, USA.
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21
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Stack BC, Tolley NS, Bartel TB, Bilezikian JP, Bodenner D, Camacho P, Cox JPDT, Dralle H, Jackson JE, Morris JC, Orloff LA, Palazzo F, Ridge JA, Scott-Coombes D, Steward DL, Terris DJ, Thompson G, Randolph GW. AHNS Series: Do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: Definitive multidisciplinary joint consensus guidelines of the American Head and Neck Society and the British Association of Endocrine and Thyroid Surgeons. Head Neck 2018; 40:1617-1629. [PMID: 30070413 DOI: 10.1002/hed.25023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/13/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Revision parathyroid is challenging due to possible diagnostic uncertainty as well as the technical challenges it can present. METHODS A multidisciplinary panel of distinguished experts from the American Head and Neck Society (AHNS) Endocrine Section, the British Association of Endocrine and Thyroid Surgeons (BAETS), and other invited experts have reviewed this topic with the purpose of making recommendations based on current best evidence. The literature was also reviewed on May 12, 2017. PubMed (1946-2017), Cochrane SR (2005-2017), CT databases (1997-2017), and Web of Science (1945-2017) were searched with the following strategy: revision and reoperative parathyroidectomy to ensure completeness. RESULTS Guideline recommendations were made in 3 domains: preoperative evaluation, surgical management, and alternatives to surgery. Eleven guideline recommendations are proposed. CONCLUSION Reoperative parathyroid surgery is best avoided if possible. Our literature search and subsequent recommendations found that these cases are best managed by experienced surgeons using precision preoperative localization, intraoperative parathyroid hormone (PTH), and the team approach.
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Affiliation(s)
- Brendan C Stack
- Department of Otolaryngology - Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Neil S Tolley
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | | | - John P Bilezikian
- Department of Medicine, Division of Endocrinology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Donald Bodenner
- Department of Geriatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Pauline Camacho
- Department of Medicine, Division of Endocrinology, Loyola University, Chicago, Illinois
| | - Jeremy P D T Cox
- Department of Metabolic Medicine, Imperial College Hospital, NHS Healthcare Trust, London, UK
| | - Henning Dralle
- Sektion Endokrine Chirurgie, Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinisches Zentrum, Germany
| | - James E Jackson
- Department of Imaging, Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John C Morris
- Department of Medicine, Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Lisa Ann Orloff
- Department of Otolaryngology - Head and Neck Surgery, Stanford University, Palo Alto, California
| | - Fausto Palazzo
- Hammersmith Hospital, Imperial College NHS Healthcare Trust, London, UK
| | - John A Ridge
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | | | - David L Steward
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati, Cincinnati, Ohio
| | - David J Terris
- Department of Otolaryngology - Head and Neck Surgery, Augusta University, Augusta, Georgia
| | | | - Gregory W Randolph
- Department of Otolaryngology - Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard University, Boston, Massachusetts
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22
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Hamidi M, Sullivan M, Hunter G, Hamberg L, Cho NL, Gawande AA, Doherty GM, Moore FD, Nehs MA. 4D-CT is Superior to Ultrasound and Sestamibi for Localizing Recurrent Parathyroid Disease. Ann Surg Oncol 2018; 25:1403-1409. [PMID: 29484563 DOI: 10.1245/s10434-018-6367-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Recurrent primary hyperparathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing parathyroid adenomas in recurrent or persistent PHPT. METHODS We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of parathyroid lesions were collected for each patient. RESULTS A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. CONCLUSION 4D-CT localized parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
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Affiliation(s)
- Moska Hamidi
- Division of General Surgery, London Health Sciences Center, London, ON, Canada
| | - Michael Sullivan
- Division of General Surgery, Jersey Shore University Medical Center, Neptune City, NJ, USA
| | - George Hunter
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Leena Hamberg
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Nancy L Cho
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Atul A Gawande
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Gerard M Doherty
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Francis D Moore
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Matthew A Nehs
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA. .,General and Endocrine Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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23
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Guerin C, Paladino NC, Lowery A, Castinetti F, Taieb D, Sebag F. Persistent and recurrent hyperparathyroidism. Updates Surg 2017; 69:161-169. [PMID: 28434176 DOI: 10.1007/s13304-017-0447-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/08/2017] [Indexed: 12/26/2022]
Abstract
Despite remarkable progress in imaging modalities and surgical management, persistence or recurrence of primary hyperparathyroidism (PHPT) still occurs in 2.5-5% of cases of PHPT. The aim of this review is to expose the management of persistent and recurrent hyperparathyroidism. A literature search was performed on MEDLINE using the search terms "recurrent" or "persistent" and "hyperparathyroidism" within the past 10 years. We also searched the reference lists of articles identified by this search strategy and selected those we judged relevant. Before considering reoperation, the surgeon must confirm the diagnosis of PHPT. Then, the patient must be evaluated with new imaging modalities. A single adenoma is found in 68% of cases, multiglandular disease in 28%, and parathyroid carcinoma in 3%. Others causes (<1%) include parathyromatosis and graft recurrence. The surgeon must balance the benefits against the risks of a reoperation (permanent hypocalcemia and recurrent laryngeal nerve palsy). If surgery is necessary, a focused approach can be considered in cases of significant imaging foci, but in the case of multiglandular disease, a bilateral neck exploration could be necessary. Patients with multiple endocrine neoplasia syndromes are at high risk of recurrence and should be managed regarding their hereditary pathology. The cure rate of persistent-PHPT or recurrent-PHPT in expert centers is estimated from 93 to 97%. After confirming the diagnosis of PHPT, patients with persistent-PHPT and recurrent-PHPT should be managed in an expert center with all dedicated competencies.
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Affiliation(s)
- Carole Guerin
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France. .,Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.
| | - Nunzia Cinzia Paladino
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France
| | - Aoife Lowery
- Department of Surgery, University Hospital Limerick and Graduate Entry Medical School University of Limerick, Limerick, Ireland
| | - Fréderic Castinetti
- Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.,Department of Endocrinology, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France
| | - David Taieb
- Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France.,Department of Nuclear Medicine, La Timone Hospital, Assistance Publique Hopitaux de Marseille, 264 Rue Saint-Pierre, 13385, Marseille, France
| | - Fréderic Sebag
- Department of Endocrine Surgery, La Conception Hospital, Assistance Publique Hopitaux de Marseille, 147 BD Baille, 13005, Marseille, France.,Aix-Marseille University, Medical School, 27, bd Jean Moulin, 13385, Marseille Cedex 05, France
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