MINIMALLY INVASIVE PARATHYROIDECTOMY FOR PRIMARY HYPERPARATHYROIDISM

The Current Role of Parathyroid Fine-Needle Biopsy (P-FNAB) with iPTH-Washout Concentration (iPTH-WC) in Primary Hyperparathyroidism: A Single Center Experience and Literature Review

Introduction. Primary hyperparathyroidism (PHPT) is a condition characterized by disorders of calcium–phosphate metabolism and bone metabolism caused by pathological overproduction of parathyroid hormone (PTH). The diagnosis of overt PHPT is based on the presence of clinical symptoms and laboratory abnormalities typical of this condition: hypercalcemia, hypercalciuria and elevated iPTH levels. Imaging studies are not used for diagnostic purposes; they are performed to localize the parathyroid glands prior to potential surgical treatment. Technetium 99 m sestamibi scintigraphy (Tc99 m-MIBI) is the gold standard in the assessment of pathologically altered parathyroid glands. Other diagnostic options include cervical ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). Parathyroid biopsy (P-FNAB) with iPTH washout concentration (iPTH-WC) assessment is still an underestimated method of preoperative parathyroid gland localization. Few studies have reported the utility of US-guided P-FNAB in preoperative assessment of parathyroid lesions. The aim of the study was to present our experience with 143 P-FNAB with iPTH-WC assessment. Material and methods. Laboratory results, US findings, P-FNAB complications and comparison with other imaging techniques were described and analyzed. Results. In 133 (93.0) patients, iPTH washout-to-serum ratio exceeded threshold level 0.5 and were classified as positive results. Median iPTH-WC in this group was 16,856 pg/mL, and the iPTH-WC to serum iPTH ratio was 158. There was no correlation between iPTH-WC and serum PTH, serum calcium, parathyroid gland volume and shape index. In the group of 46 operated patients, 44 demonstrated positive iPTH-WC results, which corresponds to a sensitivity of 95.6%. In Tc99-MIBI, radiotracer retention was found in 17 cases (in 24 MIBI performed), which corresponds to a sensitivity of 52.2%. P-FNAB did not cause any major side effects −92.5% of all patients had no or mild adverse events after this procedure. Conclusions. P-FNAB with iPTH-WC is a reliable method in parathyroid adenoma localization during PHPT. Its sensitivity for diagnosis of PHPT is much higher than that of Tc99-MIBI, and in some situations, P-FNAB with iPTH-WC may even replace that method. Furthermore, cost-effectiveness of iPTH-WC is at least similar to that of Tc99-MIBI. Complications of P-FNAB are mild and we can describe this method as a safe procedure.

CLINICAL FEATURES OF HYPERCALCEMIC CRISIS IN PRIMARY HYPERPARATHYROIDISM

CONTEXT

Primary hyperparathyroidism related hypercalcemic crisis (PHHC) is a condition that may result in fetal course. So, the early diagnosis and treatment of these patients are important.

OBJECTIVE

This study aimed to investigate the clinical features for hypercalcemic crisis (HC) by comparing the groups with and without primary hyperparathyroidism related calcemic crisis.

DESIGN

All patients operated with primary hyperparathyroidism (PH) diagnosis in a single clinic between March 2015 and March 2020 were included in this retrospective study.

SUBJECTS AND METHODS

119 patients included the study.Patients with serum calcium (Ca) level > 14 mg/dl were regarded as HC and the patients were divided into two groups as HC and non-HC. These two groups were compared for demographic data, preoperative biochemical parameters, preoperative localization studies, histopathological assessment and postoperative results.

RESULTS

Serum Parathormone (PTH), Ca, Alkaline phosphatase (ALP) and creatinine values among preoperative biochemical parameters were higher in the HC group than the non-HC (p<0.005). The hyper-functional parathyroid size of the patients in the HC group was also bigger compared to non-HC (p<0.05). No difference was observed in the demographic and histopathological data, preoperative localization studies and postoperative results of the two groups (p>0.05).

CONCLUSIONS

PH is usually an elective operation and PHCC treatment should be relatively more urgent as it can be mortal. Higher HC occurrence possibility should be considered in PH patients with high serum PTH, ALP and creatinine values and large tumor diameters and those patients should be prioritized for treatment.

Personalized nuclear imaging protocol in cases with nodular goiter and parathyroid adenoma

A 62 years old woman was diagnosed with multinodular toxic goiter and primary hyperparathyroidism/left parathyroid adenoma by hormonal assessment, ultrasound and nuclear thyroid/parathyroid scans. Cervical ultrasound illustrated a multinodular aspect of the thyroid with solid nodules and cystic-component nodules; the larger one represented a multinodular complex with necrosis areas in the left thyroid lobe, ACR TI-RADS score 4 (moderately suspicious). Functional nuclear imaging was performed for accurate differential diagnosis between thyroid vs. parathyroid localization, between cold vs. hot nodules, and eventually, for guiding the choice of a subsequent Fine-Needle Aspiration Biopsy (FNAB). Scans described an early intense ^99mTc-sestaMIBI uptake with no ^99mTc-pertechnetate uptake in the left thyroid lobe larger nodule. Due to the suspicion of malignancy for this nodule, we performed an additional scan (1 hour before the classical 2 hours parathyroid delayed scan). The intense uptake persists in both delayed scans suggesting no malignant phenotype and which was confirmed after surgery by benign histology. In conclusion, using a ^99mTc-sestaMIBI personalized protocol, related to the radiotracer cellular uptake mechanisms: 1 hour scan (supplementary image, corresponding to the maximum uptake pattern of ^99mTc-sestaMIBI for cancer cells) and 2 hours scan (for parathyroid washout evaluation) may avoid unnecessary extensive thyroid surgery.

Endoscopic parathyroidectomy via unilateral axillobreast approach

Endoscopic parathyroid and thyroid surgery is becoming increasingly common. In this study, we present the results of patients who underwent Endo- scopic parathyroid via unilateral axillo-breast approach (EP via UABA). Three patients underwent EP via UABA. Patients were discharged on the next day after surgery, while at one month follow up all of them reported no further symptoms. Operation performed via two axiller and one areolar trochar. As different from open surgery, the strap muscles don't pulled laterally and not entered into the thyroid lobe from the midline. In this technique, the strap muscles are separated from the middle part of the strap muscles and the thyroid gland is reached from the middle of the strap muscles. In this way, N. laryngeal recurrence and parathyroid gland that usually located in the posterior aspect of the thyroid gland can be revealed clearly by reducing the risk of complications. EP via UABA can be performed safe effective procedure via good cosmetic results.

Primary Hyperparathyroidism: To Evaluate Benefit of Ultrasound and Tc99m-SESTAMIBI Scan in Localizing Abnormal Parathyroid Gland Before Surgery, in a Secondary Care Hospital

Introduction

Primary hyperparathyroidism is a common endocrine condition requiring parathyroidectomy for curative management. Localization of parathyroid gland by ultrasound and Tc99m-SESTAMIBI is important to opt for less invasive and comparatively lower complication risk surgery minimal invasive parathyroidectomy (MIP) instead of four-gland exploration surgery.

Aim

To evaluate ultrasound and Tc99m-SESTAMIBI in localization of abnormal parathyroid gland before surgery.

Method and materials

All patients of primary hyperparathyroidism (PHPT) that presented to a secondary care hospital (endocrinology department) from 2015-2019 were recruited retrospectively from electronic fusion system of hospital. Results of ultrasound parathyroid and Tc99m-SESTAMIBI done for localization of abnormal parathyroid gland were analyzed.

Results

Total PHPT patients recruited were 59, mean age 64.2 years, male 11 (18.64%) and female 48 (81.3%). Ultrasound parathyroid was done in 44 patients, Tc 99m-SESTAMIBI was done in 31, both tests were done in 31 patients. Combined concordant adenoma in both tests was seen in 11 (35%) cases which can opt for minimal invasive parathyroidectomy (MIP) with confidence whereas 65% of cases would require either four-gland exploration or further testing like single-photon emission computed tomography-computed tomography (SPECT-CT) or intraoperative parathyroid hormone measurement to opt for MIP.

Conclusion

Combined ultrasound parathyroid and Tc 99m-SESTAMIBI scan was useful in localization of parathyroid adenoma in 11 (35%) patients that can opt for MIP which is a lower complication risk surgery whereas 20 (65%) patients would need further investigation with SPECT-CT or intraoperative parathyroid hormone measurement or four-gland exploration surgery.

Recommendation

Third modality of investigation such as SPECT-CT or intraoperative parathyroid hormone measurement needs evaluation so that more patients can benefit from MIP instead of four-gland exploration surgery.