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Mohan Kumar R, Pannu A, Metcalfe E, Senbeto M, Balasubramanian SP. Findings of pilot study following the implementation of point of care intraoperative PTH assay using whole blood during surgery for primary hyperparathyroidism. Front Endocrinol (Lausanne) 2023; 14:1198894. [PMID: 37693360 PMCID: PMC10486897 DOI: 10.3389/fendo.2023.1198894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/09/2023] [Indexed: 09/12/2023] Open
Abstract
Objective To report findings of pilot study using a novel point of care (POC) intraoperative parathyroid hormone (IOPTH) assay for parathyroid hormone (PTH) using whole blood during surgery for primary hyperparathyroidism (PHPT). Methods Patients undergoing surgery for primary hyperparathyroidism from March to November 2022 where intraoperative PTH assay was performed using the NBCL CONNECT IOPTH and the laboratory PTH assay were included (group 1). The biochemistry results were reviewed to determine concordance between NBCL and lab PTH values and diagnostic test parameters of the NBCL CONNECT assay. 'In-theatre' times were then compared with a historical cohort (group 2) where the lab-based IOPTH assay alone was used. Results Of the 141 paired samples in group I, correlation between NBCL and the lab assay was high (rho=0.82; p<0.001). PTH levels using the NBCL assay dropped satisfactorily (>50% of the basal or 0 min sample; whichever was lower - i.e. positive test) in 23 patients; giving a positive predictive value of 100%. Of the 9 patients that did not demonstrate a drop, two were true negative (negative predictive value of 22%) leading to cure after excision of another gland. Group 1 (150 mins) had a significantly shorter 'in-theatre' time compared to group 2 (167 mins) (p=0.007); despite much higher use of near infra-red autofluorescence (NIRAF) (72% vs 11.6% in group I and 2 respectively). Conclusion The NBCL CONNECT POC IOPTH assay gives comparable results to lab based PTH assays and can be performed without need for a centrifuge or qualified technicians. Surgeons, however, need to be aware of the potential for false-negative results.
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Affiliation(s)
- Rahul Mohan Kumar
- Sheffield Endocrine Surgery Unit, Sheffield Teaching Hospitals, Sheffield, United Kingdom
- School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, United Kingdom
| | - Arslan Pannu
- Sheffield Endocrine Surgery Unit, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Emily Metcalfe
- Sheffield Endocrine Surgery Unit, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Mesfin Senbeto
- Sheffield Endocrine Surgery Unit, Sheffield Teaching Hospitals, Sheffield, United Kingdom
| | - Saba P. Balasubramanian
- Sheffield Endocrine Surgery Unit, Sheffield Teaching Hospitals, Sheffield, United Kingdom
- School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, United Kingdom
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Frye CC, Sanka SA, Sullivan J, Brunt LM, Gillanders WE, Pandian T, Brown TC. Analysis of Preoperative Predictors of Single and Multigland Primary Hyperparathyroidism. J Surg Res 2023; 288:148-156. [PMID: 36966595 DOI: 10.1016/j.jss.2023.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 02/05/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023]
Abstract
INTRODUCTION Preoperative differentiation of single-gland (SG) versus multigland (MG) primary hyperparathyroidism (PHPT) can assist with surgical planning, treatment prognostication, and patient counseling. The aim of this study was to identify preoperative predictors of SG-PHPT. METHODS Retrospective analysis of 408 patients with PHPT who underwent parathyroidectomy at a tertiary referral center. Comprehensive preoperative parameters, including demographic, laboratory, clinical, and imaging results were analyzed. Univariate analysis and binary logistic regression identified preoperative predictors of SG-PHPT. Receiver operator curves were used to analyze the predictive values of existing and novel preoperative predictive models. RESULTS Elevated parathyroid hormone (PTH) (99.1 pg/mL in SG versus 93.0 pg/mL in MG), elevated calcium (10.8 mg/dL in SG versus 10.6 mg/dL in MG), lower phosphate levels (2.80 mg/dL in SG versus 2.95 mg/dL in MG), and positive imaging (ultrasound 75.6% in SG versus 56.5% in MG; sestamibi 70.8% in SG versus 45.5% in MG) were significantly associated with SG-PHPT. The Washington University Score (a predictive scoring system made from calcium, PTH, phosphate, ultrasound, and sestamibi) and the Washington University Index ([calcium × PTH]/phosphate) were comparable to previous scoring systems used to predict SG versus MG-PHPT. CONCLUSIONS The association of lower phosphate with SG-PHPT is a novel finding. Previously identified predictors of SG-PHPT, including elevated PTH and positive imaging were confirmed. The Washington University Score and Index are comparable to previously described models and can be used to help surgeons predict if a patient may have SG versus MG-PHPT.
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Arshad MF, Arambewela MH, Bennet WM, Sterrenburg M, Balasubramanian SP. Primary hyperparathyroidism in pregnancy: experience of a tertiary centre. Surg Today 2022; 53:470-475. [PMID: 36107253 PMCID: PMC10042935 DOI: 10.1007/s00595-022-02583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 08/03/2022] [Indexed: 11/24/2022]
Abstract
Abstract
Background and purpose
The management of primary hyperparathyroidism (PHPT) during pregnancy is challenging and there is no clear consensus on whether it increases the risk of complications in pregnancy. We conducted this study to review the maternal and fetal outcomes of pregnant women treated for PHPT in a single centre.
Methods
Data on relevant clinical parameters, demographics, management strategies, maternal and fetal outcomes were collected from the medical records of pregnant patients with PHPT diagnosed between 2012 and 2019.
Results
Of 15 pregnant women with PHPT, 6 were managed medically and 9 underwent surgery. The median age at their index pregnancy was 28 years [range 19–42]. The median highest adjusted calcium level in the medical group was 2.90 [range 2.61–3.25] mmol/L vs. 3.11 [2.78–4.95] mmol/L in the surgical group. There was one miscarriage and the stillbirth of twins in the medical group, but no such outcomes in the surgical group. The median gestational ages were 39 + 3 weeks [range 24 + 2–41 + 2 weeks] and 39 + 4 weeks [range 37 + 1–39 + 5 weeks] in the medical and surgical groups, respectively. No birth was complicated by neonatal tetany or convulsions.
Conclusion
More complications developed in the pregnant PHPT patients who were managed medically than in those who underwent surgery. Surgery performed during the second trimester resulted in good outcomes. Multi-centre prospective studies are required to ascertain the risk of various complications in women with PHPT during pregnancy.
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Affiliation(s)
- Muhammad Fahad Arshad
- Oncology and Metabolism, University of Sheffield Medical School, Sheffield, S10 2RX, UK.
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK.
| | - Maulee Hiromi Arambewela
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
- University of Sri Jayewardenepura, Nugegoda, Sri Lanka
| | - William M Bennet
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Monique Sterrenburg
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
| | - Saba P Balasubramanian
- Oncology and Metabolism, University of Sheffield Medical School, Sheffield, S10 2RX, UK
- Sheffield Teaching Hospitals, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
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Liu L, Zhang JQ, Wang GG, Zhao K, Guo C, Huang C, Li SQ, Chen YY. Surgical Treatment of Ectopic Mediastinal Parathyroid Tumors: A 23-Year Clinical Data Study in a Single Center. J INVEST SURG 2022; 35:1747-1753. [PMID: 35914896 DOI: 10.1080/08941939.2022.2106392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Background. Ectopic mediastinal parathyroid glands are parathyroid glands located completely below the clavicle. At present, most literature reports on ectopic mediastinal parathyroid tumors (EMPT) are case reports or small case sequences.Methods. This study conducted a retrospective analysis of ectopic mediastinal parathyroid tumors cases treated over the past 23 years, summarizing and analyzing general conditions, preoperative positioning, postoperative pathology, intraoperative conditions, and long-term follow-up results.Results. This study enrolled 28 patients. Among them, 27 patients underwent preoperative localization diagnosis using 99mTc-sestamibi scan (MIBI) in conjunction with chest computed tomography (CT), including 26 cases of the anterior superior mediastinum and 2 cases of middle mediastinum. Postoperative pathology revealed 23 cases of parathyroid adenoma, 4 cases of parathyroid hyperplasia, and 1 case of parathyroid cyst. In this study, 12 patients underwent video-assisted thoracoscopic surgery (VATS) and thoracotomy approaches. Using Mann-Whitney U test, we discovered that VATS approach group is significantly superior in surgical time (P = 0.039) and intraoperative bleeding (P < 0.001). Within one week of surgery, 26 patients with primary hyperparathyroidism (PHPT) experienced a significant decrease in blood parathyroid hormone (PTH) (P < 0.001) and blood calcium (P < 0.001), and all achieved long-term remission.Conclusions. EMPT is most frequently performed in the anterior superior mediastinum. EMPT is predominantly parathyroid tumors, and most of them are associated with PHPT. MIBI and chest CT combination can be used for preoperative lesion localization (positive rate 96.15%). VATS can be used as a better surgical approach. PHPT patients before surgery can achieve long-term symptom relief with surgical treatment.
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Affiliation(s)
- Lei Liu
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Jia-Qi Zhang
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Gui-Ge Wang
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Ke Zhao
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Chao Guo
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Cheng Huang
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Shan-Qing Li
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
| | - Ye-Ye Chen
- Department of Thoracic Surgery, Peking, Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking, P.R. China
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Neuberger M, Dropmann JA, Kleespies A, Fuerst H. Determinants and clinical significance of negative scintigraphic findings in primary hyperparathyroidism: a retrospective observational study. Nuklearmedizin 2022; 61:440-448. [PMID: 35913079 DOI: 10.1055/a-1868-5050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM In patients with recurrent primary hyperparathyroidism (pHPT) or preceding thyroid operation, scintigraphic localization of the pathological parathyroid gland is sometimes unsuccessful. Reason for diagnostic failure, and its clinical relevance is poorly understood. METHODS This retrospective observational study in patients suffering from a pHPT evaluated independent predictors of a negative preoperative scintigraphy (SC) result, and its relevance for intraoperative outcome using logistic regression analysis. RESULTS Among 86 pHPT patients scheduled for parathyroid operation, 63 (73%) had a history of a preceding thyroid or parathyroid operation. Preoperative SC could not identify an adenoma in 30 patients (34.9%), and in 12 patients (14.0%), the surgeon was subsequently unable to localize abnormal parathyroid tissue. Preoperative parathyroid hormone concentration was the only significant independent predictor of a negative SC finding (non-linear and indirect association). Independent from surgical history, an unsuccessful intraoperative focus localization was exclusively predicted by preoperative ultrasonographic (US) and SC findings (OR per diagnostic category 2.98; 95%-CI 1.03-8.58, p=0.043, and OR 2.26; 95%-CI: 1.10-4.63, p=0.027, respectively). Compared to exclusive US, however, the combination of SC and US significantly increased the sensitivity and predictive power to identify patients at a high risk for a complicated surgical procedure. CONCLUSION In patients before parathyroidectomy, a low preoperative parathyroid hormone concentration is significantly associated with a high likelihood for a negative SC finding. Combining US with SC before operation significantly increases the chance to identify patients prone to negative intraoperative findings.
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Affiliation(s)
- Michael Neuberger
- München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Jan Axl Dropmann
- München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Axel Kleespies
- HELIOS Amper-Klinikum Dachau, Dachau, Germany.,München, Klinik für Allgemeine, Viszeral- und Transplantationschirurgie, Klinikum der Universität München, München, Germany
| | - Heinrich Fuerst
- Chirurgische Klinik, Krankenhaus Martha-Maria Munchen, München, Germany
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Afreen S, Weinstein LS, Simonds WF, Jha S. Case of Recurrent Primary Hyperparathyroidism, Congenital Granular Cell Tumor and Aggressive Colorectal Cancer. J Endocr Soc 2022; 6:bvac096. [DOI: 10.1210/jendso/bvac096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
We present the case of a 53-year-old African-American male with recurrent primary hyperparathyroidism (PHPT), multi-focal benign granular cell tumor (GCT) and metastatic colon adenocarcinoma. PHPT was diagnosed on routine blood testing [ionized calcium 1.66 (1.12-1.32) mmol/L, PTH 110pg/mL, Vitamin D-25-OH-D: 18ng/mL, PTHrP: undetectable]. Medical history was notable for two reoccurrences of PHPT with persistent disease after most recent parathyroidectomy. Lymph node (LN) dissection during this last surgery showed a 2-mm focus of poorly differentiated adenocarcinoma in 1/5 LNs. Additionally, patient had a history of multi-focal GCTs diagnosed at age two. On exam, there were no Lisch nodules, axillary, or inguinal freckling, neurofibromas or café-au-lait macules but a prominent abdominal wall nodule was noted. En bloc resection of a tumor in the tracheoesophageal groove, identified by sestamibi scan and excision of 4.5-cm abdominal wall nodule showed both masses having histology consistent with GCT. Serum calcium and PTH did not decrease indicating another unsuccessful surgery. Genetic testing was negative for germline variants in PHPT-associated genes, APC or genes of RAS-MAPK signaling pathway. The LN finding of metastatic adenocarcinoma prompted an endoscopy and trans-bronchial biopsy leading to the diagnosis of widely metastatic colonic adenocarcinoma, eventually resulting in his death a year later. Source of patient’s persistent PHPT remained unidentified. This is the first case with co-association of recurrent PHPT, multi-focal GCT and colon cancer. Whether the disparate tumors in this patient share common driver(s) remains unknown. Prospective surveillance of patients for similar associations may provide clues for a novel syndromic form of PHPT.
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Affiliation(s)
| | - Lee S Weinstein
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health , Bethesda, MD
| | - William F Simonds
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health , Bethesda, MD
| | - Smita Jha
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health , Bethesda, MD
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Wei Y, Zhao ZL, Cao XJ, Peng LL, Li Y, Wu J, Yu MA. Microwave ablation versus parathyroidectomy for the treatment of primary hyperparathyroidism: a cohort study. Eur Radiol 2022; 32:5821-5830. [PMID: 35381852 PMCID: PMC9381471 DOI: 10.1007/s00330-022-08759-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 03/06/2022] [Accepted: 03/21/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To compare the clinical outcomes between microwave ablation (MWA) and parathyroidectomy (PTX) for the treatment of primary hyperparathyroidism (pHPT). MATERIALS AND METHODS This retrospective study enrolled 212 patients with pHPT treated by either MWA (MWA group) or PTX (PTX group) from January 2015 to October 2020. The baseline data were balanced through propensity score matching. Clinical cure was evaluated by the Kaplan-Meier method and compared between the MWA and PTX groups. The risk factors related to persistent or recurrent pHPT were screening out using a Cox proportional hazards regression model. RESULTS After propensity score matching, a total of 174 patients were enrolled in the present study, with 87 patients in each group. During the follow-up period (median, 28.5 months), there were no differences between the two groups regarding the clinical cure (hazard ratio, 1.71; 95% confidence interval: 0.81-3.62; p = .155), persistent pHPT rate (13.8% vs. 10.3%, p = .643), recurrent pHPT rate (6.9% vs. 3.4%, p = .496), or major complications (6.9% vs. 3.4%, p = .496). MWA resulted in a shorter procedure time (30 min vs. 60 min), smaller incision length (0.1 cm vs. 7 cm) and slightly higher costs (25745 CNY vs. 24111 CNY) (all p < .001). High levels of preoperative intact parathyroid hormone (p = .01) and multiple pHPT nodules (p < .001) were independent risk factors for recurrent and persistent pHPT in the two groups. CONCLUSION MWA and PTX have comparable clinical outcomes for pHPT. MWA has a shorter procedure time and smaller incision length. KEY POINTS • There were no differences in terms of clinical cure, persistent pHPT, recurrent pHPT, or major complications between MWA and PTX in the treatment of pHPT. • MWA is minimally invasive and results in a shorter procedure time. • Multiple nodules and high levels of iPTH were the independent risk factors for recurrent and persistent pHPT.
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Affiliation(s)
- Ying Wei
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Zhen-long Zhao
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Xiao-jing Cao
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Li-li Peng
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Yan Li
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Jie Wu
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
| | - Ming-an Yu
- Department of Interventional Medicine, China-Japan Friendship Hospital, No. 2 Ying-hua-yuan East Street, Chao-yang district, Beijing, 100029 China
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Shah US, McCoy KL, Kelley ML, Carty SE, Yip L. How and when is multiglandular disease diagnosed in sporadic primary hyperparathyroidism? Surgery 2021; 171:35-39. [PMID: 34924180 DOI: 10.1016/j.surg.2021.09.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/31/2021] [Accepted: 09/16/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In total, ∼15% of patients with sporadic primary hyperparathyroidism have multiglandular disease, which may be suspected preoperatively but can only be confirmed intra or postoperatively. The study aim is to determine how and when patients are diagnosed with multiglandular disease and to what extent different modalities contribute. METHODS Consecutive cases of sporadic primary hyperparathyroidism (2013-2019) undergoing initial exploration were reviewed from a single-institution prospective database. Preoperative single-photon emission tomography/computed tomography and neck ultrasound were routinely performed to help direct either bilateral or unilateral exploration guided by intraoperative parathyroid hormone monitoring using the dual criteria. Multiglandular disease was defined as either resection of >1 enlarged parathyroid or hypercalcemia at ≥6 months after single gland resection. RESULTS Of 1,890 patients with sporadic primary hyperparathyroidism, multiglandular disease was identified in 254 (13.4%); 244 (96.1%) were diagnosed intraoperatively and 10 (3.9%) postoperatively. In these multiglandular disease patients, single gland disease was suggested on single-photon emission tomography/computed tomography in 54.0%, ultrasound in 49.2%, and both were concordant for single gland disease in 29.4%. Intraoperative multiglandular disease diagnosis was prompted by an inadequate intraoperative parathyroid hormone monitoring drop in 38.5%, by surgeon interpretation of imaging in 38.1%, by observing ipsilateral gland enlargement in 11.0%, by finding an initial gland <200 mg in 10.3%, and 2.0% had unexpected multiglandular disease during thyroidectomy. Multiglandular disease was diagnosed by postoperative hypercalcemia in 10 of 254 patients (4.9%). CONCLUSION To avoid failure at parathyroidectomy for primary hyperparathyroidism, expert surgeons use multiple approaches to diagnose and manage multiglandular disease. Preoperative localization studies alone are insufficient, missing multiglandular disease in at least 30% of cases. All examined adjuncts are informative, including intraoperative parathyroid hormone monitoring, imaging, and intraoperative visual cues.
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Affiliation(s)
- Ujas S Shah
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Kelly L McCoy
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | | | - Sally E Carty
- Division of Endocrine Surgery, University of Pittsburgh, PA
| | - Linwah Yip
- Division of Endocrine Surgery, University of Pittsburgh, PA.
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Latge A, Riehm S, Vix M, Bani J, Ignat M, Pretet V, Helali M, Treglia G, Imperiale A. 18F-Fluorocholine PET and 4D-CT in Patients with Persistent and Recurrent Primary Hyperparathyroidism. Diagnostics (Basel) 2021; 11:2384. [PMID: 34943620 DOI: 10.3390/diagnostics11122384] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [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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Agirre L, de la Quintana A, Martínez G, Arana A, Servide MJ, Larrea J. Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy. Cir Esp 2021; 100:18-24. [PMID: 34876364 DOI: 10.1016/j.cireng.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. METHODS Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an endocrine surgery unit for 18 years. The cure rate, the intraoperatory PTH, the etiology and the pathological glands location were analyzed. RESULTS In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. 14.1% presented a multigland disease. 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. CONCLUSIONS The absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.
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Affiliation(s)
- Leire Agirre
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, Spain.
| | | | - Gloria Martínez
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, Spain
| | - Ainhoa Arana
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, Spain
| | - María José Servide
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, Spain
| | - Jasone Larrea
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, Spain
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Unlu MT, Aygun N, Akgun IE, Yetkin SG, Erol RS, Isgor A, Uludag M. Parathyroidectomy Results in Primary Hyperparathyroidism: Analysis of the Results From a Single Center. Sisli Etfal Hastan Tip Bul 2021; 55:173-8. [PMID: 34349592 DOI: 10.14744/SEMB.2021.72681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/14/2021] [Indexed: 11/20/2022]
Abstract
Objectives The curative treatment of primary hyperparathyroidism (PHPT) is surgery. Persistent and recurrent disease may develop after surgical treatment. In this study, we aimed to evaluate the surgical cure rate in patients who underwent surgery for PHPT in our clinic. Methods The data of patients who underwent parathyroidectomy for PHPT by two experienced surgeons between 2000 and 2015 in our clinic were retrospectively evaluated. Patients who were followed for at least 6 months after their first parathyroidectomy were included in the study. Surgical cure and persistent and recurrent disease rates were evaluated in patients. Results During this period, 368 interventions were performed in 357 patients (293 F and 64 M) who were operated for PHPT in our clinic, with a mean age of 54.9±13.1 years. In the first surgery, 116 patients (32.5%) had bilateral neck exploration, 251 patients (67.5%) had unilateral neck exploration (UNE) or focused parathyroid surgery (FPS). In the first operation, 343 patients (96.1%) had cure, 14 patients (13 F and 1 M) remained persistent. Secondary surgical intervention was performed in 11 patients. UNE or FPS was performed to 10 patients (90.9%); partial sternotomy was performed to one patient. Ten of the patients had cure. Three of these patients had a solitary parathyroid adenoma that was not removed in the first surgery, and seven patients had a second adenoma. Four patients remained persistent (1.1%). Recurrent disease developed in four patients during follow-up (1.1%). Total cure rate was 97.8%. Conclusion The only definitive treatment for PHPT is surgery. High surgical cure can be achieved by pre-operative evaluation and appropriate surgical planning. However, persistent PHPT may develop, especially due to double adenoma or ectopic location. Patients with persistent PHPT can be evaluated with repeat imaging methods and with appropriate surgical planning, a high cure rate can be obtained in secondary surgery, which can increase the total surgical cure rate. Recurrence rate is rare.
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Loderer T, Rossini M, Cozzani F, Bonati E, Del Rio P. A peculiar manifestation and clinical course of occult primary hyperparathyroidism: a case report. Acta Biomed 2021; 92:e2021155. [PMID: 33944838 PMCID: PMC8142757 DOI: 10.23750/abm.v92is1.9660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 12/01/2020] [Indexed: 11/23/2022]
Abstract
We present the clinical case of a patient who developed acute hypercalcemia diagnosed after presenting acute pancreatitis.Male patient, age 67, arrived at the Emergency Department of the University Hospital of Parma for upper abdominal pain, radiated to the back, and associated with nausea. Laboratory tests showed elevation of lipase, serum calcium levels, PTH levels and serum creatinine. Due to the persistence on hypercalcemia an ultrasound scan of the cervical region was performed and showed a hyperechoic nodule of about 25x26x30 mm at the level of the lower pole of the left thyroid lobe, compatible with hyperplastic parathyroid. In the light of clinical-radiological examinations, acute edematous pancreatitis due to hypercalcemia was diagnosed. Hypercalcemia was attributable to primary hyperparathyroidism, so surgical indication to parathyroidectomy was gave.After medical treatment there was a progressive improvement of the clinical conditions and a few days later the patient underwent surgical operation of lower left parathyroidectomy with progressive normalization of the serum calcium levels. If hypercalcemia persists after the beginning of a specific therapy there is an indication to perform an emergency parathyroidectomy; in our case the surgical procedure was performed some days after the diagnosis because the calcium serum levels had returned to normal values with significant improvement of the clinical conditions, despite persistence of high PTH values.
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Affiliation(s)
- Tommaso Loderer
- Department of Medicine and Surgery, General Surgery Unit, Parma University Hospital.
| | - Matteo Rossini
- Department of Medicine and Surgery, General Surgery Unit, Parma University Hospital.
| | - Federico Cozzani
- Department of Medicine and Surgery, General Surgery Unit, Parma University Hospital.
| | - Elena Bonati
- Department of Medicine and Surgery, General Surgery Unit, Parma University Hospital.
| | - Paolo Del Rio
- Department of Medicine and Surgery, General Surgery Unit, Parma University Hospital..
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Ignat M, Pérouse M, Lefebvre F, Kadoche D, Imperiale A, Swanstrom L, Vix M, Mutter D. Original Preoperative Localization Technique of Parathyroid Adenomas by 3-Dimensional Virtual Neck Exploration. Surg Innov 2021; 28:261-271. [PMID: 33745354 DOI: 10.1177/15533506211001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective. Preoperative imaging in primary hyperparathyroidism (PHPT) is essential for planning of parathyroidectomy-particularly for selection of a minimally invasive approach. The objective of this cohort study was to evaluate the diagnostic precision of 3D virtual neck exploration (3D-VNE), to evaluate its impact on choice of surgical approach, and to document the correlation with long-term outcomes. Methods. 235 consecutive patients with PHPT were studied (January 2014 to December 2018), with 6-month follow-up. 220 patients had a preoperative computed tomography (CT), 172 of these had a 3D-VNE based on the CT, and 226 patients had a Tc-99m sestamibi scan. Results. Sensitivity of exact, per gland, adenoma localization was 57.09% (95% CI: 50.85-63.10%) for nonspecialized radiologist interpretation of CT scan, 58.17% (95% CI: 51.99-64.10%) for Tc-99m sestamibi scan, and 90.21% (95% CI: 85.21-93.64%) for 3D-VNE, and thereby favoring 3D-VNE compared to CT scan alone (OR 34.5, 95% CI: 9.19-290.56%, P < 2.2 × 10-16) and to Tc-99m sestamibi scan (OR 16.25, 95% CI: 6.05-61.42%, P = 3.1 × 10-15). Specificity was 87.38% for CT scan, 86.36% for 3D-VNE, and 90% for Tc-99m sestamibi scan (P > .05). The cure rate was 100%. The long-term recurrence rate (RR) was 2.978%. The RR was 1.324% in the video-assisted parathyroidectomy group of 151 patients and 5.952% in the group of 84 patients with cervicotomy (P = .0459). Conclusion. CT-based 3D-VNE proved to be the most accurate localizing study in PHPT and aided in selecting patients for targeted minimally invasive parathyroidectomy, which was associated with the lower recurrence rate. 3D-VNE could be proposed as a first-line imaging study in patients with PHPT.
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Affiliation(s)
- Mihaela Ignat
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Madeleine Pérouse
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - François Lefebvre
- Department of Medical Informatics, 27083University Hospital of Strasbourg, Strasbourg, France
| | - Deborah Kadoche
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Alessio Imperiale
- 27083Médecine Nucléaire et Imagerie Moléculaire, ICANS, Strasbourg, France.,Imagerie Moléculaire, DRHIM, Institut Pluridisciplinaire Hubert Curien (IPHC), UMR, CNRS / Unistra, Strasbourg, France
| | - Lee Swanstrom
- 54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Michel Vix
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
| | - Didier Mutter
- Department of Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.,54809IHU/IRCAD, Institute of Image-guided Surgery, Strasbourg, France
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Ilyicheva EA, Bersenev GA. Parathyromatosis as a cause of recurrence primary hyperparathyroidism: A case report. Int J Surg Case Rep 2021; 80:105689. [PMID: 33752295 PMCID: PMC7940790 DOI: 10.1016/j.ijscr.2021.105689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/16/2021] [Accepted: 02/20/2021] [Indexed: 11/28/2022] Open
Abstract
Parathyromatosis in primary hyperparathyroidism are a difficult diagnostic and therapeutic task. The main method of treatment is the surgical removal of all foci of parathyromatosis. In the postoperative period, observation of such patients is required with laboratory and visual screening to exclude recurrence hyperparathyroidism.
Introduction and importance Parathyromatosis is a rare cause of recurrent hyperparathyroidism. The main cause of this pathology is secondary implantation into the surrounding tissues of the damaged parathyroid gland (rough manipulation of the gland tissue) during the primary operation. Nowadays, parathyromatosis remain a difficult diagnostic and therapeutic task. Case presentation A 57-year-old woman 12 years ago underwent right inferior parathyroid adenomectomy. For the last 2 years, the patient began to worry about pain in large tubular bones, thoracic spine. In the biochemical analysis of the patient's blood, the serum ionized calcium level was increased - 1.56 mmol/l, parathyroid hormone - 144 pg/ml. Ultrasound scan of the neck showed the presence of two hypoechoic formations with dimensions of 24 × 12 × 6 mm and 14 × 9 × 8 mm behind the right lobe of the thyroid gland (the site of a previously operation).The patient underwent cervicotomy, removal of 3 fragments of the parathyromatosis tissue. According to a histological study, there fragments are presented by diffuse-nodular hyperplasia from dark main cells. Remission of primary hyperparathyroidism was achieved. Clinical discussion This clinical case shows the need for differential diagnosis in recurrence primary hyperparathyroidism with parathyroid cancer, secondary hyperparathyroidism, parathyromatosis. Conclusion The main method of treatment is the surgical removal of all foci of parathyromatosis. In the postoperative period, observation of such patients is required with laboratory and visual screening to exclude recurrence hyperparathyroidism.
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Affiliation(s)
- Elena A Ilyicheva
- Federal State Budgetary Scientific Institution "Irkutsk Scientific Center of Surgery and Traumatology", ul. Bortsov Revolyutsii 1, Irkutsk, Irkutsk Region, 664003, Russian Federation.
| | - Gleb A Bersenev
- Federal State Budgetary Scientific Institution "Irkutsk Scientific Center of Surgery and Traumatology", ul. Bortsov Revolyutsii 1, Irkutsk, Irkutsk Region, 664003, Russian Federation.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Agirre L, de la Quintana A, Martínez G, Arana A, Servide MJ, Larrea J. Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy. Cir Esp 2020; 100:S0009-739X(20)30385-7. [PMID: 33349461 DOI: 10.1016/j.ciresp.2020.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. METHODS Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an Endocrine Surgery Unit for 18 years. The cure rate, the intraoperatory parathyroid hormone (PTH), the etiology and the pathological glands location were analyzed. RESULTS In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. The 14.1% presented a multigland disease; 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. CONCLUSIONS The absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.
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Affiliation(s)
- Leire Agirre
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España.
| | - Aitor de la Quintana
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España
| | - Gloria Martínez
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España
| | - Ainhoa Arana
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España
| | - María José Servide
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España
| | - Jasone Larrea
- Unidad de Cirugía Endocrina, Hospital Universitario de Cruces, Barakaldo, España
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Fowler GE, Chew PR, Lim C, Balasubramanian SP. Is there a role for routine laryngoscopy before and after parathyroid surgery? Surgeon 2019; 17:102-6. [DOI: 10.1016/j.surge.2018.08.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/22/2018] [Accepted: 08/01/2018] [Indexed: 11/24/2022]
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Al-Kurd A, Levit B, Assaly M, Mizrahi I, Mazeh H, Mekel M. Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure. Surgery 2018; 164:S0039-6060(18)30093-X. [PMID: 29699804 DOI: 10.1016/j.surg.2018.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Revised: 02/06/2018] [Accepted: 02/20/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Accurate preoperative localization is critical to the success of minimally invasive parathyroidectomy. This investigation aimed to assess the correlation among preoperative imaging results, intraoperative findings, and postoperative cure rates in patients undergoing operation for primary hyperparathyroidism. METHODS A retrospective review of all patients who underwent operation for primary hyperparathyroidism between June 2010 and March 2016 was performed. RESULTS During the study period, 398 patients underwent parathyroidectomy. The overall cure rate was 97.5%. The ultrasonography performed by the surgeon was superior to the ultrasonography performed by the radiologist and to the sestamibi scan in lateralizing the adenoma correctly (80% vs 62% vs 70%, P < .001, respectively), and had the greatest sensitivity (93%) and accuracy (80%) among all tests (P < .001). Age ≥65 was found to be associated with lesser cure rates (94% vs 99.2%, P = .003). The number of positive preoperative studies correlated with cure rate, ranging from 80% for patients with 0 positive studies, to 100% in those with 4 positive studies (P = .0004). In patients with a negative sestamibi and an ultrasonography performed by the radiologist, there was no significant difference in the cure rates among those with no preoperative computed tomography, a positive preoperative computed tomography, or a negative preoperative computed tomography. CONCLUSION An ultrasonography performed by an experienced surgeon is an extremely valuable preoperative localization modality. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative ultrasonography performed by a nonexperienced radiologist and a negative sestamibi scan, the performance of computed tomography does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.
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Affiliation(s)
- Abbas Al-Kurd
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel.
| | - Barak Levit
- Department of General Surgery, Rambam-Health Care Campus, Haifa, Israel
| | - May Assaly
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
| | - Ido Mizrahi
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
| | - Haggi Mazeh
- Department of Surgery, Hadassah-Hebrew University Medical Center, Mount Scopus, Jerusalem, Israel
| | - Michal Mekel
- Department of General Surgery, Rambam-Health Care Campus, Haifa, Israel
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Scott-Coombes DM, Rees J, Jones G, Stechman MJ. Is Unilateral Neck Surgery Feasible in Patients with Sporadic Primary Hyperparathyroidism and Double Negative Localisation? World J Surg 2018; 41:1494-1499. [PMID: 28116482 DOI: 10.1007/s00268-017-3891-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ultrasound and Tc99mMIBI scans are used to localise parathyroid tumours in sporadic primary hyperparathyroidism (pHPT). Intra-operative PTH (ioPTH) assay facilitates unilateral neck exploration (UNE). When both ultrasound and MIBI are negative, it is our policy to explore the left side of the neck and only proceed to bilateral neck exploration (BNE) when either a tumour is not found or when ioPTH does not fall to >50% of the highest pre-excision value. The aim of this study was to investigate the outcome of our approach to 'double negative' patients. METHODS A retrospective analysis of patients undergoing primary parathyroidectomy for pHPT. Data were obtained from a prospective surgical database and the hospital electronic patient record. RESULTS Between January 2004 and November 2014, 746 patients underwent a parathyroidectomy for pHPT. Those who did not have both pre-operative scans, ioPTH or a minimum of 6-month follow-up were excluded. Of 552 patients, 111 (20%) had double negative scans (group A), and in 441, either one or both scans were positive (group B). Median age was 61.5 years (range 10-88). Pre-operative PTH level was significantly lower in group A: 11.8 pmol/l (range 3.1-38.8) versus 14.9 pmol/l (range 2.8-101.6; P < 0.01). Median tumour weight was significantly lower in group A: 280 mg (range 50-3710) versus 573 mg (range 10-12,000; P < 0.01). Overall rate of multiple gland disease (MGD) was 11%; 24% in group A and 7% in group B (P < 0.01). Overall rate of UNE in Group A was 28% and converse to the rate in Group B (76%; P < 0.01). Sensitivity and specificity of ioPTH to detect MGD were 98 and 98% in Group A versus 98 and 100% in Group B. First-time cure rate was 92.7% in group A and 96.8% in group B (P < 0.05). CONCLUSION A double negative scan is associated with small tumours and higher rates of MGD. Despite these challenges, surgery is successful in this group of patients reinforcing the message that negative localisation is not a contraindication for parathyroidectomy. We demonstrated that it is feasible to offer unilateral neck surgery to 28% of patients with double negative scans. A randomised trial is needed to compare BNE with ioPTH/UNE in this select population.
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Affiliation(s)
- D M Scott-Coombes
- Department of Endocrine Surgery, C2 Office, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK.
| | - J Rees
- Department of Radiology, University Hospital of Wales, Cardiff, UK
| | - G Jones
- Department of Clinical Chemistry, University Hospital of Wales, Cardiff, UK
| | - M J Stechman
- Department of Endocrine Surgery, C2 Office, University Hospital of Wales, Heath Park, Cardiff, CF14 4XW, UK
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Thier M, Daudi S, Bergenfelz A, Almquist M. Predictors of multiglandular disease in primary hyperparathyroidism. Langenbecks Arch Surg 2018; 403:103-9. [PMID: 29294178 DOI: 10.1007/s00423-017-1647-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 12/01/2017] [Indexed: 12/02/2022]
Abstract
Background Primary hyperparathyroidism (pHPT) is caused by single- or multiglandular disease (MGD). Patients with MGD have an increased risk of complications at surgery and for persistence and recurrence after surgery. The study evaluated whether preoperative clinical and biochemical characteristics could predict MGD in patients with pHPT. Methods We retrospectively evaluated patients operated 1989–2013 for first-time, non-hereditary pHPT. MGD was defined in patients with more than one pathological gland excised at surgery or with persistent hypercalcemia after the excision of a single pathological parathyroid gland, confirmed by histopathology. Clinical and biochemical variables were compared in patients with single- and multiglandular disease. Logistic regression was used to identify variables predicting MGD, yielding odds ratios (OR) with 95% confidence intervals (CI). Results There were 707 patients, of which 79 (11%) had MGD. Patients with MGD were more likely to have negative sestamibi scintigraphy than patients with single-gland disease, 15 of 49 (31%) vs. 70 of 402 (17%; p = 0.03), to suffer from diabetes (12 of 74, 16%) vs. 45 out of 626 patients (7.2%; p < 0.01) and had lower preoperative levels of urinary calcium (3.80 vs. 4.44 mmol/L; p = 0.04). Multivariable analysis identified negative scintigraphy (OR 2.42; 95% CI 1.18 to 4.79), diabetes (OR 2.75; 95% CI 1.31 to 4.97) and elevated levels of osteocalcin (OR 3.79, 95% CI: 1.75 to 8.21) as predictors of MGD. Conclusion Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels were predictors of MGD.
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Cron DC, Kapeles SR, Andraska EA, Kwon ST, Kirk PS, McNeish BL, Lee CS, Hughes DT. Predictors of operative failure in parathyroidectomy for primary hyperparathyroidism. Am J Surg 2017; 214:509-514. [PMID: 28108069 DOI: 10.1016/j.amjsurg.2017.01.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 01/08/2017] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Many adjuncts guide surgical decision making in parathyroidectomy, yet their independent associations with outcome are poorly characterized. We examined a broad range of perioperative factors and used multivariate techniques to identify independent predictors of operative failure (persistent disease) after parathyroidectomy. METHODS This was a retrospective review of 2239 patients with primary hyperparathyroidism who underwent parathyroidectomy at a single-center from 1999 to 2014. We used multivariate logistic regress to measure associations between multiple perioperative factors and an operative failure (persistent hypercalcemia). RESULTS Operative failure was identified in 67 patients (3.0%). The following variables were independently associated with operative failure on multivariate analysis: IOPTH criteria met (protective, OR = 0.22, P < 0.001), preoperative calcium (risk factor, OR = 2.27 per unit increase, P < 0.001), weight of excised gland(s) (protective, OR = 0.70 per two-fold increase, P = 0.003), and preoperative PTH (protective, OR = 0.55 per two-fold increase, P = 0.008). CONCLUSION In addition to the well-established IOPTH criteria, we suggest that consideration of the above independent perioperative risk factors may further inform surgical decision-making in parathyroidectomy.
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Affiliation(s)
- David C Cron
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Steven R Kapeles
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Elizabeth A Andraska
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Sebastian T Kwon
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Peter S Kirk
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Brendan L McNeish
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Christopher S Lee
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - David T Hughes
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI, USA.
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Jinih M, O’Connell E, O’Leary DP, Liew A, Redmond HP. Focused Versus Bilateral Parathyroid Exploration for Primary Hyperparathyroidism: A Systematic Review and Meta-analysis. Ann Surg Oncol 2016; 24:1924-1934. [DOI: 10.1245/s10434-016-5694-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Indexed: 11/18/2022]
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Weber T, Gottstein M, Schwenzer S, Beer A, Luster M. Is C-11 Methionine PET/CT Able to Localise Sestamibi-Negative Parathyroid Adenomas? World J Surg 2017; 41:980-5. [DOI: 10.1007/s00268-016-3795-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Gasparri G, Palestini N, Freddi M, Sisto G, Camandona M. Parathyroid Exploration for Primary Hyperparathyroidism. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Barczyński M, Bränström R, Dionigi G, Mihai R. Sporadic multiple parathyroid gland disease--a consensus report of the European Society of Endocrine Surgeons (ESES). Langenbecks Arch Surg 2015; 400:887-905. [PMID: 26542689 PMCID: PMC4747992 DOI: 10.1007/s00423-015-1348-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 10/05/2015] [Indexed: 01/05/2023]
Abstract
BACKGROUND Sporadic multiglandular disease (MGD) has been reported in literature in 8-33 % of patients with primary hyperparathyroidism (pHPT). This paper aimed to review controversies in the pathogenesis and management of sporadic MGD. METHODS A literature search and review was made to evaluate the level of evidence concerning diagnosis and management of sporadic MGD according to criteria proposed by Sackett, with recommendation grading by Heinrich et al. and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Results were discussed at the 6th Workshop of the European Society of Endocrine Surgeons entitled 'Hyperparathyroidism due to multiple gland disease: An evidence-based perspective'. RESULTS Literature reports no prospective randomised studies; thus, a relatively low level of evidence was achieved. Appropriate surgical therapy of sporadic MGD should consist of a bilateral approach in most patients. Unilateral neck exploration guided by preoperative imaging should be reserved for selected patients, performed by an experienced endocrine surgeon and monitored by intraoperative parathormone assay (levels of evidence III-V, grade C recommendation). There is conflicting or equally weighted levels IV-V evidence supporting that cure rates can be similar or worse for sporadic MGD than for single adenomas (no recommendation). Best outcomes can be expected if surgery is performed by an experienced parathyroid surgeon working in a high-volume centre (grade C recommendation). Levels IV-V evidence supports that recurrent/persistence pHPT occurs more frequently in patients with double adenomas hence in situations where a double adenoma has been identified, the surgeon should have a high index of suspicion during surgery and postoperatively for the possibility of a four-gland disease (grade C recommendation). CONCLUSIONS Identifying preoperatively patients at risk for MGD remains challenging, intraoperative decisions are important for achieving acceptable cure rates and long-term follow-up is mandatory in such patients.
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Affiliation(s)
- Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, 37 Prądnicka Street, 31-202, Kraków, Poland.
| | - Robert Bränström
- Endocrine and Sarcoma Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Gianlorenzo Dionigi
- First Division of Surgery, Research Center for Endocrine Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Radu Mihai
- Department of Endocrine Surgery, Oxford University Hospitals NHS Trust, Oxford, UK
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McIntyre CJ, Allen JLY, Constantinides VA, Jackson JE, Tolley NS, Palazzo FF. Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy. Ann R Coll Surg Engl 2015; 97:598-602. [PMID: 26444799 PMCID: PMC5096614 DOI: 10.1308/rcsann.2015.0039] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2015] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Reoperative parathyroidectomy is required when there is persistent or recurrent hyperparathyroidism following the initial surgery (at least 5% of parathyroidectomies nationally). By convention, 'persistent disease' is defined as the situation where the patient has not been cured by the first operation. The term 'recurrent hyperparathyroidism' is used when the patient was confirmed to be biochemically cured for six months from the first operation but has hyperparathyroidism after this date. Reoperative surgery is associated with higher rates of postoperative complications as well as a greater rate of failure to cure. The aim of our study was to review our departmental experience of reoperative parathyroidectomy, with a view to identify patterns of disease persistence and recurrence. METHODS Using a departmental database, patients were identified who had undergone reoperative parathyroidectomy between 2006 and 2014. All the pre, intra and postoperative information was documented including the operative note so as to record the location of the abnormal parathyroid gland found at reoperation. RESULTS Almost two-thirds (63%) of patients had negative, equivocal or discordant conventional imaging so secondary investigative tools were required frequently. The majority of abnormal glands were found in eutopic locations. The most common locations for ectopic glands were intrathyroidal, mediastinal and intrathymic. A third (33%) of the patients had multigland disease and over a quarter (28%) had coexisting thyroid disease. CONCLUSIONS Persistent hyperparathyroidism represents a challenging patient subgroup for which access to all radiological modalities and intraoperative parathyroid hormone monitoring are required. Patient selection for reintervention is a key determinant in the reoperation cure rate.
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Affiliation(s)
- C J McIntyre
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | | | | | - J E Jackson
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | - N S Tolley
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
| | - F F Palazzo
- Hammersmith Hospital, Imperial College Healthcare NHS Trust , UK
- Imperial College London , UK
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Mourad M, Buemi A, Darius T, Maiter D. Surgical options for primary hyperparathyroidism. Ann Endocrinol (Paris) 2015; 76:638-42. [PMID: 26505316 DOI: 10.1016/j.ando.2015.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/20/2015] [Indexed: 11/21/2022]
Abstract
Over the last two decades, surgery for primary hyperparathyroidism has evolved to offer a panel of procedures based on improvements in imaging, new technology and, consequently, novel surgical techniques. Multiple courses of action are possible, consistent with varying degrees of complexity. From the simplest scenario of a single adenoma localized by at least two preoperative tests in the context of sporadic primary hyperparathyroidism, to revision surgery related to recurrent, persistent or multiglandular disease, the surgeon has the opportunity to adapt his strategy. However, whatever surgical approach is used, even in the absence of formal guidelines, the clinical judgment of an experienced and skilled practitioner in endocrine surgery is the real guide and key of success in complex situations.
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Hindié E, Zanotti-Fregonara P, Tabarin A, Rubello D, Morelec I, Wagner T, Henry JF, Taïeb D. The Role of Radionuclide Imaging in the Surgical Management of Primary Hyperparathyroidism. J Nucl Med 2015; 56:737-44. [DOI: 10.2967/jnumed.115.156018] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/25/2015] [Indexed: 02/07/2023] Open
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Nawrot I, Chudziński W, Ciąćka T, Barczyński M, Szmidt J. Reoperations for persistent or recurrent primary hyperparathyroidism: results of a retrospective cohort study at a tertiary referral center. Med Sci Monit 2014; 20:1604-12. [PMID: 25201515 PMCID: PMC4166223 DOI: 10.12659/msm.890983] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Parathyroid reoperations are challenging and achieving a cure requires multidisciplinary treatment team cooperation. The aims of this study were to summarize our experience in revision surgery for persistent (pHPT) or recurrent primary hyperparathyroidism (rHPT) and to explore factors underlying failure to cure at initial surgery. MATERIAL AND METHODS This was a retrospective cohort study of patients who underwent reoperations for pHPT or rHPT at a tertiary referral center. The database of parathyroid surgery was searched for eligible patients (treated in the years 2000-2012). The primary outcome was the cure rate. All the patients were followed-up for at least 12 months postoperatively. Factors underlying failure to cure at initial surgery were reviewed based on hospital records. RESULTS The study group comprised 88 patients (69 women, 19 men) operated on for persistent (n=57) or recurrent disease (n=31), who underwent 98 reoperations, including 26 (2.4%) patients first operated on at our institution, and 72 (81.8%) patients operated on elsewhere, but referred for revision surgery. A long-term cure was achieved in 83/88 patients (94.3%). The mean post-reoperation follow-up was 91.7 (12-176) months. Missed hyperfunctioning parathyroid gland was found on reoperation in eutopic position in 49 (55.5%) patients, and in ectopic position in 39 (44.3%) patients, including 20 (22.7%) cases of cervical ectopy and 19 (21.6%) cases of mediastinal ectopy. CONCLUSIONS Multidisciplinary treatment team cooperation at a tertiary referral center, consisting of an accurate preoperative localization, expertise in parathyroid re-explorations, and correct use of intraoperative adjuncts, contribute to the high success rate of parathyroid reoperations.
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Affiliation(s)
- Ireneusz Nawrot
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Witold Chudziński
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Ciąćka
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Barczyński
- Department of Endocrine Surgery, Third Chair of General Surgery, Jagiellonian University Medical College, Cracow, Poland
| | - Jacek Szmidt
- Department of General, Vascular, and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
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Abstract
Parathyroidectomy is the most cost-effective treatment for hyperparathyroidism. Randomized prospective trials have shown no difference in cure rate between focused parathyroidectomy and bilateral exploration. Costs of the two techniques differ depending on the preoperative and intraoperative localization used, speed of the operation, ability to discharge the patient on the same day as the operation, cure rate, and complications. It may be less costly and more effective to use a policy of routine 4-gland exploration without the use of preoperative or intraoperative localization studies. The potential economic impact and the expected outcome of the various strategies should be formally evaluated.
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Affiliation(s)
- Dina Elaraj
- Section of Endocrine Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Chicago, IL 60611, USA
| | - Cord Sturgeon
- Section of Endocrine Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, 676 North Saint Clair Street, Chicago, IL 60611, USA.
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Affiliation(s)
- Ritesh Agrawal
- Department of General Surgery, Aarupadai Veedu Medical College, Kirumampakkam, Puducherry, 607402, India,
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