Multimodal Preoperative Localization Improves Outcomes in Reoperative Parathyroidectomy: A 25-Year Surgical Experience

2019 ◽  
Vol 85 (9) ◽  
pp. 939-943 ◽  
Author(s):  
Snehal G. Patel ◽  
Neil D. Saunders ◽  
Salman Jamshed ◽  
Collin J. Weber ◽  
Jyotirmay Sharma
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Preoperative Localization ◽  
Preoperative Imaging ◽  
Complication Rates ◽  
Recurrent Nerve ◽  
Cure Rate ◽  
Recurrent Nerve Palsy ◽  
Preoperative Serum ◽  
Cure Rates

Reoperative parathyroid surgery (REOPS) is often associated with lower cure rates and greater risk of nerve injury and hypoparathyroidism. The aim of this study was to evaluate cure rates, pathology, complications, and the efficacy of preoperative localization in patients requiring REOPS. Between 1992 and 2017, 2491 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism. With Institutional Review Board approval, our prospectively collected parathyroidectomy outcomes database was queried for operative findings, outcomes, pathology, and localization methodology. Three hundred forty-six patients had REOPS (111 men/32% and 235 women/68%), with an overall cure rate of 91 per cent and a mean follow-up of 1.9 ± 0.7 years. The average preoperative serum calcium and parathyroid hormone were 11 ± 1 mg/dL and 373 ± 796 pg/mL, respectively. Normalization of intraoperative parathyroid hormone occurred in 248 patients and it was predictive of cure in 98.8 per cent of patients. A single adenoma was resected in 253 patients (75%), and the superior gland location was most common at 57 per cent. Ectopic glands were identified in only 33 patients. When preoperative imaging localized a lesion, a tumor was identified in that location in 75.4 per cent of sestamibi or SPECT/CTscans, 57.8 per cent of CT, 61.2 per cent of MRI, and 46.2 per cent of US. When at least two imaging modalities were concordant, sensitivity improved to 91.6 per cent ( P < 0.001). Complication rates of permanent hypoparathy-roidism and recurrent nerve palsy occurred in 0.03 per cent of patients. REOP for recurrent or persistent primary hyperparathyroidism has a cure rate of 91 per cent. Most missed parathyroid tumors are in the neck, and multimodal imaging improves preoperative localization and success.

Effects of Parathyroidectomy on Normocalcemic Primary Hyperparathyroidism and the Role of Intraoperative PTH Measurement

2021 ◽  
pp. 000313482110488
Author(s):  
Ehab Alameer ◽  
Mahmoud Omar ◽  
Marcus Hoof ◽  
Hosam Shalaby ◽  
Mohamed Abdelgawad ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Cure Rate ◽  
Tertiary Hyperparathyroidism ◽  
Intraoperative Pth ◽  
Intraoperative Parathyroid Hormone ◽  
Cure Rates ◽  
Current Guidelines ◽  
Normocalcemic Hyperparathyroidism

Background Normocalcemic primary hyperparathyroidism (NCpHPT) and normohormonal primary hyperparathyroidism (NHpHPT) are recently recognized variants of primary hyperparathyroidism. Current guidelines for the management hyperparathyroidism recognize NCpHPT as one of the areas that are recommended for more research due to limited available data. Methods A retrospective review of patients who had parathyroidectomy between 2014 and 2019. We excluded patients with multiple endocrine neoplasia syndromes and secondary and tertiary hyperparathyroidism. Included patients were classified based on the biochemical profile into classic or normocalcemic hyperparathyroidism group. Collected data included demographics, preoperative localizing imaging, intraoperative parathyroid hormone levels, and postoperative cure rates. Results 261 patients were included: 160 patients in the classic and 101 patients in the normocalcemic group. Patients in the normocalcemic group had significantly more negative sestamibi scans (n = 58 [8.2%] vs 78 [51.3%], P = <.01), smaller parathyroid glands (mean weight 436.0 ± 593.0 vs 742.4 ± 1109.0 mg, P = .02), higher parathyroid hyperplasia rates (n = 51 [50.5%] vs 69 [43.1%]), and significantly higher intraoperative parathyroid hormone at 10 minutes (78.1 ± 194.6 vs 43.9 ± 62.4 1, P = .04). Positive predictive value of both intraoperative parathyroid hormone and cure rate was lower in the normocalcemic group (84.2% vs 95.7%) and (80.5% vs 95%), respectively. Conclusion Normocalcemic hyperparathyroidism is a challenging disease. Surgeons should be aware of the lower cure rate in this group, interpret intraoperative parathyroid hormone with caution, and have a lower threshold for bilateral neck exploration and 4 glands visualization.

scholarly journals Current predictive models do not accurately differentiate between single and multi gland disease in primary hyperparathyroidism: a retrospective cohort study of two endocrine surgery units

2018 ◽  
Vol 100 (2) ◽  
pp. 140-145 ◽  
Author(s):  
O Edafe ◽  
EE Collins ◽  
CS Ubhi ◽  
SP Balasubramanian
Keyword(s):  
Cohort Study ◽  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Positive Predictive Value ◽  
Predictive Models ◽  
Predictive Value ◽  
Endocrine Surgery ◽  
Preoperative Imaging ◽  
Original Report ◽  
Cure Rates

Background Minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism is dependent upon accurate prediction of single-gland disease on the basis of preoperative imaging and biochemistry. The aims of this study were to validate currently available predictive models of single-gland disease in two UK cohorts and to determine if these models can facilitate MIP. Methods This is a retrospectively cohort study of 624 patients who underwent parathyroidectomy for primary hyperparathyroidism in two centres between July 2008 and December 2013. Two recognised models: CaPTHUS (preoperative calcium, parathyroid hormone, ultrasound, sestamibi, concordance imaging) and Wisconsin Index (preoperative calcium, parathyroid hormone) were validated for their ability to predict single-gland disease. Results The rates of single- and multi-gland disease were 491 (79.6%) and 126 (20.2%), respectively. Cure rates in centres 1 and 2 were 93.2% and 93.8%, respectively (P = 0.789). The positive predictive value (PPV) of CaPTHUS score . 3 in predicting single-gland disease was 84.6%, compared with 100% in the original report. CaPTHUS . 4 and 5 had a PPV of 85.1 and 87.1, respectively. There were no differences in Wisconsin Index (WIN) between patients with single- and multi-gland (P = 0.573). A WIN greater than 1600 and weight of excised gland greater than 1 g had a positive predictive value of 86.7% for single-gland disease. Conclusions The use of CaPTHUS and WIN indices without intraoperative adjuncts (such as IOPTH) had the potential to result in failure to cure in up to 15% (CaPTHUS) and 13% (WIN) of patients treated by MIP targeting a single enlarged gland.

scholarly journals Surgeon-performed Ultrasound in Preoperative Parathyroid Localization: The Cutting Edge of Endocrine Surgeon

2009 ◽  
Vol 1 (1) ◽  
pp. 19-22
Author(s):  
MA Yahya ◽  
K Normayah ◽  
AN Hisham
Keyword(s):  
Primary Hyperparathyroidism ◽  
Bilateral Neck Exploration ◽  
Preoperative Localization ◽  
Neck Exploration ◽  
Preoperative Imaging ◽  
Cure Rate ◽  
Unilateral Approach ◽  
Unilateral Exploration ◽  
Parathyroid Localization ◽  
Unilateral Neck Exploration

ABSTRACT Background Over the years surgery for primary hyperparathyroidism has evolved from bilateral neck exploration to focus unilateral approach. This has been made possible by the advancement in localization technique and availability of the preoperative imaging. This study aimed to determine the feasibility and accuracy of focus unilateral neck approach for primary hyperparathyroidism with surgeon- performed ultrasound as the main decisive preoperative localization imaging technique. Method The decision of focus unilateral approach was stipulated if an enlarged parathyroid adenoma was confidently seen in the preoperative localization by surgeon-performed ultrasound. The focus unilateral exploration was terminated if the diseased gland was found. Nonetheless if in doubt, the exploration was extended to include the opposite side of the neck. More importantly any negative preoperative ultrasound will be considered for bilateral neck exploration. Results 118 consecutive patients were accrued in this study, 76 females and 42 males with mean age of 50 years. Focus unilateral neck exploration was performed on 86 (72.9%) patients and 96.5% of them were successfully explored and cured. 13 (13.1%) patients had exploration of both sides of the neck although the initial decision was only to explore one side. The overall cure rate was 93.2% with the sensitivity and specificity of ultrasound were 78.3% and 95.1% respectively. Conclusion Surgeon-performed ultrasound in parathyroid localization in coupled with focus unilateral approach in primary HPT can be performed 73% of patients with a success rate of more than 96%.

scholarly journals Contemporary surgical treatment of primary hyperparathyroidism without intraoperative parathyroid hormone measurement

2015 ◽  
Vol 97 (8) ◽  
pp. 603-607 ◽  
Author(s):  
OA Mownah ◽  
G Pafitanis ◽  
WM Drake ◽  
JN Crinnion
Keyword(s):  
Parathyroid Hormone ◽  
Surgical Treatment ◽  
Primary Hyperparathyroidism ◽  
Frozen Section ◽  
Lateral Approach ◽  
Preoperative Imaging ◽  
Surgical Cure ◽  
Focused Parathyroidectomy ◽  
Intraoperative Parathyroid Hormone ◽  
Iopth Measurement

Introduction Primary hyperparathyroidism (pHPT) is usually the result of a single adenoma that can often be accurately located preoperatively and excised by a focused operation. Intraoperative parathyroid hormone (IOPTH) measurement is used occasionally to detect additional abnormal glands. However, it remains controversial as to whether IOPTH monitoring is necessary. This study presents the results of a large series of focused parathyroidectomy without IOPTH measurement. Methods Data from 2003 to 2014 were collected on 180 consecutive patients who underwent surgical treatment for pHPT by a single surgeon. Preoperative ultrasonography and sestamibi imaging was performed routinely, with computed tomography (CT) and/or selective venous sampling in selected cases. The preferred procedure for single gland disease was a focused lateral approach guided by on-table surgeon performed ultrasonography. Frozen section was used selectively and surgical cure was defined as normocalcaemia at the six-month follow-up appointment. Results Focused surgery was undertaken in 146 patients (81%) and 97% of these cases had concordant results with two imaging modalities. In all cases, an abnormal gland was discovered at the predetermined site. Of the 146 patients, 132 underwent a focused lateral approach (11 of which were converted to a collar incision), 10 required a collar incision and 4 underwent a mini-sternotomy. At 6 months following surgery, 142 patients were normocalcaemic (97% primary cure rate). Three of the four treatment failures had subsequent surgery and are now biochemically cured. There were no complications or cases of persistent hypocalcaemia. Conclusions This study provides further evidence that in the presence of concordant preoperative imaging, IOPTH measurement can be safely omitted when performing focused parathyroidectomy for most cases of pHPT.

Use of Preoperative Imaging in Primary Hyperparathyroidism

2020 ◽  
Vol 106 (1) ◽  
pp. e328-e337
Author(s):  
David T Broome ◽  
Robert Naples ◽  
Richard Bailey ◽  
Zehra Tekin ◽  
Moska Hamidi ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Ct Scan ◽  
Predictive Value ◽  
Imaging Modalities ◽  
Preoperative Imaging ◽  
Multiglandular Disease ◽  
Cure Rate ◽  
4D Ct ◽  
Operative Findings ◽  
Double Adenomas

Abstract Context Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. Objective Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. Design, Setting, and Patients This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. Main Outcome Measures Surgical cure rate, concordance of imaging with operative findings, and imaging performance. Results The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. Conclusions Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

Preoperative Serum Osteocalcin may Predict Postoperative Elevated Parathyroid Hormone in Patients with Primary Hyperparathyroidism

2012 ◽  
Vol 36 (6) ◽  
pp. 1320-1326 ◽  
Author(s):  
Nahid Rianon ◽  
Gillian Alex ◽  
Glenda Callender ◽  
Camilo Jimenez ◽  
Mimi Hu ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Serum Osteocalcin ◽  
Preoperative Serum
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