Dificulties of perioperative topical diagnostics of primary hyperparathyroidism in case of multiglandular disease and intrathyroid location of parathyroid gland

Surgery for persistent primary hyperparathyroidism remains a major challenge for surgeons and these reoperative procedures require an experienced parathyroid surgeon. The goal of reoperative surgery is to excise the abnormal parathyroid gland(s) and limit exploration to help minimise the potential complications. At least two positive and concordant localising studies should be available before reoperation because the technical difficulties in these cases make an exact localisation necessary before surgery. We describe the placement of a metallic harpoon under ultrasonography guidance as a safe, simple and inexpensive technique for localisation of the enlarged gland prior to conservative surgery.

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Primary Hyperparathyroidism due to Parathyroid Adenoma Originated from Supernumerary Gland

Case Reports in Otolaryngology ◽

10.1155/2018/6482546 ◽

2018 ◽

Vol 2018 ◽

pp. 1-4

Author(s):

Fernando Mendoza-Moreno ◽

Ángel Rodriguez-Pascual ◽

María Rocío Díez-Gago ◽

Marina Pérez-González ◽

Laura Jiménez‐Alvárez ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Parathyroid Adenoma ◽

Parathyroid Gland ◽

Imaging Techniques ◽

High Sensitivity ◽

Parathyroid Glands ◽

Parathyroid Surgery ◽

Thyroid Lobe ◽

The Impact ◽

Supernumerary Gland

Introduction. The variability of the location of the parathyroid glands is directly related to the events that occur during embryonic development. The impact that an individual submits more than four parathyroid glands is close to 13%. However the presentation of a parathyroid adenoma in a supernumerary gland is an uncommon event. Case report. A 30-year-old man diagnosed with primary hyperparathyroidism with matching findings on ultrasonography and scintigraphy for parathyroid adenoma localization lower left regarding the thyroid gland. A cervicotomy explorer showed four orthotopic parathyroid glands. The biopsy of the inferior left gland was normal. No signs of adenoma were seen in the biopsy. Following mobilization of the ipsilateral thyroid lobe, fifth parathyroid gland was found increased significantly in size than proceeded to remove, confirming the diagnosis of adenoma. After the excision, the levels of serum calcium and parathyroid hormone were normalized. Conclusions. The presentation of a parathyroid adenoma in a supernumerary gland is a challenge for the surgeon. The high sensitivity having different imaging techniques has been a key to locate preoperatively the pathological parathyroid gland. Analytical or clinical persistence of primary hyperparathyroidism after parathyroid surgery can occur if the location of the adenoma is a supernumerary or ectopic gland location.

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Surgeon-Performed Ultrasound Improves Localization of Abnormal Parathyroid Glands

The American Surgeon ◽

10.1177/000313480507100704 ◽

2005 ◽

Vol 71 (7) ◽

pp. 557-563 ◽

Cited By ~ 9

Author(s):

Carmen C. Solorzano ◽

Theresa M. Lee ◽

Marcela C. Ramirez ◽

Denise M. Carneiro ◽

George L. Irvin

Keyword(s):

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Thyroid Tissue ◽

Parathyroid Tissue ◽

Initial Step ◽

Multiglandular Disease ◽

Venous Sampling ◽

Sporadic Primary Hyperparathyroidism ◽

Operative Findings ◽

Abnormal Tissue

With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy (LPX). We investigated whether ultrasonography in the hands of the surgeon (SUS) could improve the localization of abnormal parathyroids when sestamibi scans (MIBI) were negative or equivocal. One hundred eighty patients with sporadic primary hyperparathyroidism (SPHPT) underwent preoperative SUS and MIBI scans before LPX guided by intraoperative parathormone assay. When the sestamibi scans were negative, SUS was used to localize the parathyroid, distinguish parathyroid from thyroid tissue, and to guide the intraoperative jugular venous sampling for differential elevation of parathyroid hormone (PTH). Operative findings, intraoperative hormone dynamics, and postoperative calcium levels determined successful localization. MIBI was negative or equivocal in 36/180 (20%) patients: 1) showed no parathyroid gland in 22 patients, 2) suggested an incorrect location for the abnormal gland in 9, and 3) was insufficient in recognizing multiglandular disease in 5. In these 36 patients, the addition of SUS led to the successful identification of the abnormal tissue in 19/36 (53%). In the remaining 17 patients with negative/equivocal scans, the parathyroid could not be clearly visualized by SUS. In these patients, SUS facilitated LPX by aiding preoperative transcutaneous jugular venous sampling for differentially elevated PTH (n = 3) and identifying questionable thyroid nodule versus parathyroid tissue (n = 1). Overall, SUS was useful in 23/36 (67%) patients with nonlocalizing MIBI scans, thus improving the rate of localization from 80 per cent to 93 per cent ( P < 0.01). Surgeon-performed cervical ultrasonography improved the localization of abnormal parathyroids by MIBI scan, adding to the success of limited parathyroidectomy.

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Minimally Invasive Parathyroid Surgery, The Norman 20% Rule: Is It Valid?

The American Surgeon ◽

10.1177/000313481107700428 ◽

2011 ◽

Vol 77 (4) ◽

pp. 484-487 ◽

Cited By ~ 2

Author(s):

Amy R. Quillo ◽

Jeffery M. Bumpous ◽

Richard E. Goldstein ◽

Muffin M. Fleming ◽

Ccrp ◽

...

Keyword(s):

Parathyroid Hormone ◽

Primary Hyperparathyroidism ◽

Minimally Invasive ◽

Parathyroid Gland ◽

Ex Vivo ◽

Frozen Section ◽

Postoperative Management ◽

Average Percentage ◽

Parathyroid Hormone Monitoring ◽

Intraoperative Parathyroid Hormone

The 20 per cent rule proposed by Norman established a guideline using radioactivity in the minimally invasive radioguided parathyroidectomy (MIRP) technique to localize and confirm removal of an abnormal parathyroid gland in patients with primary hyperparathyroidism. If radioactivity in the resected gland was at least 20 per cent of excision site/background radioactivity, the 20 per cent rule was satisfied. Patients meeting these criteria underwent unilateral MIRP without intraoperative parathyroid hormone assay or intraoperative frozen section. The study aim was to independently evaluate the 20 per cent rule in MIRP patients with primary hyperparathyroidism. Using the University of Louisville Parathyroid Database from January 1, 1999 to December 31, 2007, 216 MIRP patients with complete radioguided and postoperative management data were identified. The average percentage of ex vivo parathyroid gland radioactivity compared with excision site/background radioactivity was 107 per cent with a range from 14 to 388 per cent. For 99 per cent (196/198) radioactivity recorded from the excised gland was at least 20 per cent of radioactivity recorded from the excision site. Normocalcemia was documented in 98.5 per cent (195/198) at 12 month follow-up. Our data supports the 20 per cent rule in that in 99 per cent of MIRP patients the resected gland radioactivity was at least 20 per cent of excision site radioactivity allowing localization and confirmation of an overactive gland without intraoperative parathyroid hormone monitoring or tissue analysis.

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