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

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

Incidence of tubercle of Zuckerkandl of the thyroid and it’s surgical relation with recurrent laryngeal nerve and the superior parathyroid gland

Background: This study was carried out with the objective to identify the tubercle of Zuckerkandl in patients undergoing thyroidectomy and to establish the relationship of TZN with the recurrent laryngeal nerve and superior parathyroid gland.Methods: 100 patients posted for thyroidectomy for various causes in Government medical college, Kozhikode for a period of 1 year between March 2014 and March 2015. 92 patients underwent total thyroidectomy, 4 patients underwent left hemithyroidectomy and 4 patients underwent right hemithyroidectomy. A total of 192 lobes i.e. 96 right lobes and 96 left lobes were studied.Results: Of the 100 patients studied TZN was identified in 63 (63%) patients. Of the 192 lobes studied, TZN was identified in 100 lobes (52.08%). This was 59 of 96 (61.40%) lobes on the right side and 41 of 96 (42.70%) lobes on the left side. Of the 92 Total Thyroidectomies, TZN was found bilaterally in 36 (39.10%) cases. RLN was identified ‘posteromedial’ in relation in 99 of the 100 (99%) TZNs studied and not visualized in relation to TZN in 1 (1%) case. The Superior Parathyroid was identified ‘superolateral’ in relation in 93 (93%), ‘lateral’ in 6 (6%) and ‘inferolateral’ in 1 (1%) of 100 TZNs studied.Conclusions: Zuckerkandl’s tubercle is a posterior extension of lateral lobes of the thyroid gland, maintains a constant relationship with the RLN and the superior parathyroid gland. It can be used as an anatomical landmark to assist in preservation of the RLN and the superior parathyroid gland during thyroid surgery.

PREVENTATIVE EFFECTS OF PROBIOTIC (MIACLOST) ON EXPERIMENTALLY INDUCED HYPOCALCEMIC RICKETS IN BROILER CHICKS.

A trial was conducted to study the effects of probiotic (Miaclost) supplement on experimentally induced hypocalcemic rickets in broiler chicks, a total of 180 one-day-old broiler chicks (Ross 308) were randomly divided into three equal groups 60 chicks per group with 3 replicates (20 birds /replicate) the dietary treatments consisted of a normal ration for G1, calcium-deficient ration 5% for G2 and calcium-deficient ration with addition of probiotics in drinking water for G3.Initial signs of rickets have been observed at 35-day of age in G2.while, in G1 and G3 no clinical signs observed, the gross lesions appeared enlargement of parathyroid gland, costochondral junction and increase in the width of growth plate of tibial bone of G2 whereas no gross lesions recorded in G1 and G3, the histopathological examination of parathyroid gland in G2 there were a focal parathyroid hyperplasia and increasing in numbers of syncytial cells and normal in G1 and G3, no intestinal histopathological changes in G1 and G2 and increase in height and width of the intestinal villi in probiotic group G3. Marked increase in the thickness of proliferation zone within growth plate of tibia bone in G2 and normal thickness in G1 and G3. the serum biochemical analysis of calcium of G2 recorded significantly low level in G2 and high level in G3 comparatively with G1, finally the serum alkaline phosphatase values were high significantly in G2 and normal in G3, it is concluded that probiotic (MiaClost) can be used as prophylaxis to prevent hypocalcemic rickets in broiler chicks

Contrast-Enhanced Ultrasound Qualitative and Quantitative Characteristics of Parathyroid Gland Lesions

Background and Objectives: preoperative differentiation of enlarged parathyroid glands may be challenging in conventional B-mode ultrasound. The aim of our study was to analyse qualitative and quantitative characteristics of parathyroid gland lesions, using multiparametric ultrasound protocol—B-mode, Colour Doppler (CD), and contrast-enhanced ultrasound (CEUS)—and to evaluate correlation with morphology in patients with hyperparathyroidism (HPT). Materials and Methods: consecutive 75 patients with 88 parathyroid lesions and biochemically confirmed HPT prior to parathyroidectomy were enrolled in the prospective study. B-mode ultrasound, CD, and CEUS were performed with the subsequent qualitative and quantitative evaluation of acquired data. We used 1 mL or 2 mL of intravenous ultrasound contrast agent during the CEUS examination. Correlation with post-surgical morphology was evaluated. Results: seventy parathyroid adenomas were hypoechoic and well contoured with increased central echogenicity (44.3%), peripheral-central vascularization (47%), and polar feeding vessel (100%). Twelve hyperplasias presented with similar ultrasound appearance and were smaller in volume (p = 0.036). Hyperplasias had a tendency for homogenous, marked intense enhancement vs. peripherally enhanced adenomas with central wash-out in CEUS after quantitative analysis. No significant difference was observed in contrasting dynamics, regardless of contrast media volume use (1 mL vs. 2 mL). We achieved 90.9% sensitivity and 72.7% specificity, 93% positive predictive value (PPV), 87.3% negative predictive value (NPV), and 87.3% accuracy in the differentiation of parathyroid lesions prior to post-processing. In a quantitative lesion analysis, our sensitivity increased up to 98%, specificity 80%, PPV 98%, and NPV 80% with an accuracy of 96.4%. Conclusions: CEUS of parathyroid lesions shows potential in the differentiation of adenoma from hyperplasia, regardless of the amount of contrast media injected. The quantitative analysis improved the sensitivity and specificity of differentiation between parathyroid lesions. Hyperplasia was characterized by homogeneous enhancement, fast uptake, and homogeneous wash-out appearance; adenoma—by peripheral uptake, central wash-out, and reduced hemodynamics. The use of CEUS quantification methods are advised to improve the ultrasound diagnostic role in suspected parathyroid lesions.

Nodular hyperplasia of parathyroid gland in chronic kidney disease – A case report

Nodular hyperplasia of parathyroid gland is an advanced state commonly seen in a secondary and tertiary hyperparathyroidism. It shares similarities on histology with parathyroid adenoma creating a diagnostic dilemma. Adequate history, biochemical investigations and radiological studies majorly supports the accurate diagnosis. Identifying correct state of hyperparathyroidism is essential in a view of therapeutic management and its outcome.

Improved intraoperative verification of parathyroid glands by determining their autofluorescence in the infrared spectrum

Background. Detection of parathyroid glands by spectroscopy of their autofluorescence in the near-infrared spectrum (NIRAF) is considered a promising intraoperative tool in addition to their verification with visual identification. The study was aimed to evaluate the role of NIRAF by using two different imaging systems to confirm parathyroid glands during operations for benign and malignant thyroid and parathyroid tumors. Materials and methods. The study included 62 patients who underwent verification of NIRAF by using two different imaging systems equipped with a near-infrared (NIR) camera during surgery. Intravenous fluorophore of indocyanine green was applied to amplify the NIRAF signal. Results. Normal parathyroid glands were identified and mobilized after a visual inspection in 50 patients (80 %), which was subsequently confirmed by evaluation with NIRAF spectroscopy. Determination of NIRAF in the parathyroid glands and their differentiation from lymph nodes was achieved in 8 (13 %) patients with papillary thyroid carcinoma. In 3 (5 %) patients, the parathyroid gland was identified in the area of the postoperative scar, using NIRAF but not by the visual identification. In 2 (3 %) cases, the appearance of the signal was determined but with a decrease in the intensity of the NIRAF from the parathyroid glands during their unintentional removal. The strong NIRAF signal intensity was observed from the parathyroid gland after changing the position of the NIR camera when using the Fluobeam 800 device at an angle of approximately 45–65° to the area of the parathyroid gland location. The Fluobeam LX demonstrated a satisfactory NIRAF signal without any specific changes in camera position. NIRAF signal was determined in the tissue of toxic thyroid adenomas. NIRAF signal of the low intensity was detected in the invasion of thyroid carcinoma in a capsule of a thyroid gland. No NIRAF signal was observed from metastatic and normal lymph nodes. Conclusions. The use of NIRAF parathyroid spectroscopy technology allows impro-ving their imaging and verification as an additional method during surgery of the neck. The practical value of NIRAF spectroscopy of the parathyroid gland is increased in the case of reoperations due to the risk of accidental removal of the parathyroid gland as well as for differential diagnosis between the parathyroid gland and metastatic lymph nodes.