Usefulness of PET/CT with Carbon-11-Labeled Methionine in the Diagnosis of Tertiary Hyperparathyroidism.

Introduction: Tertiary hyperparathyroidism (tHP) may develop in patients treated with hemodialysis or peritoneal dialysis. Parathyroidectomy may result in a significant reduction in the severity of symptoms. For the effective surgical treatment of hyperparathyroidism, proper localization of the parathyroid glands prior to surgery is essential. The sensitivity of scintigraphy in the diagnosis of tHP is lower than in the diagnosis of primary hyperparathyroidism. In recent years, positron emission tomography (PET/CT) has been gaining importance, usually as a complementary technique. Aim: The aim of this study was to determine the usefulness of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tertiary hyperparathyroidism caused by chronic kidney disease, in whom first-line diagnostic methods did not allow the localization of pathologically parathyroid glands. Material and methods: The study was conducted in a group of 19 adult patients with severe tHP who were resistant or intolerant to non-invasive treatment, with negative results of scintigraphy and ultrasonography of the neck. The study protocol included measurement of the concentration of calcium, phosphorus, and PTH in the blood serum and performing PET/CT with [11C]MET. Results: A positive result of PET/CT was obtained in 89.5% of the patients (17/19). Parathyroidectomy was performed in 52.9% of the patients (9/17) with positive results of PET/CT with [11C]MET, which were fully consistent with the results of the histopathological examinations of the removed parathyroid glands. On this basis, the sensitivity of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tHP was found to be 100%. Multiple lesions were visualized in 57.9% of the patients (11/19). Ectopic lesions were visualized in 21.1% of the patients (4/19). Conclusions: PET/CT with [11C]MET is a sensitive technique for the second-line preoperative imaging of parathyroid glands in patients with tertiary hyperparathyroidism in whom first-line examinations, such as ultrasound and scintigraphy, has failed.

Correlation Between the Parathyroid Glands Size and Parathormones Value in Patients with Hyperparathyroidism.

INTRODUCTION: Hyperparathyroidism is a common endocrine disorder with potential complications of bone, renal, neurocognitive and cardiovascular system. AIM: To determine the correlation between the size of parathyroid glands and parathormone values in the patients with hyperparathyroidism. METHODS: We analyzed a retrospective-prospective database of 79 consecutive patients who underwent parathyroidectomy for hyperparathyroidism at our institution between January 2011 and February 2018. The values of parathormone, calcium and phosphorus were determined in all patients before and after surgery. Ultrasonography were performed before surgery. Imaging results were confirmed by pathology. We analyzed the correlation between the sizes parathyroid glands obtained trough ultrasonography and pathology with parathormone values. RESULTS: The median age of the patients were 51 age (range 20-73) and 67,1% of the patients were female. Our study demonstrated that between actual glands sizes (volumes), expresses in millimeters, measured on pathohistological analysis and ultrasound examination and size value of parathormone its increased value does not affect the size of the gland. We investigate the correlation between the size of glands measured according to the pathohistological finding and the value of parathormone we obtained the correlation results close to the statistical features. The correlation value of parathormone and glands sizes according to the pathohistological finding measured trough the determined assessment scale we determined the statistically important of medium value. CONCLUSION: One of the important factors for parathyroidectomy is the value of parathormone. Serum parathormone level might be predictable by a total size of parathyroid glands and could be an effective the predictor of gland localisation.

The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.

Importance: Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades. Objective: To develop evidence-based guidelines to enhance the appropriate, safe, and effective practice of parathyroidectomy. Evidence Review: A multidisciplinary panel used PubMed to review the medical literature from January 1, 1985, to July 1, 2015. Levels of evidence were determined using the American College of Physicians grading system, and recommendations were discussed until consensus. Findings: Initial evaluation should include 25-hydroxyvitamin D measurement, 24-hour urine calcium measurement, dual-energy x-ray absorptiometry, and supplementation for vitamin D deficiency. Parathyroidectomy is indicated for all symptomatic patients, should be considered for most asymptomatic patients, and is more cost-effective than observation or pharmacologic therapy. Cervical ultrasonography or other high-resolution imaging is recommended for operative planning. Patients with nonlocalizing imaging remain surgical candidates. Preoperative parathyroid biopsy should be avoided. Surgeons who perform a high volume of operations have better outcomes. The possibility of multigland disease should be routinely considered. Both focused, image-guided surgery (minimally invasive parathyroidectomy) and bilateral exploration are appropriate operations that achieve high cure rates. For minimally invasive parathyroidectomy, intraoperative parathyroid hormone monitoring via a reliable protocol is recommended. Minimally invasive parathyroidectomy is not routinely recommended for known or suspected multigland disease. Ex vivo aspiration of resected parathyroid tissue may be used to confirm parathyroid tissue intraoperatively. Clinically relevant thyroid disease should be assessed preoperatively and managed during parathyroidectomy. Devascularized normal parathyroid tissue should be autotransplanted. Patients should be observed postoperatively for hematoma, evaluated for hypocalcemia and symptoms of hypocalcemia, and followed up to assess for cure defined as eucalcemia at more than 6 months. Calcium supplementation may be indicated postoperatively. Familial pHPT, reoperative parathyroidectomy, and parathyroid carcinoma are challenging entities that require special consideration and expertise. Conclusions and Relevance: Evidence-based recommendations were created to assist clinicians in the optimal treatment of patients with pHPT.

Safety and efficacy of minimally-invasive parathyroidectomy (MIP) under local anaesthesia without intra-operative PTH measurement.

BACKGROUND: Minimally invasive parathyroidectomy (MIP) is the choice of treatment in patients with sporadic adenomas localized on preoperative imaging. Currently there is no centre in the UK which performs this procedure under local anaesthesia. The aim of this study was to assess the efficacy and safety of MIP under local anaesthesia in patients with sporadic primary hyperparathyroidism (pHPT). METHODS: This is a prospective, nonrandomized study of 86 patients with pHPT localized with Tc99m Sestamibi scan and ultrasound. MIPs were performed under local anaesthesia and sedation at the Oxford University Hospitals. Serum Ca and PTH were measured before discharge, at 6 weeks follow up, and at 6 months. Main outcome measures were cure at 6 months, complications with the procedure and operative time. RESULTS: 86 patients (58 females: 28 males) with a mean age of 65 (range 24-87) underwent MIP under local anaesthesia and sedation. All patients (100%) were normocalcaemic at 6 months following surgery. There was no incidence of temporary or permanent recurrent laryngeal nerve palsy or persistent hypercalcaemia. Two patients had temporary hypocalcaemia that resolved in 6 weeks. In one patient the neck incision needed extension for bleeding, with no incidence of wound haematoma or infection. CONCLUSION: This study demonstrates that MIP (without ioPTH) can be safely performed under local anaesthesia for patients with sporadic primary hyperparathyroidism.

Orbital involvement in craniofacial brown tumors.

PURPOSE: To describe the clinical and radiologic features of orbital involvement in craniofacial brown tumors and to compare the rate of brown tumors in primary and secondary hyperparathyroidism. METHODS: A retrospective hospital-based study of 115 patients with chronic kidney disease and secondary hyperparathyroidism and 34 with primary hyperparathyroidism was conducted. Laboratory results such as serum levels of alkaline phosphatase, calcium, phosphorus, and parathyroid hormone were recorded. Demographic data (age, sex, duration of disease) and image findings (bone scan scintigraphy, skull and long bone x-rays, CT) were also obtained. The main outcome measures were analysis of clinical, biochemical, and radiologic findings of all patients. RESULTS: Of the 115 patients with chronic kidney disease, 10 (8.7%) had brown tumors in different bones of the skeleton. Five patients had lesions in the craniofacial bones. The maxilla, mandible, maxillary sinus, and nasal cavity were the most affected sites. The orbit was involved in 2 patients with lesions arising in the maxillary and ethmoid sinuses. One patient had facial leontiasis. All patients with brown tumors had extremely high levels of parathyroid hormone (>1,000 pg/ml, normal values 10-69 pg/ml) and alkaline phosphatase (>400 U/l, normal values 65-300 U/l). The mean serum levels of phosphorus and calcium were not abnormal among the patients with brown tumors. Age and time of renal failure were similar for patients with and without brown tumors. Among the patients with primary hyperparathyroidism, only 2 (5.8%) had brown tumors, and in just 1, the lesion was localized in the craniofacial skeleton. A 2-tailed Z test applied to compare the proportion of occurrence of brown tumors in the 2 groups revealed that the difference at the 90% of confidence level was not significant. CONCLUSIONS: Brown tumors are equally found in secondary and primary hyperparathyroidism. Craniofacial brown tumors involve the orbit, usually because of the osteodystrophy process that involves the maxilla and paranasal sinuses. The lesions do not necessarily need to be excised and may regress spontaneously after the control of hyperparathyroidism.

Relation between Tc-99m sestamibi uptake and biological factors in hyperparathyroidism.

PURPOSE: The aim of this study was to evaluate the relation between uptake ratios of Tc-99m sestamibi (MIBI) and tumor volume, serum biochemical values (i-PTH, Ca, P) and oxyphil cell content. MATERIALS AND METHODS: The study population consisted of 19 patients (2 M, 17 F; mean +/- SD: 47 +/- 12 y). Anterior planar images of the neck and chest were acquired early (15 min) and triple late phase (1, 2 and 3-4 h) after intravenous injections of 740 MBq MIBI. Each of the surgical materials was reviewed retrospectively. The percentage of cell type (chief, oxyphil and clear cells) in the tumors was calculated by light microscopy. RESULTS: The uptake ratio obtained from L1 (1 hour) phase was found to be higher than the uptake ratio obtained from early phase, and the difference was statistically significant (1.57 +/- 0.34 and 1.43 +/- 0.29, p = 0.004, respectively). There was no significant correlation between uptake ratios that were obtained from 4 different imaging phases and lesion volumes, i-PTH levels and calcium levels (p > 0.05). However, there was a significant adverse correlation between L2 and L3 uptake ratios and serum phosphorus values (r = -0.44, p = 0.04 and r = -0.46, p = 0.04, respectively). Additionally, no significant correlation between MIBI uptake ratios of each imaging phase and the laboratory data, volume of lesion or oxyphil percentage volume was found after the multiple regression analysis (E: p = 0.46, r = 0.49; L1: p = 0.24, r = 0.58; L2: p = 0.27, r = 0.57; L3: p = 0.32, r = 0.55, respectively. There was no correlation between gland oxyphil percentage volume and MIBI uptake ratios (p > 0.05). CONCLUSION: The results of our study show that the optimal imaging times after intravenous injection of MIBI are 15 minutes and 1 hour because of the shorter examination time without loss of diagnostic ability. In the present study, there was no significant correlation between MIBI uptake ratios and increased gland volume, or serum Ca and i-PTH levels. Besides, we think that oxyphil cell content may not have a main effect on MIBI uptake and retention. The fact of an adverse relation between phosphorus and MIBI retention in our study suggests that phosphorus level should be considered prior to MIBI imaging.

99mTc labelled cationic lipophilic complexes in malignant and benign tumors: the role of SPET and pinhole-SPET in breast cancer, differentiated thyroid carcinoma and hyperparathyroidism.

Single photon emission tomography (SPET) represents an indispensable diagnostic tool in nuclear medicine. Due to better contrast resolution, cross sectional and 3D images, SPET plays a useful complementary tool to bidimensional planar scintigraphy in certain clinical conditions, while representing the procedure of choice in others. However, high resolution SPET with pinhole collimator (P-SPET) can improve conventional SPET sensitivity with parallel hole collimators. This review summarizes data on the employment of conventional SPET and P-SPET in breast cancer, differentiated thyroid cancer (DTC) and hyperparathyroidism patients, using the cationic lipophilic complexes [(99m)Tc]metoxy isobutyl isonitrile (sestaMIBI) and [(99m)Tc]tetrofosmin as oncotropic radiotracers. In breast cancer patients, SPET with these radiotracers can play an important complementary role to planar scintimammography in detecting primary tumors, especially when non palpable and small in size, whereas SPET and particularly P-SPET represents the procedure of choice in preoperative axillary lymph node status evaluation in which planar is almost always irrelevant. In DTC follow-up patients, SPET and P-SPET with cationic lipophilic radiotracers are indicated in both locoregional and distant metastasis detection, especially in patients with high Tg serum levels and negative radioiodine scanning in whom these procedures represent a reliable alternative to diagnostic (131)I scanning. Moreover, the combined use of [(99m)Tc]tetrofosmin P-SPET and US can identify recurrences and lymph node metastases in the neck, both fixing and non fixing iodine, downstaged or negative at (131)I scanning. SPET can also be a useful complementary tool to planar parathyroid scintigraphy in the detection and localization of small and ectopic parathyroid adenomas in the neck or mediastinum, while neck P-SPET seems to also significantly increase planar sensitivity in hyperplastic glands. SPET and P-SPET are indicated in persistent and recurrent hyperparathyroidism including from carcinoma.

Hammers and nails: a report.

A case report where parathyroid bone disease simulates bone metastases. Subsequent treatment of underlying hyperparathyroidism causes a marked improvement in bone disease, leading to a review of the initial diagnosis.

Ultrasound-guided percutaneous ethanol ablation of parathyroid hyperplasia: preliminary experience in patients on chronic dialysis.

OBJECTIVE: We report on a 3-year experience using single-shot, ultrasonography-guided, percutaneous ethanol ablation (PEA) of hyperplastic parathyroid glands in chronic dialysis patients suffering from secondary or tertiary hyperparathyroidism. MATERIALS AND METHODS: Seventeen uraemic patients (mean age 52 +/- 14 years) with hypercalcaemia and elevated serum levels of parathyroid hormone were assessed for ethanol ablation. Ten patients did not fulfil the inclusion criteria and underwent surgical parathyroidectomy. Seven patients were treated using PEA. RESULTS: All patients treated with PEA tolerated the procedure well, and no major complications were observed. Three out of seven patients underwent further ethanol ablation due to recurrent symptomatic hyperparathyroidism. Following the procedures, serum values of total calcium and parathyroid hormone remained within target range with concomitant medical therapy in all patients. CONCLUSION: PEA performed as a single-shot therapy can be used as a minimally invasive and safe supplement to medical therapy in the treatment of secondary or tertiary hyperparathyroidism in selected patients. In case of recurrence, treatment can be repeated without any problems.

Prospective evaluation of ultrasonography plus MIBI scintigraphy in selecting patients with primary hyperparathyroidism for unilateral neck exploration under local anaesthesia.

BACKGROUND: Unilateral neck exploration (UNE) is currently replacing conventional bilateral neck exploration with cervicotomy for the surgical treatment of primary hyperparathyroidism (PHPT). However, many concerns still exist about the indications and the effectiveness of this minimally invasive approach. METHODS: Prospective evaluation of operative results in consecutive patients having indications for UNE on the basis of strict selection criteria consisting of ultrasound-MIBI agreement in adenoma localization, absence of thyroid disease, and psychological suitability for undergoing a procedure under local anesthesia. No intraoperative confirmation study was adopted. RESULTS: Among 149 consecutive PHPT patients, 45 (30.2%) had indications for UNE. No operative morbidity or mortality was observed. Mean operative time for the UNE procedure was 42 minutes (range 25 to 57). Conversion to general anesthesia was chosen for 5 patients (11.1%), whereas conversion to bilateral neck exploration was chosen for 3 patients (6.6%). For the UNE procedure, the success rate was as high as 91.7%. When the only factor indicated UNE, ultrasound-MIBI localization agreement had low sensibility (44.1%) and specificity (55.6%) but a high positive predictive value (91.1%). CONCLUSIONS: We concluded that UNE performed under local anesthesia, without intraoperative confirmation studies, could be considered a safe and effective approach to treating patients with PHPT, but we regret the low rate of patients selected for this procedure because of the low sensitivity of the imaging-inclusion criterion.

Tertiary hyperparathyroidism in patients on hemodialysis for chronic renal failure: subtotal parathyroidectomy or conservative treatment?

BACKGROUND: To report our experience in novel surgical strategy in the treatment of tertiary hyperparathyroidism in hemodialysis patients for chronic renal failure and to assess the impact of this type of surgery on postoperative clinical and laboratory variables in this population. METHODS: Fifteen hemodialysis (12 female and 3 male) patients with chronic renal failure were operated on for tertiary hyperparathyroidism. Cervical ultrasound was performed in all patients (n = 15). RESULTS: Preoperative cervical ultrasound showed one enlarged parathyroid gland (n = 4) or few enlarged parathyroid glands (n = 11). Group I consisted of four patients with single parathyroid gland enlargement on ultrasound. These patients underwent resection of only the enlarged gland; three by unilateral approach under local anesthesia and one by cervicotomy under general anesthesia. Group II consisted of 11 patients with enlargement of all parathyroid glands on ultrasound. These patients were assumed to have hyperplasia and underwent subtotal parathyroidectomy (3.5 glands) and thymectomy by cervicotomy under general anesthesia. Postoperatively, patients in group I were normocalcemic (n = 4) and patients in group II were normocalcemic (n = 4) or had transient hypocalcemia (n = 7). The pathology showed an adenoma in patients of group I (n = 4) and hyperplasia in patients of group II (n = 11). Postoperatively, both patients in Group I and II had a similar resolution of their symptoms. CONCLUSION: Tertiary hyperparathyroidism secondary to chronic renal failure may be treated by parathyroidectomy of one or few enlarged parathyroid gland(s). Parathyroidectomy by unilateral approach under local anesthesia may be of value when preoperative localization studies show a single parathyroid gland enlargement.

Limited sensitivity of parathyroid imaging with (99m)Tc-sestamibi/(123)I subtraction in an endemic goiter area.

UNLABELLED: Double-phase single-tracer scintigraphy with (99m)Tc-sestamibi is now generally used for parathyroid imaging but, at least in endemic goiter areas, complementary thyroid scintigraphy is recommended. Although (123)I-sodium iodide is considered to be the optimal thyroid agent, it is hardly ever used because of high costs and logistic difficulties. Our study presents the results of using the (99m)Tc-sestamibi/(123)I subtraction technique in a region with a high goiter prevalence. Special attention was paid to the changes in sensitivity and specificity and their relationship to thyroid volume as well as to autonomous and nodular thyroid disease. METHODS: One hundred three scintigraphic parathyroid examinations on 96 patients were included in this study. Fifty-eight of all patients had concomitant morphologic or functional alterations of the thyroid. Initially, 10 MBq (123)I-sodium iodide were injected. Then, 150 MBq (99m)Tc-sestamibi were administered after 3-5 h, followed by planar scintigraphic imaging of the neck and upper chest region using a double-isotope technique. RESULTS: An area with increased tracer uptake on the subtraction image was found in 44 cases. Forty-three of them proved to be true-positive. No suspicious lesions were detected scintigraphically on the remaining 59 examinations. However, histologic examination revealed a parathyroid adenoma or hyperplasia in 11 of these cases. The mean parathyroid volume of these false-negative patients was 0.9 mL. Secondary hyperparathyroidism with multiple enlarged parathyroid glands was found in 4 of these cases. The sensitivity of the parathyroid scintigraphy was 80% (43/54) and the specificity was 98% (48/49). There was a distinct difference in the sensitivity between the subgroups with thyroid volumes of >15 mL and <15 mL (76% vs. 88%), although the resected parathyroid glands had a similar size in both subgroups. The specificity was 97% and 100%, respectively. No significant difference in the sensitivity and specificity was observed between the subgroups with and without morphologic or functional alterations of the thyroid (80% vs. 79% and 96% vs. 100%, respectively). CONCLUSION: The sensitivity of parathyroid imaging with (99m)Tc-sestamibi/ (123)I subtraction depends mainly on the thyroid and parathyroid volumes rather than on the presence of nodular or autonomous thyroid disease.

Graphic trace analysis of ultrasound at the phalanges may differentiate between subjects with primary hyperparathyroidism and with osteoporosis: a pilot study.

Bone loss characterizes both primary hyperparathyroidism (PHPT) and osteoporosis (OP) but with a different histologic pattern, and this could partially explain the different fracture incidence in these two populations. Quantitative ultrasound (QUS), influenced by bone structural parameters other than bone mineral density (BMD), could evidence these differences, opening new perspectives in the evaluation of patients with metabolic bone diseases. The aim of the present study was to investigate the usefulness of QUS graphic trace parameters, assessed at the phalanx, in discriminating between PHPT bone disease and osteoporosis. We studied 34 patients with PHPT (mean age 59.7 +/- 12.7 years), 35 patients with OP (mean age 60.6 +/- 7.1 years) and 34 healthy subjects as controls (mean age 59.1+/- 9.4 years). In all subjects QUS measurements were performed at the phalanx with a Bone Profiler (IGEA, Italy), obtaining the amplitude-dependent speed of sound (AD-SoS), fast wave amplitude (FWA), signal dynamic (SDy), bone transmission time (BTT) and ultrasound bone profile index (UBPI). Moreover, serum calcium, phosphorus, parathyroid hormone (PTH), bone isoenzyme of alkaline phosphatase (B-ALP) and ionized calcium were measured in all subjects in the morning under fasting conditions. In PHPT patients BTT was correlated with PTH, ionized calcium and B-ALP levels (r = -0.47, -0.57 and -0.44, respectively; p < 0.01), whereas FWA, SDy and UBPI correlated only with B-ALP (r = -0.43, -0.46 and -0.50, respectively; p <0.01). Moreover, FWA, SDY and UBPI were significantly (p<0.01) lower and BTT significantly (p<0.001) higher in OP than in PHPT patients. UBPI, BTT, FWA and the BTT/FWA ratio, but not SDy, were able to discriminate between the two groups (area under the curve =0.66, 0.69, 0.67 and 0.81, respectively). Our findings show that ultrasound signal parameters are differently influenced by bone changes characterizing primary hyperparathyroidism or osteoporosis. This suggests that the QUS signal could be a useful instrument in discriminating and studying some of the bone alterations typical of metabolic bone diseases.

[Comparative characteristics of diagnostic methods of primary hyperparathyroidism in patients with urolithiasis]. / Sravnitel'naia kharakteristika metodov diagnostiki pervichnogo giperparatireoza u bol'nykh mochekamennoi bolezn'iu.

Nephrolithiasis (NL) is a frequent complication of hyperparathyroidism (HPT). Such patients account for 5% of those with nephrolithogenesis. The study included 89 HPT patients (age 34.8 +/- 1.9 years) with NL, 22 patients (age 38 +/- 1.4 years) with NL and 10 healthy controls (age 30 +/- 1.2 years). Hypercalciemia was seen in 27-20% of patients with HPT and NL, 9-10% of patients with nephrolithiasis. Evaluation of parathyroid hormone (PTH) levels in the blood of the examinees showed its high diagnostic value: in 89% of HPT patients this level was high. It was also elevated in 10% of NL patients. cAMP in HPT and NL was elevated in 68.48 and 12% of patients, respectively, serum concentration of Ca2+ was high in 81.4 and 24.5%, Ca load test was positive in 80.9 and 10% of the patients, respectively. It is important for diagnosis that in HPT bone mass is low.

Refractory renal hyperparathyroidism: clinical features and outcome of surgical therapy.

Despite improvements in medical management parathyroidectomy has an important role in treatment of refractory renal hyperparathyroidism (HPT). The medical records of all patients who underwent parathyroidectomy from 1991 through 2000 were reviewed to determine the clinical and laboratory features and outcomes of treatment in patients with renal versus primary HPT. Twenty-one of 92 patients who underwent parathyroidectomy had renal HPT with a mean age of 47+/-3 years compared with 56+/-2 years for patients with primary HPT (P < 0.05). Clinical manifestations included osteodystrophy (19), pruritus (six), extraosseous calcification (three), and calciphylaxis (one). Parathyroid hormone, phosphorus, and alkaline phosphatase levels and weights of excised glands were higher in renal versus primary HPT (P < 0.05). Supernumerary glands were found in three patients (14%) with renal HPT and none of nine patients with primary parathyroid hyperplasia. After surgical therapy persistent or recurrent HPT occurred in three (14%) patients with renal and one (1.4%) patient with primary HPT (P < 0.05). Postoperative hypocalcemia occurred in 20 (95%) patients with renal HPT all of whom required intravenous calcium, compared with 25 (35%) patients with primary HPT (P < 0.05) of whom only three (4%) required intravenous calcium (P < 0.05). In contrast to those with primary HPT patients with renal HPT are younger and more likely to have severe osteodystrophy, postoperative hypocalcemia, and persistent or recurrent HPT.

Minimally invasive parathyroid surgery.

More surgeons are performing unilateral exploration for primary hyperparathyroidism (HPT) than ever before. This article reviews the factors that have led to the trend toward less invasive surgery. Discussion includes the history of unilateral exploration for HPT, the advent of magnetic resonance sestamibi imaging, and the development of intraoperative assays for parathyroid hormone. Results of minimally invasive techniques, including radio-guided parathyroidectomy, endoscopic parathyroidectomy, and outpatient parathyroidectomy, also are presented.

The utility of sestamibi scanning in the operative management of patients with primary hyperparathyroidism.

BACKGROUND: The role of imaging studies before parathyroidectomy has been extensively debated and recent advances in unilateral parathyroidectomy intensify this controversy. The purpose of this study was to review the parathyroidectomy experience of a single surgeon, looking at the role of sestamibi scans and a standard postoperative care regimen. STUDY DESIGN: Retrospective review of office and hospital charts was completed on 90 patients with primary hyperparathyroidism who underwent parathyroidectomy from 1991 to 1998. Patient workup and outcomes were noted, as were results of preoperative imaging. True-positive scans visualized an abnormality ipsilateral to the adenoma found at operation. Statistics were performed using nonparametric testing and Student's t-test. RESULTS: There were 21 male and 69 female patients, with an average age of 54 years (range 29 to 81). There were zero mortalities, three morbidities (3.3%), and three patients who had persistent hypercalcemia, yielding a 96.7% success rate. Sixty-seven patients underwent preoperative sestamibi scanning, with a sensitivity of 74% and positive predictive value of 89%. Operative time in imaged patients averaged 103 +/- 49.9 minutes versus 121.5 +/- 85.9 minutes for patients without sestamibi scans. Operating time differences were not statistically significant and a preoperative sestamibi scan did not affect the success of parathyroidectomy. Discharge on postoperative day 1 was accomplished in 80% of patients and 13% were discharged the next day. There was no morbidity from hypocalcemia. CONCLUSIONS: A preoperative sestamibi scan does not improve efficacy or decrease operating time for primary hyperparathyroidism when bilateral neck exploration is performed. A postoperative care protocol including oral calcium and vitamin D supplementation allows the majority of patients to be discharged on postoperative day 1 with excellent results.

Bilateral neck exploration for parathyroidectomy under local anesthesia: a viable technique for patients with coexisting thyroid disease with or without sestamibi scanning.

BACKGROUND: Bilateral neck exploration (BNE) with the patient under general anesthesia has been the standard for parathyroidectomy. In efforts to minimize invasiveness and recovery from the procedure, unilateral neck exploration with the patient under local anesthesia in combination with sestamibi scanning is being done. Patients with a nonlocalized adenoma, concurrent thyroid disease, and/or multiple parathyroid adenomas have been excluded from this minimally invasive procedure. METHODS: Two hundred thirty-six patients underwent BNE under local anesthesia for primary hyperparathyroidism that was performed by a single surgeon between 1988 and April 1999. RESULTS: The percentage of patients who underwent parathyroidectomy under local anesthesia increased from 3% in 1988 to 97% in 1999. Twenty-three percent of patients underwent a concurrent thyroid procedure, and 84% of patients had a single adenoma removed. Sixty-two percent of patients had a negative preoperative sestamibi scan or did not have a scan at all. The incidence of frozen section decreased in the initial 50 cases from 100% to 39% during the last 100 cases. Average operative time was 43 minutes without a thyroid procedure and 66 minutes with a thyroid procedure. Overall, 70% of patients were discharged within 6 hours of the surgical procedure; this percentage increased to 91% during the last 5 months. CONCLUSIONS: BNE with the patient under local anesthesia can be performed safely and effectively in patients with coexisting thyroid disease and a nonlocalized adenoma.

Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism.

Unilateral neck exploration (UNE) is a controversial approach to the treatment of primary hyperparathyroidism (PHP), and most surgeons favor bilateral neck exploration. The aim of this study was to assess the value of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of urinary cyclic AMP (UcAMP) or 1-84 PTH in 200 patients undergoing unilateral neck exploration under local anesthesia. Conditions for UNE were (1) a presumed solitary adenoma detected by ultrasonography, (2) no thyroid disease, and (3) no family history of PHP or multiple endocrine neoplasia. Patient's consent was obtained for conversion to bilateral exploration according to surgical and biologic findings. Sensitivity of ultrasonography was 92.5%. Sestamibi scintigraphy, performed in 70 patients, was less sensitive than ultrasonography (80%). Persistent PHP was accurately detected by intraoperative measurement of UcAMP or 1-84 PTH in all cases. At follow-up, 96.0% of the patients were cured either after unilateral neck exploration only (90.5%), or after conversion into bilateral exploration. Ultrasonography and intraoperative measurement of 1-84 PTH allow unilateral neck exploration with excellent results in a selected group of patients with PHP.

Primary hyperparathyroidism: is technetium 99m-Sestamibi/iodine-123 subtraction scanning the best procedure to locate enlarged glands before surgery?

Technetium99m (99mTc)-Sestamibi/123I subtraction scanning was prospectively performed in 30 patients with primary hyperparathyroidism in an attempt to locate enlarged glands before first surgery. Imaging results were compared to surgical findings; the surgeon tried to identify all parathyroid glands. Twenty-seven patients were found to have a solitary adenoma during surgery, and 3 had multiglandular parathyroid hyperplasia. Twenty-six parathyroid adenomas (96%) were accurately located before surgery. The smallest gland detected weighted 125 mg. Preoperative detection of two mediastinal adenomas allowed them to be excised by median sternotomy during the initial operation. 99mTc-Sestamibi/123I subtraction scanning predicted multiglandular involvement in two patients with parathyroid hyperplasia, whereas it showed a solitary image in the third. Ten patients (33%) had associated nodular thyroid disease, hindering image analysis and leading to one false positive result. 99mTc-Sestamibi scanning seems to be better for locating enlarged parathyroid glands than other noninvasive imaging techniques. However, 1) difficulties associated with thyroid nodules call for complementary thyroid scanning; and 2) images showing a solitary enlarged parathyroid gland do not rule out multiglandular disease. This technique should help in detecting lesions, such as mediastinal glands, that are difficult to find at initial surgery.