Preoperative parathyroid localization. Relevance of MIBI SPECT-CT in adverse scenarios.

PURPOSE: Selective parathyroidectomy, the treatment of choice for primary hyperparathyroidism, requires precise preoperative localization. Our purpose was to compare the accuracy and concordance of pre-surgical MIBI parathyroid scintigraphy and ultrasonography, as well as to assess the relevance of hybrid acquisition (SPECT/CT) in compromised circumstances: low-weight or ectopic adenomas, coexisting thyroid disease and re-interventions. METHODS: The study included 223 patients with primary hyperparathyroidism operated in a single Surgical Unit from August 2016 to March 2021. Preoperative ultrasonography and double-phase MIBI were performed with early SPECT/CT acquisition. A minimally invasive surgical approach was initially attempted, except in patients with concomitant thyroid surgery or multiglandular parathyroid disease. RESULTS: Selective parathyroidectomy was accomplished in 179 patients (80.2%); cervicotomy and/or thoracoscopy in 44. Removal of the parathyroid lesion was achieved in 211 patients (94.6%), corresponding 204 (96.7%) to adenomas (37 ectopic). The cure rate was 94.2%. Preoperative MIBI SPECT/CT showed higher sensitivity and accuracy (84%; 80%) compared to ultrasound (72%; 71%), being more precise in defining the exact anatomical location (75.8% vs 68.7%). These differences reached statistical significance in ectopic glands. The existence of concomitant thyroid pathology did not decrease the sensitivity of SPECT/CT (84.2%). Mean parathyroid weight was 692.2mg (95%CI: 443.5-941) in MIBI-negative cases and 1145.9mg (95%CI: 983.6-1308.3) in MIBI-positive (p=0.001). Re-intervention was successful in the 8 patients with previous surgery. CONCLUSION: MIBI SPECT/CT presents greater sensitivity, accuracy and anatomical precision than ultrasound for preoperative parathyroid localization, even in the case of ectopic glands or coexisting thyroid pathology. The weight of the pathological gland is a significantly limiting factor.

Procedimiento radioguiado en la cirugía mínimamente invasiva del hiperparatiroidismo primario / Radio-guided procedure in minimally invasive surgery for primary hyperparathyroidism

La paratiroidectomía mínimamente invasiva, de elección en la mayoría de casos de hiperparatiroidismo primario, muestra una elevada tasa de detección, fundamentada en una precisa localización preoperatoria mediante gammagrafía con MIBI (SPECT/TC) y ecografía cervical. La paratiroidectomía mínimamente invasiva radioguiada es una técnica aún más efectiva, acorta los tiempos quirúrgicos y mantiene una mínima incisión y escasas complicaciones; permite además la comprobación inmediata de la exéresis de la lesión paratiroidea y es especialmente interesante en pacientes con adenomas ectópicos o antecedentes quirúrgicos cervicales. En el presente trabajo se exponen las indicaciones, los protocolos y las diferencias entre los dos procedimientos disponibles de cirugía radioguiada mínimamente invasiva de paratiroides (MIBI y ROLL). (AU)

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radio-guided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radio-guided parathyroid surgery procedures (MIBI and ROLL) are exposed. (AU)

Radio-guided procedure in minimally invasive surgery for primary hyperparathyroidism.

Minimally invasive parathyroidectomy, of choice in most cases of primary hyperparathyroidism, shows a high detection rate, based on precise preoperative localization by MIBI scintigraphy (SPECT/CT) and neck ultrasound. Radioguided minimally invasive parathyroidectomy is an even more effective technique, which shortens surgical times, maintains minimal incision and few complications, allows immediate verification of parathyroid adenoma removal and is especially interesting in patients with ectopic lesions or cervical surgical history. In this paper, the indications, protocols and differences between the two available radioguided parathyroid surgery procedures (MIBI and R.O.L.L.) are exposed.

Sentinel node tumor burden in cutaneous melanoma. Survival with competing risk analysis and influence in relapses and non-sentinel node status: retrospective cohort study with long follow-up in a Spanish population.

Several authors have studied the potential of sentinel lymph node (SLN) tumor burden as prognostic factor but the microscopic classifications used in different study groups were variable. We examined the prognostic role of tumor burden in SLN on melanoma specific-survival and competing causes of death. We also analysed clinical and histological factors as predictors of disease relapses and additional non sentinel lymph node (NSLN) metastases. We included all patients with cutaneous melanoma that underwent SLN biopsy between 2002 and 2012 at Complejo Hospitalario de Navarra (Spain). The study end-points were death due to melanoma, melanoma relapse and involvement of NSLN. We used Fine-Gray test for competing risk analysis. A logistic regression model was performed to predict the risk of involvement of NSLN. Between 2002 and 2012, there were 348 patients who underwent SLN biopsy in our centre (308 were eligible for the study). 26.9% patients positive SLN. 88 patients died during the follow-up period and 66 (75%) died from melanoma. The 5-year cumulative incidence of melanoma death was 15.33% (95 % CI 15.25-15.42). The cumulative probability of death from melanoma was associated with gender, histological subtype, Breslow thickness, mitotic rate, ulceration and SLN tumor burden. In multivariable analysis, Breslow thickness and SLN tumor burden remained as independent prognostic factors. SLN tumor burden appears to be an important prognostic factor. It is very important reporting these characteristics in pathological reports. More prospective studies would be necessary to analyze these variables and to be able to make recommendations in management of melanoma patients.

Study of cutaneous melanoma recurrences after sentinel node biopsy: Patterns of dissemination and use of complementary test in follow-up.

OBJECTIVES: To investigate the patterns of melanoma recurrence in the local population, including factors that may influence in this event and timing of relapse, and to determine the mode of detection of them. METHODS: This is a retrospective cohort study of patients with melanoma who underwent sentinel lymph node biopsy at the Complejo Hospitalario de Navarra (Spain) from 2002 to 2012. The following data were collected of each patient: age, gender, date of diagnosis, location of melanoma, histological subtype, Breslow thickness, ulceration, mitosis, sentinel node status, AJCC 8th edition stage, site of first diagnosed metastasis, mode of relapse, date of first relapse and time of death. RESULTS: Of 308 patients, 30% people suffered metastasis. The mean follow-up time was 68.63 months. 51.1% of relapses were locoregional and 48.9% haemato-visceral. Sentinel node status was the only variable associated with higher risk of haemato-visceral metastasis (p < 0.001). The mean time between diagnosis of melanoma and recurrence was 2.7 years. Most recurrences were detected by the patient himself or had any type of symptoms and were consequently selected for a complementary test. CONCLUSION: It is important to follow-up all patients with diagnosis of cutaneous melanoma, essentially during the first 5 years after diagnosis.

Cirugía radioguiada de lesiones ocultas: tenemos mucho que sembrar / Radioguided surgery of non palpable lesions: we have much to sow

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Análisis de los factores relacionados con la sobreestadificación y la positividad del ganglio centinela en las pacientes con diagnóstico inicial de carcinoma ductal in situ / Analysis of factors related to upstaging and sentinel node positivity in the initial diagnosis of ductal carcinoma in situ

Objetivo. Determinar el porcentaje de pacientes con diagnóstico inicial de carcinoma ductal in situ (CDIS) que presentó infiltración tras la excisión quirúrgica e identificar los factores relacionados tanto con la sobreestadificación como con la positividad del ganglio centinela (GC) en el estudio definitivo. Material y métodos. Análisis retrospectivo de 135 pacientes diagnosticadas mediante biopsia core de CDIS a las que se les realizó biopsia selectiva del GC de forma consecutiva de 2003 a 2011. La técnica fue mixta en el período inicial y posteriormente mediante administración intraperilesional de radiocoloides. En 2009 se introdujo una gammacámara portátil y se inició el estudio intraoperatorio molecular mediante amplificación de ácido nucleico de un solo paso. Resultados. Se produjo sobreestadificación en 45 de las 135 pacientes (33,3%), de las que 30 (22,2%) presentaron CDIS con microinfiltración y 15 (11,1%) carcinoma infiltrante. Los CDIS con microinfiltración mostraron mayor tamaño, mayor porcentaje de alto grado, de HER2 positivo y de Ki-67 alto que los CDIS (p < 0,001, p < 0,001, p = 0,002 y p = 0,031, respectivamente). Los porcentajes de positividad del GC fueron del 3,6% en el CDIS, del 6,9% en el CDIS con microinfiltración y del 20% en los carcinomas infiltrantes, correspondiendo a 8 pacientes, de las cuales 6 presentaron HER2 positivo y Ki-67 alto. Conclusiones. El porcentaje global de infraestimación fue alto, principalmente debido a la presencia de microinfiltración. Tanto esta como la afectación metastásica del GC mostró relación con el HER2 positivo y el Ki-67 alto, por tanto, disponer de estos datos en la biopsia percutánea podría ser relevante para establecer la indicación de realización de biopsia selectiva del GC en el CDIS

Objective. To determine the percentage of patients with ductal carcinoma in situ (DCIS) with infiltration after surgical excision and to identify the factors related to both upstaging and sentinel node (SN) positivity in the final study. Material and methods. A retrospective analysis was performed in 135 patients diagnosed with DCIS by core biopsy who subsequently underwent sentinel lymph node biopsy from 2003 to 2011. In the first period of the study, the technique was mixed and subsequently consisted of intra-perilesional radiocolloid administration. In 2009, a portable gamma camera was introduced and we began to use intraoperative one-step nucleic acid amplification. Results. Upstaging occurred in 45 of the 135 patients (33.3%), of which 30 (22.2%) had DCIS with microinfiltration and 15 (11.1%) had invasive carcinoma. Compared with DCIS, DCIS with microinfiltration were larger and showed a higher percentage of high grade, HER2 positivity and high Ki-67 (P < .001, P < .001, P = .002 and P = .031, respectively). SN positivity rates were 3.6% in DCIS, 6.9% in DCIS with microinfiltration, and 20% in invasive carcinomas, corresponding to 8 patients, of whom 6 showed HER2-positivity and high Ki-67. Conclusions. Overall underestimation was high, mainly due to the presence of microinfiltration. Both microinfiltration and metastatic SN involvement were associated with HER2-positivity and high Ki-67. Therefore, the availability of this information in core needle biopsy could be relevant in establishing the indication for sentinel lymph node biopsy in DCIS