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Parathyroidectomy preoperative and intraoperative localization of abnormal parathyroid glands

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... Feinmesser, Raphael MD a; Joshua, Ben-Zion MD a; Shpitzer, Thomas MD a; Morgenstein ... thyroidectomy. Laryngoscope. 1999;109:1238. 4. McIntyre RC ... – PowerPoint PPT presentation

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Title: Parathyroidectomy preoperative and intraoperative localization of abnormal parathyroid glands


1
Parathyroidectomy preoperative and
intraoperative localization of abnormal
parathyroid glands
  • Rummana Aslam, MD

2
Anatomic distribution of the parathyroids
  • Upper gland in order of frequency,
  • the cricothyroid junction the dorsum of the
    upper pole of the thyroid and the
    retropharyngeal space
  • Lower gland
  • at the lower pole of the thyroid and the thymic
    tongue rarely in the upper, the lateral neck, or
    the mediastinum
  • Subcapsular located within the surgical capsule
    of the thyroid
  • Extracapsular in posteriorior or anterior
    mediastinum
  • Supernumerary, fused, and intrathyroidal
    parathyroids
  • Wang,. Ann Surg Mar 1976

3
The anatomy of primary hyperthyroidism
  • Single gland enlargement (adenoma) 218/273
    patients (80) Hyperplasia of all identified
    parathyroid glands 42/273 patients (15)
  • Two adenomas 7 patients (2.6).
  • Biochemical evidence of the disease with normal
    glands at neck exploration 7 patients (2.6)
  • Ectopic right superior gland adenomas (mean size
    2.6 cm) 39
  • Ectopic left superior gland adenomas (mean size
    2.62 cm) 36.
  • Intrathyroid superior adenomas none.
  • Intrathyroid inferior adenomas five of 223 (2)
  • Inferior gland adenomas within the thymus
  • Failure rate of cervical exploration (4)
    attributed to mediastinal adenomas, and a
    second adenoma, and incorrect diagnosis

Thompson NW. Surgery. 1982 Nov.
4
  • 48 patients with neck exploration for parathyroid
    adenomas
  • Thirty-two of the 48 patients (67) had
    successful unilateral exploration
  • 16 patients underwent bilateral exploration, and
    7/16 had no reduction in PTH level
  • Of these seven, five were found to have a second
    adenoma and two had slow metabolism of hormone
    with no additional abnormal tissue found.
  • In 5 of the 16 patients, bilateral exploration
    was performed for erroneous localization.
  • Four additional patients underwent bilateral
    exploration for improved exposure or negative
    results on localization tests.
  • Conclusions 70 rate of unilateral neck
    exploration
  • Intrinsic 15 rate of multinodular primary
    hyperparathyroidism combined with limited
    results of preoperative localizing techniques

Moore, Francis D. Jr. Annals of surgery 1999
5
Preoperative localization
  • Hajioff d., (2004) Clin. otolarygol
  • accuracy of ultrasonography, sestamibi
    scintigraphy and their combination in 48 cases of
    primary hyperparathyroidism
  • Ultrasound had a sensitivity of 64.3
  • and positive predictive value (PPV) of 100
    (81.5100) for correct lateralization.
  • Sestamibi had a sensitivity of 83.3 (69.892.5)
    and PPV of 87.1 (73.795.1).
  • The simple combination of ultrasound with
    sestamibi had a sensitivity of 82.1 (63.193.9)
    and a PPV of 92.0 (74.099.0) little different
    from sestamibi alone.

Hajioff d., (2004) Clin. otolarygol
6
Preoperative localization
  • Twenty-three consecutive patients underwent 24
    operations for primary hyperparathyroidism.
  • preoperative technetium 99m-sestamibi planar
    scintigraphy,
  • preoperative administration of 7.5 mg/kg
    methylene blue initiated within 60 minutes of
    surgical incision, and surgical neck exploration
    supervised by a single surgeon.
  • RESULTS All patients were cured of
    hypercalcemia.
  • Sensitivity for sestamibi and for methylene blue
    staining was 76 and 79, respectively.
  • Specificity for sestamibi and for methylene blue
    was 98 and 93, respectively.
  • Agreement between sestamibi and methylene blue
    was 96.

Orloff, Lisa A. MD., Larygoscope 2001
7
Intraoperative PTH assay
  • Miami criterion (gt50 drop from highest baseline
    IOPTH level at 10 minutes after excision)
  • criterion 1 (gt50 drop from preincision IOPTH
    level at 10 minutes)
  • criterion 2 (gt50 drop from highest baseline
    IOPTH level at 10 minutes and final IOPTH level
    within the reference range)
  • criterion 3 (gt50 drop from highest baseline
    IOPTH level at 10 minutes and final IOPTH level
    less than the preincision value)
  • criterion 4 (gt50 drop from highest baseline
    IOPTH level at 5 minutes), and criterion 5 (gt50
    drop from preexcision IOPTH level at 10 minutes).
  • Conclusions Satisfying criterion 2 had a high
    operative success but resulted in additional
    unnecessary surgical exploration. Criterion 1 was
    better at predicting postoperative normocalcemia
    than criterion 2.
  • Chiu, Bill MD, Arch of Surgery, May 2006

8
  • The adenoma is confined by the thyroid capsule
    and mimics the shape of the thyroid pole.
  • This conformation can often be confirmed on
    anterior and lateral pinhole views using a
    dual-isotope technique. In these cases,
  • 109 patients identified, 10 were diagnosed with
    parathyroid hyperplasia and 99 with parathyroid
    adenomas
  • Of the 99 adenomas, 16 (16) were in subcapsular
    locations.Three patterns as related to thyroid
  • (1) focal convex distortion of the posterior
    aspect of the thyroid, 11/16
  • (2) polar lentiform configuration, and 3/16
  • (3) compression of the posterior thyroid
    parenchyma.2/16 Kraas J. Clinical Nuclear
    Medicine. April 2005.

Kraas J. Clinical Nuclear Medicine. April 2005
9
References
  • 1. Sackett WR, Barraclough B, Reeve TS, et al.
    Worldwide trends in the surgical treatment of
    primary hyperparathyroidism in the era of
    minimally invasive parathyroidectomy. Arch Surg.
    20021371055.
  • 2. Thompson NBahar, Gideon MD a Feinmesser,
    Raphael MD a Joshua, Ben-Zion MD a Shpitzer,
    Thomas MD a Morgenstein, Sara MD b Popovtzer,
    Aharon MD a Shvero, Jacob MD a Hyperfunctioning
    intrathyroid parathyroid gland A potential cause
    of failure in parathyroidectomy. Surgery.
    139(6)821-826, June 2006
  • 3. Lee NJ, Blakey JD, Bhuta S, et al.
    Unintentional parathyroidectomy during
    thyroidectomy. Laryngoscope. 19991091238.
  • 4. McIntyre RC Jr, Eisenach JH, Pearlman NW, et
    al. Intrathyroidal parathyroid glands can be a
    cause of failed cervical exploration for
    hyperparathyroidism. Am J Surg. 1997174750.
  • 5. Clark PB, Case D, Watson NE Jr, et al.
    Enhanced scintigraphic protocol required for
    optimal preoperative localization before targeted
    minimally invasive parathyroidectomy. Clin Nucl
    Med 200328955.
  • 6. Kumar A, Cozens NJA, Nash JR. Sestamibi
    scan-directed unilateral neck exploration for
    primary hyperparathyroidism due to a solitary
    adenoma. Eur J Surg Oncol 200026785.

10
  • 7. Chapuis Y, Fulla Y, Bonnichon P, et al. Values
    of ultrasonography, sestamibi scintigraphy, and
    intraoperative measurement of 1-84 PTH for
    unilateral neck exploration of primary
    hyperparathyroidism. World J Surg 1996 20
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  • 8. Casas A7. Mariani G, Gulec SA, Rubello D, et
    al. Preoperative localization and radioguided
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  • 9. Feliciano DV. Parathyroid pathology in an
    intrathyroidal position. Am J Surg. 1992164496.
  • 10. Lorberboym M, Minski I, Macadziob S, et al.
    Incremental diagnostic value of preoperative
    99mTc-MIBI SPECT in patients with a parathyroid
    adenoma. J Nucl Med. 200344904.
  • 11.T, Burke GJ, Mansberger AR, Wei JP. Impact of
    technetium-99m-sestamibi localization on
    operative time and success of operations for
    primary hyperparathyroidism. Am Surg 1994 60
    1217.
  • 12. Takei H, Iino Y, Endo K, et al. The efficacy
    of technetium-99m-MIBI scan and intraoperative
    methylene blue staining for the localization of
    abnormal parathyroid glands. Surgery Today 1999
    29 307312.
  • 13. Flynn MB, Bumpous JM, Schill K, McMasters KM.
    Minimally invasive radioguided parathyroidectomy.
    J Am Coll Surg 2000 191 2431.

11
  • 14. Westerdahl, Johan PhD Bergenfelz, Anders PhD
    Parathyroid Surgical Failures With Sufficient
    Decline of Intraoperative Parathyroid Hormone
    Levels Unobserved Multiple Endocrine Neoplasia
    as an Explanation. Archives of Surgery.
    141(6)589-594, June 2006.
  • 15. W, Eckhauser FE, Harness JK. The anatomy of
    primary hyperparathyroidism. Surgery.
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