Bilateral Exploration Research Articles

How and when is multiglandular disease diagnosed in sporadic primary hyperparathyroidism?

BackgroundIn total, ∼15% of patients with sporadic primary hyperparathyroidism have multiglandular disease, which may be suspected preoperatively but can only be confirmed intra or postoperatively. The study aim is to determine how and when patients are diagnosed with multiglandular disease and to what extent different modalities contribute. MethodsConsecutive cases of sporadic primary hyperparathyroidism (2013–2019) undergoing initial exploration were reviewed from a single-institution prospective database. Preoperative single-photon emission tomography/computed tomography and neck ultrasound were routinely performed to help direct either bilateral or unilateral exploration guided by intraoperative parathyroid hormone monitoring using the dual criteria. Multiglandular disease was defined as either resection of >1 enlarged parathyroid or hypercalcemia at ≥6 months after single gland resection. ResultsOf 1,890 patients with sporadic primary hyperparathyroidism, multiglandular disease was identified in 254 (13.4%); 244 (96.1%) were diagnosed intraoperatively and 10 (3.9%) postoperatively. In these multiglandular disease patients, single gland disease was suggested on single-photon emission tomography/computed tomography in 54.0%, ultrasound in 49.2%, and both were concordant for single gland disease in 29.4%. Intraoperative multiglandular disease diagnosis was prompted by an inadequate intraoperative parathyroid hormone monitoring drop in 38.5%, by surgeon interpretation of imaging in 38.1%, by observing ipsilateral gland enlargement in 11.0%, by finding an initial gland <200 mg in 10.3%, and 2.0% had unexpected multiglandular disease during thyroidectomy. Multiglandular disease was diagnosed by postoperative hypercalcemia in 10 of 254 patients (4.9%). ConclusionTo avoid failure at parathyroidectomy for primary hyperparathyroidism, expert surgeons use multiple approaches to diagnose and manage multiglandular disease. Preoperative localization studies alone are insufficient, missing multiglandular disease in at least 30% of cases. All examined adjuncts are informative, including intraoperative parathyroid hormone monitoring, imaging, and intraoperative visual cues.

OV03 TEP IN COLORS: ANATOMICAL VIEW USING ARTICULATED FORCEPS

Abstract Aim Present through an illustrative and educational video, an anatomical and colorful vision of the totally extraperitoneal laparoscopic approach (TEP) of inguinofemoral hernias, with the aim of favoring the learning process of this technique, facilitating the identification of the main anatomical structures, ensuring a safe and effective approach. Material and Methods In this video we show the laparoscopic approach to inguinofemoral hernias via TEP, highlighting the most important anatomical structures with different colors. Additionally, the surgical technique of this approach using articulated forceps is shown, which we consider to be a good resource for dissection in a space as small as the preperitoneal one. Results The anatomical study of the inguinofemoral area constitutes the basis of a correct preperitoneal approach, especially in PET, where the most difficult is probably the space location and the identification of the structures. Conclusions The preperitoneal PET route is a relatively novel approach for inguinofemoral hernia repair. Its benefits are based on the ability to identify all the anatomical structures of the myopectineal orifice from a preperitoneal view without the need to access the peritoneal cavity. The knowledge of preperitoneal anatomy is the cornerstone for learning the TEP approach, and we consider that anatomical videos of real surgeries are good strategies to shorten the learning curve. Mastering the preperitoneal anatomy ensures obtaining the benefits inherent to the TEP approach, such as bilateral exploration of the myopectineal orifice, direct visualization of the pain and doom triangles, tension-free repair with mesh of all possible defects and faster postoperative recovery.

Dormant Pseudomonas aeruginosa infection seven years post-augmentation mastopexy: A case report.

Introduction and importanceAround 1% of all complications associated with breast implants are attributable to infection, classified as acute, subacute, or late-onset, with late-onset infections being the rarest. Even when symptoms are not obvious, an infection may still be lingering. Sub-clinical presentations have been implicated in the pathophysiology of breast implant capsular contracture. Organisms can establish dormancy through biofilm formation, and can also be idiopathically activated, and present as a late-onset infection, as has been clearly described in the literature with the infamous Enterococcus avium.Case presentationWe report the case of a 44-year-old woman who underwent bilateral augmentation mastopexy seven years ago complicated by an acute perioperative infection that was resolved with a full course of antibiotics. She presented to the clinic complaining of left breast pain and swelling accompanied by fever for four days. Ultrasonic imaging showed moderate peri-implant fluid positive for Pseudomonas aeruginosa upon aspiration. The patient therefore underwent bilateral breast exploration and capsulectomy.Clinical discussionWe believe that the dormant P. aeruginosa contributed to the capsular contracture and was idiopathically activated, manifesting as a late-onset infection seven years post-augmentation mastopexy.ConclusionTo the best of our knowledge, no previous studies or case reports have described a late-onset infection due to idiopathic activation, where dormant P. aeruginosa is isolated from an implant capsule many years after augmentation mastopexy. More studies are required to examine the role of dormant bacteria in capsular contracture and their idiopathic activation considering the consequences on patient outcomes.

Perinatal testicular torsion: The clear cut, the controversial, and the "quiet" scenarios

BackgroundPerinatal testicular torsion (PTT) is a catastrophic event that occurs in utero or up to 30 days postnatally, with testicular loss being the most common outcome. ObjectiveTo assess clinical evaluation, surgical management and clinical outcomes in patients with PTT in a quaternary referral pediatric center, to determine testicular salvageability and propose future management options. MethodsWe retrospectively reviewed a cohort of males born outside the quaternary center with a diagnosis of PTT, from May 2000 to July 2020. Data collection included mode of delivery, gestational age, birth weight, testicular examination at birth, clinical presentation, ultrasound results at diagnosis, surgical management and findings, perioperative complications, and follow-up. Results62 patients, including 2 patients with bilateral asynchronous PTT, were identified. Median (IQR) gestational age and birth weight were 39 (38–39.4) weeks and 3.4 (3.1–3.72) kg, respectively. Abnormal testicular examination at birth was found in 69% (Table 1). Doppler ultrasound was performed in all but 1 patient. 59 patients underwent surgery, 21 within 4 h, with bilateral exploration in 44 cases. Affected and non-affected testicles were explored in 76% and 98% of cases, respectively. 3 "nubbins" were found, of which 2 were excised. 3 nonsurgical complications were identified. During a median (IQR) follow-up of 3 (3–3) months, 63 testicles were removed or found to be non-functional, with compensatory hypertrophy in 38% of patients. ConclusionGiven that 3% of our patients presented with asynchronous bilateral PTT, as well as the safety of general anesthesia in a referral pediatric hospital, early bilateral scrotal exploration of PTT is recommended. Level of evidenceIV

Ambidirectional cohort study on the agreement of ultrasonography and surgery in the identification of parathyroid pathology, and predictors of postoperative hypocalcemia in 47 dogs undergoing parathyroidectomy due to primary hyperparathyroidism.

ObjectiveTo investigate (1a) agreement of ultrasonographic, surgical, and histopathologic findings in the diagnosis of a neoplastic etiology underlying primary hyperparathyroidism (PHPT), (1b) the ability of ultrasonographically determined parathyroid gland size to distinguish between malignant (carcinoma) and non‐malignant (hyperplasia, adenoma) pathology, and (2) variables associated with postoperative hypocalcemia in dogs undergoing surgical treatment of PHPT.Study DesignAmbidirectional cohort study.AnimalsForty‐seven client owned dogs with PHPT (34 retrospective; 13 prospective).MethodsData were extracted from medical records. Method agreements were explored using Cohen's Kappa statistic. A receiver operating characteristic curve (ROC) was used to determine a cut‐off separating parathyroid pathologies. Univariable and multivariable models assessed associations between postoperative hypocalcemia and potential risk factors.ResultsAgreement of ultrasound and surgery for number and side of affected glands was 31/47 (65.9%) and 34/47 (72.3%), respectively. In 37/47 (78.7%) cases, parathyroid tissue was correctly assessed as pathologic by the surgeon. An ultrasonographic cut‐off of ≥8.0 mm (ROC AUC = 0.82) best distinguished malignant from benign pathologies. Dogs with a preoperative serum ionized calcium (iCa) concentration ≥1.75 mEq/L had 7.5 times greater odds of becoming hypocalcemic postoperatively.ConclusionA fair agreement existed between ultrasonographic and surgical findings in dogs with PHPT. A parathyroid mass ≥8.0 mm on ultrasonographic examination was suggestive of malignancy, while dogs with a preoperative serum iCa concentration ≥1.75 mEq/L were at increased risk for postoperative hypocalcemia in this study.Clinical significanceThis study supports the use of bilateral cervical surgical exploration to identify abnormal parathyroid glands for the treatment of PHPT.

Is a contralateral testicular exploration required at microdissection testicular sperm extraction for men with nonobstructive azoospermia, cryptozoospermia or severe oligozoospermia?

Men with nonobstructive azoospermia (NOA), cryptozoospermia and severe oligozoospermia are candidates for microdissection testicular sperm extraction (micro-TESE) and intracytoplasmic sperm injection (ICSI). We sought to evaluate micro-TESE outcomes and the need for bilateral testicular exploration in the three groups of men. We conducted a retrospective study of 233 consecutive micro-TESEs in men with nonobstructive azoospermia (n=173), cryptozoospermia (n=43) and severe oligozoospermia (n=17). The decision to terminate the micro-TESE after a unilateral or bilateral testicular exploration was determined at the time of surgery and was based on the presence or absence of mature spermatozoa in the harvested micro-biopsies. Final assessment of sperm recovery, on the day of ICSI, was reported as successful (available spermatozoon for ICSI) or unsuccessful (no spermatozoon for ICSI). Unilateral testicular exploration resulted in successful sperm retrieval in 43% (75/173), 79% (34/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively. Therefore, 57%, 21% and none of the men with NOA, cryptozoospermia and severe oligozoospermia, respectively, required a bilateral micro-TESE. Overall, micro-TESE resulted in successful sperm retrieval in 52% (90/173), 91% (39/43) and 100% (17/17) of men with NOA, cryptozoospermia and severe oligozoospermia respectively. Our data indicate that men with severe oligozoospermia are unlikely to require a bilateral testicular exploration at micro-TESE. Moreover, most cryptozoospermic men will have a successful sperm retrieval by micro-TESE with the majority of these patients requiring a unilateral exploration. In contrast, over 50% of the men with nonobstructive azoospermia will require a bilateral micro-TESE.

Parathyroid Surgery: What Radiologists Need to Know.

Surgical intervention remains the mainstay of treatment of hyperparathyroidism and provides the highest chance at cure. After the disease is confirmed by biochemical testing, surgeons must use a combination of patient clinical history and radiographic imaging to determine the most appropriate surgical strategy. Through either minimally invasive parathyroidectomy or bilateral cervical exploration, surgeons provide high rates of cure for hyperparathyroidism with low rates of persistence or recurrence.

Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery

PurposeRepeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse.MethodsA retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated.ResultsNeck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24–48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%.ConclusionThese findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.

Bilateral Neck Exploration May Not Reduce the Risk of Persistence but Shows a Perspective Advantage

There is still no consensus for an optimal surgical treatment of primary hyperpararthyroidism (PHPT). Virtually, most of the patients could be successfully treated with the selective parathyroidectomy (SPTE) based on preoperative visualization. However, this approach still has a “blind area” of undetected multiglandular disease (MGD). Bilateral neck exploration (BNE) may serve as a reasonable alternative but it meets the higher requirements for the surgical technique. A retrospective cohort study was conducted in order to reveal factors associated with the persistence of PHPT. 587 cases of PHPT patients who had received surgical treatment at SPSU Hospital in 2017–2018 were included. All the patients have at least one preoperative visualization study (neck ultrasound performed by a surgeon) before the operation. In 356 cases two studies were performed (additional 4D CT or MIBI scan) and 116 cases had all three. A surgeon was free to choose a type of the operation (selective or explorative) according to their strategic preferences. Bilateral neck exploration was performed in 160 cases. There was no difference in bilateral exploration rate (p = 0.3896) between the groups (with 1, 2 or 3 studies performed) indicating that the additional visualization does not allow to avoid bilateral exploration. MGD rate accounted for 7.4% (40 cases). It is important that any set of preoperative visualization modalities prove the absence of MGD reliably and select patients for SPTE precisely. Negative predictive value for different combinations of concordant studies (US+MIBI, US+CT and US+CT+MIBI) did not differ significantly and was 96.95%, 97.4% and 97.7% respectively. 26 cases of persistent disease were reported with no significant difference between BNE and SPTE groups. (6 vs 20 respectively, p = 0.792). A history of the thyroid or parathyroid operations was found to be the only factor predicting the higher risk of persistence (OR = 7.98; 95% CI [2.62 - 24.27]), while neither the number of parathyroid glands found during the surgery nor the number of preoperative visualization studies showed statistical significance. Only 47,5% cases of BNE was reported to have all four glands visualized. There rate of failure to found each gland was similar. Surprisingly, the superior parathyroid adenomas (P4) were more likely to be removed (chi-squared 10.378, p = 0.0006) but not in the cases with all four glands visualized intraoperatively (chi-squared 1.822, p = 0.0884). The true rate difference due to a hypothetical feature of parathyroid physiology seems to be not very likely. One may rather suggest than it is not an uncommon for a surgeon to identify a P3 gland as a P4 unless all for glands are visualized. This fact shows a perspective advanantage which may prevent some cases of persistence.

What to do when the parathyroid gland is not found during a transcervical exploration?

The most frequent cause of suboptimal results in a parathyroid adenoma resection is an ectopic location, mainly in the anterior mediastinum. These cases may not always be resected through a traditional cervical access. We present 2 cases of primary hyperparathyroidism who underwent an unsuccessful bilateral cervical exploration due to parathyroid tissue located inside the thymic gland. A video-assisted thoracoscopic surgery thymectomy with intraoperative determination of blood parathormone levels was performed. A 50% reduction of intraoperatory parathyroid hormone blood from the highest basal level at 5 and 10 min after resection was obtained. Final pathological results showed an intra-thymic parathyroid adenoma in the first patient and an intra-thymic focus of parathyroid hyperplasia in the second patient. In conclusion, video-assisted thoracoscopic surgery thymectomy could be the optimal approach to resect ectopic parathyroid adenomas located in the anterior mediastinum.

A retrospective analysis of the diagnostic performance of 11C-choline PET/CT for detection of hyperfunctioning parathyroid glands after prior negative or discordant imaging in primary hyperparathyroidism

BackgroundIdentifying the correct location of a parathyroid adenoma in patients with primary hyperparathyroidism (pHPT) is crucial as it can guide surgical treatment. This study aimed to determine the diagnostic performance of 11C-choline PET/CT in patients with pHPT as a next in-line scan after primary negative or discordant first-line imaging.MethodsThis was a retrospective single-center cohort study. All patients with pHPT that were scanned utilizing 11C-choline PET/CT, after prior negative or discordant imaging, between 2015 and 2019 and who subsequently underwent parathyroid surgery were included. The results of the 11C-choline PET/CT were evaluated lesion-based, with surgical exploration and histopathological examination as the gold standard.ResultsIn total, 36 patients were included of which three patients were known to have Multiple Endocrine Neoplasia (MEN) syndrome. In these 36 patients, 40 lesions were identified on 11C-choline PET/CT and 37 parathyroid lesions were surgically removed. In 34/36 (94%) patients a focused parathyroidectomy was performed, in one patient a cervical exploration due to an ectopically identified adenoma, and in one patient a bilateral exploration was performed because of a double adenoma. Overall, per-lesion sensitivity of 11C-choline PET/CT was 97%, the positive predictive value was 95% and the accuracy was 94% for all parathyroid lesions.ConclusionsIn patients with pHPT and prior negative or discordant first-line imaging results, pathological parathyroid glands can be localized by 11C-choline PET/CT with high sensitivity and accuracy.

Surgical Experience of Primary Hyperparathyroidism: Analysis of Postoperative Outcomes

Background and Objectives The standard surgical procedure for primary hyperparathyroidism is the bilateral exploration. However, the unilateral exploration and direct focused parathyroidectomy have been performed to reduce surgical morbidity. The purpose of this study was to report the surgical outcomes and efficacy of the bilateral exploration, unilateral exploration, and direct focused approaches for primary hyperparathyroidism.Subjects and Method We retrospectively analyzed the surgical outcomes of 87 patients with primary hyperparathyroidism from January 2007 to December 2017. We compared the operative time, complication and recurrence rate between the three operative methods.Results The most common histopathology was parathyroid adenoma, which was found in 73 cases (83.9%), followed by hyperplasia. In terms of complications, there were two cases of transient vocal cord palsy, one case of hematoma, one case of hypocalcemia and one case of hungry bone syndrome. Recurrence occurred in two (2.3%) out of 87 cases. There was no significant difference in the recurrence rate between the three surgical approaches.Conclusion The success rate of surgery for primary hyperparathyroidism is high. Direct focused parathyroidectomy may be a good option for parathyroid adenoma if the localization tests localize the lesion. The bilateral exploration is effective for parathyroid hyperplasia.

Concomitant thyroid disease in patients operated for primary hyperparathyroidism.

Parathyroid and thyroid diseases are ones of the most common endocrine diseases, but simultaneous surgical treatment of both endocrine systems is still under discussion. We retrospectively evaluated 1,574 patients operated for primary hyperparathyroidism at the 3rd Department of Surgery, 1st Faculty Medicine, Charles University and University Hospital Motol in Prague with the thyroid and parathyroid ultrasound reports available. The patients were divided into two groups - with and without thyroid surgery. Thyroid surgery was performed in 34% of patients with primary hyperparathyroidism. Group 2, where thyroid surgery was performed, showed ahigher proportion of reported abnormal thyroid sonographic findings (74%), ahigher proportion of bilateral throat exploration (69%) and alonger hospital stay (3.3 days). Apatient indicated for surgery for parathyroid disease should also be indicated for possible thyroid surgery.

Upfront F18-choline PET/CT versus Tc99m-sestaMIBI SPECT/CT guided surgery in primary hyperparathyroidism: the randomized phase III diagnostic trial APACH2

BackgroundThe common endocrine disorder primary hyperparathyroidism (PHPT) can be cured by surgery. Preoperative localization of parathyroid adenoma (PTA) by imaging is a prerequisite for outpatient minimally invasive parathyroidectomy (MIP). Compared to inpatient bilateral cervical exploration (BCE) which is performed if imaging is inconclusive, MIP is superior in terms of cure and complication rates and less costly. The imaging procedure F18-choline (FCH) PET/CT outperforms Tc99m-sestaMIBI (MIBI) SPECT/CT for PTA localization, but it is much costlier. The aim of this study is to identify the most efficient first-line imaging modality for optimal patient care in PHPT without added cost to society.MethodsWe will conduct a multicenter open diagnostic intervention randomized phase III trial comparing two diagnostic strategies in patients with PHPT: upfront FCH PET/CT versus MIBI SPECT/CT. The primary endpoint is the proportion of patients in whom the first-line imaging method results in successful MIP and cure. Follow-up including biological tests will be performed 1 and 6 months after surgery. The main secondary endpoint is the social cost of both strategies. Other secondary endpoints are as follows: FCH PET/CT and MIBI SPECT/CT diagnostic performance, performance of surgical procedure and complication rate, FCH PET/CT inter- and intra-observer variability and optimization of FCH PET/CT procedure. Fifty-eight patients will be enrolled and randomized 1:1.DiscussionFCH PET/CT is a highly efficient but expensive imaging test for preoperative PTA localization and costs three to four times more than MIBI SPECT/CT. Whether FCH PET/CT improves patient outcomes compared to the reference standard MIBI SPECT/CT is unknown. To justify its added cost, FCH PET/CT-guided parathyroid surgery should lead to improved patient management, resulting in higher cure rates and fewer BCEs and surgical complications.In the previous phase II APACH1 study, we showed that second-line FCH PET/CT led to a cure in 88% of patients with negative or inconclusive MIBI SPECT/CT. BCE could be avoided in 75% of patients and surgical complication rates were low. We therefore hypothesize that upfront FCH PET/CT would improve patient care in PHPT and that the reduction in clinical costs would offset the increase in imaging costs.Trial registrationNCT04040946, registered August 1, 2019. Protocol versionVersion 2.1 dated from 2020/04/23.

Parathyroid Adenoma: Diverse Modalities of Clinical Presentation. Series of Cases and Literature Review. January 2010-October 2020

The surgical treatment of Parathyroid Disease (PD) has change in the past two decades. The Parathyroid Adenoma (PA) represents 80%, some with symptoms others asymptomatic. The technological development of imaging methods has allowed greater precision in planning the surgical approach. The goal of parathyroidectomy is to cure. There are several surgical approaches from open cervical to minimal endoscopic surgery. Objective: The main of this study is to present the clinical characteristic, the diagnosis methods: biochemical and imaging, surgical approached and follow up. Methods: Descriptive study, Cohort, Series of cases. We reviewed the record of 450 patients diagnosed with tumor in head and neck during the period January 2010 to October 2020. We selected the record of patients with diagnosed of PA and the clinical characteristics of the patients according demographic aspect, symptoms, biochemical and imaging methods, complementary diagnosis test, surgical approach, histological classification according WHO Tumor of Endocrine Organs 4th edition 2017. The frozen section during the surgery indicted with the freezing microtome and stained with hematoxylin and eosin. The univariable review realized with frequency and percentage using Excel 2016. Results: We selected 6 (1.3%) patients, male 5(83%) female 1(17%). The age range was 28-72 years, the median ages 49.6 in the neck located 4(66%), 1(17%) in upper mediastinum and 1(17%) in cervical and thoracic location. patient with recurrence after of five years. 1 with three PA and 1 with two PA. The parathyroid gland affected was: lower right 3 cases, upper left 1, lower left 5 cases and one upper mediastinum. The symptoms were nephrocalcinosis and chronic kidney failure (CKF) 4 patients, bone loss (spine/hip) 2, cardiovascular diseases 1, left neck swelling and disphagia 1. Imaging methods used: ultrasonography and technetium-99 Sestamibi Scanning the 5 patients, Magnetic Resonance Imaging (MRI) 4 and CT Scann 1 The bone densitometry: 2 (33%) patients with severe osteoporosis, 2(33%) with moderate, 1(16%) normal and 1 unknown. The surgical approach was: bilateral cervical exploration 2 patients, unilateral cervical exploration 2, minimally invasive thoracoscopic 1 and double cervical and thoracic open 1. The biochemical control of parathyroid hormone (PTH) was: range prior surgery 384-3000 pg/ML the mean 1,730.2 pg/ML. The percentage of decrease post-surgery was 99 %-98% Calcium prior surgery was 9.2-14.09 mg/dl the mean 11.2 mg/dl the range post-surgery was: 7.9-9.9 mg/dl the mean 8.6 mg/ dl. Pathology register reveled PA, 5(83%) and 1(17%) a giant nonfunctioning Parathyroid cyst. During the follow up, only 1 patient presented recurrence five years later and required reintervention. None with post-surgery complication. Conclusions: The multidisciplinary approach permitted the success obtained and surgery planning for each patient with PA. The results show like other papers, which using the technological development of imaging studies, the support of the frozen biopsy for the lack of PTH fast, allowed to corroborate the surgical remotion of the diseases gland with high percentage of cure.

18F-choline PET/4D CT in hyperparathyroidism: correlation between biochemical data and study parameters

BackgroundHyperparathyroidism (PTH) is characterised by increased levels of parathyroid hormone (PTH), surgical excision being the only definitive curative option. After establishing the need for surgery, it is essential to identify the parathyroid glands in the preoperative period to use a minimally invasive approach. Negativity and / or discrepancy in first- line studies (ultrasound and Tc-99 m MIBI parathyroid scintigraphy) require more accurate images to reduce the likelihood of bilateral cervical exploration or reintervention. Objectivesa) To demonstrate the sensitivity of 18 F-fluorocholine (18 F-choline) positron emission tomography (PET)/4D computed tomography (4D CT) in HPT. b) To check whether there is a correlation between calcaemia and preoperative PTH versus size and early and late SUVmax (Standardized Uptake Value) of the gland, determined by 18 F-choline PET/4D CT and c) to study the behaviour of parathyroid lesions with intravenous contrast (IV). Material and methodsA total of 28 patients were included between 2016 and 2019 in a single institution. Prospective observational cohort study. Correlations were analysed using Pearson's coefficient for variables with normal distribution and Spearman (rho) for those with non-normal distribution. Anatomopathological analysis was the benchmark standard to determine sensitivity was. A p < .05 was interpreted as significant. STATA 13 software was used. ResultsOf the 28 patients who underwent 18 F-choline PET/4D CT, 18 were operated. Of the 26 lesions diagnosed by 18 F-choline PET/4D CT as suggestive of parathyroid lesions, 23 corresponded to glandular disease (adenoma or hyperplasia) establishing a sensitivity of 88.5%. There was a correlation between the patient's preoperative PTH and the maximum size of the gland on 18 F-choline PET/4DCT. (Spearman .66; p = .0014). The parathyroid lesions showed, in addition to IV contrast enhancement, distinctive behavioural characteristics identified as highly suggestive. Conclusions18 F-choline PET/CT 4D is an anatomical and functional study with high sensitivity in patients with HPT with negative or discrepant first-line studies. Preoperative PTH showed a correlation with maximum gland size on 18 F-choline PET/CT 4D. Parathyroid lesions behave in a highly suggestive way and are enhanced by IV contrast.

Identification of Occult Adenomas in Primary Hyperparathyroidism With 18F-Fluorocholine PET/CT

IntroductionSingle parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. MethodsA prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical, and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. ResultsHyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia, and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2 groups. ConclusionIn our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery.

Prevalence, Diagnostic Imaging and Treatment Strategies of Intrathyroid Parathyroid Adenomas in Patients Surgically Treated for Hyperparathyroidism: A Review of the Literature

Single parathyroid adenoma is the most common cause of primary hyperparathyroidism. Surgery is the definitive treatment. Intrathyroid parathyroid adenomas (ITPAs) can result in failure of the surgical procedure and persistence or recurrence of hyperparathyroidism. The aim of this review is to assess the prevalence of ITPAs, the efficacy of imaging studies in ITPA localisation as well as the efficacy of various surgical strategies. We conducted our search using the Medline database and searched for the keywords “intrathyroid parathyroid adenoma”. Eligibility criteria specified the availability of abstracts or full-text articles in English. Twenty five articles were considered relevant and were included in the synthesis of this article. The prevalence of ITPA in patients with primary hyperparathyroidism varies between 0.5% – 22.68%, with most studies reporting a frequency of 0.5% – 4.3%. The prevalence of ITPA in patients re-operated for persistent or recurrent hyperparathyroidism was 8.6% – 11%. The imaging modalities that are most commonly used are ultrasonography (US) and Technetium-99m sestamibi scintigraphy. A combination of both methods is associated with high diagnostic accuracy (81% – 92.3%). Thorough bilateral cervical exploration followed by thyroidotomy or thyroid lobectomy is the most common surgical strategy, although there are data that support low success rates. ITPAs are a rare cause of hyperparathyroidism that should not be neglected. Preoperative imaging is useful in the localisation of ITPAs. Bilateral cervical exploration followed by tumour enucleation or thyroid lobectomy is considered the best surgical strategy.

PET/TC 4D 18F-colina en el hiperparatiroidismo: correlación entre datos bioquímicos y parámetros del estudio

BackgroundHyperparathyroidism (HPT) is characterised by increased levels of parathyroid hormone (HPT), surgical excision being the only definitive curative option. After establishing the need for surgery, it is essential to identify the parathyroid glands in the preoperative period to use a minimally invasive approach. Negativity and / or discrepancy in first-line studies (ultrasound and Tc-99m MIBI parathyroid scintigraphy) require more accurate images to reduce the likelihood of bilateral cervical exploration or reintervention. Objectivesa) To demonstrate the sensitivity of 18F-fluorocholine (18F-choline) positron emission tomography (PET)/4D computed tomography (4D CT) in HPT. b) To check whether there is a correlation between calcaemia and preoperative PTH versus size and early and late SUVmax (Standardized Uptake Value) of the gland, determined by 18F-choline PET/4D CT and c) to study the behaviour of parathyroid lesions with intravenous contrast (IV). Material and methodsA total of 28 patients were included between 2016 and 2019 in a single institution. Prospective observational cohort study. Correlations were analysed using Pearson's coefficient for variables with normal distribution and Spearman (rho) for those with non-normal distribution. Anatomopathological analysis was the benchmark standard to determine sensitivity was. A p<.05 was interpreted as significant. STATA 13 software was used. ResultsOf the 28 patients who underwent 18F-choline PET/4D CT, 18 were operated. Of the 26 lesions diagnosed by 18F-choline PET/4D CT as suggestive of parathyroid lesions, 23 corresponded to glandular disease (adenoma or hyperplasia) establishing a sensitivity of 88.5%. There was a correlation between the patient's preoperative PTH and the maximum size of the gland on 18F-choline PET/4D CT. (Spearman=.66; p=.0014). The parathyroid lesions showed, in addition to IV contrast enhancement, distinctive behavioural characteristics identified as highly suggestive. Conclusions18F-choline PET/CT 4D is an anatomical and functional study with high sensitivity in patients with HPT with negative or discrepant first-line studies. Preoperative PTH showed a correlation with maximum gland size on 18F-choline PET/CT 4D. Parathyroid lesions behave in a highly suggestive way and are enhanced by IV contrast.

Wrongness: Social Side-Effects in Psychotherapy

ABSTRACTTo help people own who they are, to get to their emotional basics, hold what they feel and be able to think even under the heaviest interpersonal pressure—this is my first and main therapeutic goal. The social consequences are that emotionally skillful people stop ignoring the inconsistencies they perceive in relationships; they ask for clarification once they no longer accept that their signaling is dismissed as “wrong” behavior. Their asking gives rise to fair conflicts, but a fair conflict is disrupting, because it involves a lot of bilateral exploration about established assumptions: relationships constantly exceed reached conclusions, if people have the courage to look at them with a fresh eye. This rupture-repair process is in turn based upon a degree of incongruence in human interactions as a source of endemic conflict: the mind is growing through its bridging of interactive gaps. Bearing the impact of full-range emotions arising from rupture-and-repair is anything but a comfortable societal ritual.