Cervical Exploration Research Articles

PSAT324 Altered Mental Status, Hypercalcemia, and Atrial Fibrillation Induced by Post-Parathyroidectomy Thyroiditis

Abstract Background Parathyroidectomy-induced thyroiditis is a rare but possibly underreported phenomenon. It has been reported in primary, secondary, and tertiary hyperparathyroidism, and typically presents with transient thyrotoxicosis in the days to weeks following surgery. Clinical Case A 66-year-old man with end stage renal disease complicated by tertiary hyperparathyroidism and no prior history of thyroid disease or cardiac dysrhythmia was admitted for parathyroidectomy. A multinodular goiter and four enlarged parathyroid glands were identified intraoperatively. With significant thyroid retraction, removal of the inferior parathyroid glands, left superior parathyroid gland, and one-half of the right superior parathyroid gland was successfully performed without complication. Despite normalization of the parathyroid hormone level after surgery, the patient's preoperative hypercalcemia was noted to paradoxically worsen, rising from a corrected total calcium of 10.9 mg/dL (ref. 8.5-10.4 mg/dL) to 12.2 mg/dL. This was observed concurrently with the development of worsening mental status and new onset atrial fibrillation with rapid ventricular rate, prompting beta blockade initiation. Administration of intravenous crystalloid and subcutaneous calcitonin rapidly normalized his serum calcium but did not resolve the altered mentation or cardiac arrhythmia. Thyroid function tests revealed thyroid stimulating hormone 0.05 mIU/L (ref. 0.49-4.67 mIU/L), free thyroxine (T4) 3.8 ng/dL (ref. 0.7-1.9 ng/dL), and total triiodothyronine 144 ng/dL (ref. 60-181 ng/dL). Thyroid stimulating immunoglobulin was negative, and a thyroid ultrasound demonstrated multiple bilateral thyroid nodules with no evidence of increased vascularity of the gland. Serial thyroid function tests over several days revealed spontaneous biochemical improvement in the patient's T4-thyrotoxicosis that correlated with improved mentation. An exhaustive metabolic, infectious, and radiologic work-up yielded no alternative explanation for his initial change in mental status. By postoperative day 6, his cardiac dysrhythmia and altered mentation completely resolved, and the free T4 improved to 2.1 ng/dL, allowing for hospital discharge. His free T4 normalized a week later. Conclusion Our patient's postoperative course appears to have been driven by surgically induced thyroiditis. There are no current recommendations for routine postoperative screening for parathyroidectomy-induced thyroiditis, but biochemical testing should be considered if signs or symptoms of thyrotoxicosis such as unexplained altered mentation, cardiac dysrhythmias, and/or worsening hypercalcemia emerge. Doing so may allow for a rapid and cost-effective approach towards a unifying diagnosis. Bilateral cervical exploration is a known risk factor. Other possible risk factors include the presence of a multinodular goiter and significant intraoperative thyroid retraction, though further characterization of these is needed. Treatment is supportive, as cases typically self-resolve. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Cricotracheal Adenoid Cystic Carcinoma: Insights Into the Diagnosis and Management of an Uncommon Anatomic Variant

Adenoid cystic carcinoma (ACC) is the second most common malignant salivary gland tumor and accounts for 30% of minor salivary gland tumors. Its location in the larynx and trachea are rare.We present the case of a 45-year-old healthy male whoseMRI revealed a posterior endoluminal tumor that invaded the posteroinferior perichondrium of the cricoid lamina and displaced the hypopharynx and esophagus. A left-limited cervical surgical exploration and an intraluminal incisional biopsy through the tracheostomy space were performed by another surgical team. The pathological study reported an ACC, T4aN0M0, stage IVA tumor. Then, a circular tracheal resection and an excision of the inferior part of the posterior cricoid lamina were carried out. The macroscopic study showed a lesion, 3cm long, 2.2cm wide, and 1cm thick, located at the posterior wall of the cricoid cartilage and proximal trachea. Only the upper margin was compromised. Microscopically, the tumor showed tubular, solid, cribriform, and trabecular patterns. One and a half years after surgery, the patient still has bilateral vocal cord mobility and normal speech. It is clear that a contrast-enhanced CT scan is useful to assess tumor extent and growth pattern in these rare variants. Among treatment alternatives, surgery sometimes complemented with radiotherapy is essential; constant follow-up is mandatory.

Persistence and Recurrence of Hypercalcemia After Parathyroidectomy Over 5 Decades (1965-2010) in a Community-based Cohort.

There is limited long-term follow-up of patients undergoing parathyroidectomy. Recurrence is described as 4% to 10%. This study evaluated persistence and recurrence of hypercalcemia in primary hyperparathyroidism after parathyroidectomy. Single-institution retrospective (1965-2010) population-based cohort from Olmsted County (MN) of patients undergoing surgery for primary hyperparathyroidism. Patients' demographic data, preoperative and postoperative laboratory values, clinical characteristics, surgical treatment, and follow-up were noted. A total of 345 patients were identified, 75.7% female, and median age 58.4 years [interquartile range (IQR): 17.6]. In all, 68% of patients were asymptomatic and the most common symptoms were musculoskeletal complaints (28.4%) and nephrolithiasis (25.6%). Preoperative median serum calcium was 11mg/dL (IQR: 10.8-11.4mg/dL), and median parathyroid hormone was 90pg/mL (IQR: 61-169 pg/dL). Bilateral cervical exploration was performed in 38% and single gland resection in 79% of cases. Median postoperative serum calcium was 9.2mg/dL (IQR: 5.5-11.3). Nine percent of patients presented persistence of hypercalcemia, and recurrence was found in 14% of patients. Highest postoperative median serum calcium was 10mg/dL (IQR: 6-12.4), and median number of postoperative calcium measurements was 10 (IQR: 0-102). Postoperative hypercalcemia was identified in 37% of patient. Fifty-three percent were attributed to secondary causes, most commonly medications, 22%. Three percent of patients required treatment for postoperative hypercalcemia. Median time to recurrence and death were 12.2 and 16.7 years, respectively. Recurrent hypercalcemia after successful parathyroidectomy is higher than previously reported. Most cases are transient and often associated to other factors with only the minority requiring treatment. Long-term follow-up of serum calcium should be considered in patients after successful parathyroidectomy.

Laryngeal Radioanatomy

The larynx, a specialized segment of the airways, is the essential organ of phonation, breathing and protection of the lower airways when swallowing by a complex anatomic structures organized around a cartilaginous skeleton. We realized a prospective study on three months, ranging from March 01 to May 31 2020, of patients referred to our service for cervical CT scan or MRI exploration in different contextes. We retained the normal exams. For scanographic exploration we used a multi-slice CT scan consisting of 64 rows of detectors. Helical acquisition in native axial slices 0.627 mm thick from the base of the skull to the arch of the aorta was performed in indifferent breathing after asking the patient not to swallow. Iodinated contrast product was injected according to the administration protocol in a single bolus of 90 ml at an average flow rate of 1.5 ml / s and to perform the acquisition with 50 second delay. A dynamic phonation maneuver (saying “eee” continuously and evenly) was used to analyse the true and false vocal cords. On MRI exploration of the larynx, we used a high-field device (1.5Tesla) with a semi-circular specific surface antenna, the phase oriented in an anteroposterior direction, the 3DT1 spin echo sequence without fat signal saturation was performed. In ultrasound, we used literature data. Knowledge of laryngeal radioanatomy contributes to the diagnosis of laryngeal cancers which occupy an important place in all cancers of the upper aerodigestive tract. They can be diagnosed early and the refinement of their endoscopic exploration and imaging allows them to make a precise extension assessment.

Test Minimally Invasive Parathyroidectomy Under Local Cervical Block Anesthesia for Primary Hyperparathyroidism and Parathyroid Adenoma

With both improvement in preoperative parathyroid tumor identification and the use of intraoperative parathyroid hormone (PTH) assay, minimally invasive parathyroidectomy (MIP) is now performed more frequently in patients with primary hyperparathyroidism (pHPT) compared to both historically and to cervical exploration. Still, many institutions are not familiar with performing MIP under regional or local anesthesia. We present such an operation under local cervical block anesthesia.

3-Dimensional Fluid and White Matter Suppression Magnetic Resonance Imaging Sequence Accelerated With Compressed Sensing Improves Multiple Sclerosis Cervical Spinal Cord Lesion Detection Compared With Standard 2-Dimensional Imaging.

Fluid and white matter suppression (FLAWS) is a recently proposed magnetic resonance sequence derived from magnetization-prepared 2 rapid acquisition gradient-echo providing 2 coregistered datasets with white matter- and cerebrospinal fluid-suppressed signal, enabling synthetic imaging with amplified contrast. Although these features are high potential for brain multiple sclerosis (MS) imaging, spinal cord has never been evaluated with this sequence to date. The objective of this work was therefore to assess diagnostic performance and self-confidence provided by compressed-sensing (CS) 3-dimensional (3D) FLAWS for cervical MS lesion detection on a head scan that includes the cervical cord without changing standard procedures. Prospective 3 T scans (MS first diagnosis or follow-up) acquired between 2019 and 2020 were retrospectively analyzed. All patients underwent 3D CS-FLAWS (duration: 5 minutes 40 seconds), axial T 2 turbo spin echo covering cervical spine from cervicomedullary junction to the same inferior level as FLAWS, and sagittal cervical T 2 /short tau inversion recovery imaging. Two readers performed a 2-stage double-blind reading, followed by consensus reading. Wilcoxon tests were used to compare the number of detected spinal cord lesions and the reader's diagnostic self-confidence when using FLAWS versus the reference 2D T 2 -weighted imaging. Fifty-eight patients were included (mean age, 40 ± 13 years, 46 women, 7 ± 6 years mean disease duration). The CS-FLAWS detected significantly more lesions than the reference T 2 -weighted imaging (197 vs 152 detected lesions, P < 0.001), with a sensitivity of 98% (T 2 -weighted imaging sensitivity: 90%) after consensual reading. Considering the subgroup of patients who underwent sagittal T2 + short tau inversion recovery imaging (Magnetic Resonance Imaging for Multiple Sclerosis subgroup), +250% lesions were detected with FLAWS (63 vs 25 lesions detected, P < 0.001). Mean reading self-confidence was significantly better with CS-FLAWS (median, 5 [interquartile range, 1] [no doubt for diagnosis] vs 4 [interquartile range, 1] [high confidence]; P < 0.001). Imaging with CS-FLAWS provides an improved cervical spinal cord exploration for MS with increased self-confidence compared with conventional T 2 -weighted imaging, in a clinically acceptable time.

Simultaneous vestibular, orbital, meningeal and medullary involvement in a patient diagnosed with neurofibromatosis type 2

Neurofibromatosis Type 2 (NF2) is an autosomal dominant genetic disease characterized by the presence of bilateral vestibular schwannomas. We report the case of a 21-year-old patient, followed up for neurofibromatosis type 2, operated two times for right parietal and orbital meningioma that complained for headache and dizziness, referred to us for brain and cervical MRI exploration including 3D-FIESTA sequence. MRI completed by CT scan noted intraosseous and cerebral extra-axial meningiomas, bilatetal shwannomas and cervical epedymomas. Neurofibromatosis type 2 is a genetic disease with nervous system lesions and MRI is important for their exploration.

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

IntroductionRadical hysterectomy (RH) with bilateral pelvic lymph node dissection is the standard treatment for early stage cervical cancer which can be performed either by an abdominal or a minimally invasive (MIS) approach. In 2018, Ramirez et al. presented their randomized-controlled trial data which demonstrated that patients who were treated with minimally invasive surgical (MIS) radical hysterectomy (RH) had higher rates of locoregional disease recurrence and lower rates of overall survival when compared to patients treated with an abdominal approach. The objective of this study is to examine the trends in management of patients diagnosed with cervical cancer in New York State (NYS) and to analyze their perioperative outcomes. MethodsUsing the Statewide Planning and Research Cooperative System (SPARCS) Database, patients undergoing RH for early stage cervical cancer in NYS between the years of 2007–2015 were identified and categorized based on surgical approach. Demographic information was collected and multivariable regression was conducted to assess the impact of hysterectomy approach on perioperative outcomes. ResultsIn NYS, 5575 patients were treated with RH for early stage cervical cancer with 3257 (58.4%) treated by abdominal RH and 2318 (41.6%) treated with MIS RH. Between the years of 2007 and 2015, patients diagnosed with cervical cancer treated with MIS RH increased from 25.7% to 48.3% respectively. Surgeons performing MIS RH were more likely to be younger (average age 47.1 vs 49.2, p < 0.001) and have less time elapsed from their fellowship graduation (20.37 vs 22.64 years, p < 0.001). Patients who saw high volume doctors (OR 1.95, CI 1.65–2.31) and were seen in high volume facilities (OR 1.40, CI 1.18–1.65) were more likely to undergo MIS RH compared to abdominal RH. Patients who underwent MIS RH were more likely to be discharged home as opposed to acute rehab or nursing facility, when compared to patients treated with abdominal RH (98.5 vs 94.2% p < 0.001). When analyzing perioperativce outcomes, patient undergoing MIS RH had a 85% decrease in length of hospital stay compared to abdominal RH, a 40% reduction in 30-day readmission rates, and a 10% reduction in hospital costs respectively. DiscussionIn our study period, between the years of 2007 and 2015, the number of cervical cancer cases treated with MIS RH increased from 25.7% to 48.3%. MIS techniques led to a reduction in length of hospital stay, patient readmission rates, and hospital costs. Based on recent data from Ramirez et al., preliminary data demonstrated decrease in MIS RH for treatment of cervical cancer after presentation of the LACC trial and our data confirmed these reported trends in NYS. With this change in surgical practice, there will be associated changes in perioperative outcomes. Moreover, for patients diagnosed with cervical cancer with microscopic disease or previous treatment with an excisions procedure, MIS approach should be considered for improvement in perioperative outcomes as long as oncologic outcomes are not compromised.

Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.

Algorithm for Surgical Decision Making in Patients with Thoracic Outlet Syndrome

Purpose: Historically the classification of Thoracic Outlet Syndrome (TOS) has been based on symptoms rather than the underlying pathology. Therefore, TOS has been classified into Neurogenic (NTOS), Venous (VTOS or Paget Schroetter Syndrome) and Arterial (ATOS) subgroups. This classification has resulted in confusion among medical practitioners, difficulty in making the diagnosis, and the poor results with surgical intervention. Methods: The published papers from PubMed on the newer understanding of the pathogenesis and the surgical treatment of TOS were reviewed. Results: More recently TOS has been classified based on the underlying pathologic entity. Based on this classification, patients who are suspected of having TOS should be classified as having 1. Cervical Rib Disease (CRD), or 2. TOS as the result of “Subclavian Vein Compression Syndrome”. This classification has resulted in more accurate diagnosis, better patient selection for surgery, and excellent surgical results. This paper outlines the algorithm for making the appropriate diagnosis in patients who present with neurovascular symptoms of the upper extremity and the selection of the appropriate patients for surgery. Conclusion: Based on the algorithm for surgical decision making, patients with Cervical Rib Disease should undergo cervical exploration and resection of the pathologic entity which results in compression of the brachial plexus or the subclavian artery in the neck. Patients with Thoracic outlet Syndrome who are found to have extrinsic compression of the subclavian vein by a pathologic tubercle at the sternocostal joint on Multiphasic MRA should undergo robotic first rib resection.

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.

Completely Intrathyroidal Parathyroid Adenoma in a Patient with a Previously Failed Cervical Exploration

Completely Intrathyroidal Parathyroid Adenoma in a Patient with a Previously Failed Cervical Exploration

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.

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.

18F]fluoro-ethylcholine-PET Plus 4D-CT (FEC-PET-CT): A Break-Through Tool to Localize the "Negative" Parathyroid Adenoma. One Year Follow Up Results Involving 170 Patients.

Background: The diagnostic performance of [18F]fluoro-ethylcholine-PET-CT&4D-CT (FEC-PET&4D-CT) to identify parathyroid adenomas (PA) was analyzed when ultrasound (US) or MIBI-Scan (MS) failed to localize. Postsurgical one year follow-up data are presented. Methods: Patients in whom US and MS delivered either incongruent or entirely negative findings were subjected to FEC-PET&4D-CT and cases from July 2017 to June 2020 were analyzed, retrospectively. Cervical exploration with intraoperative PTH-monitoring (IO-PTH) was performed. Imaging results were correlated to intraoperative findings, and short term and one year postoperative follow-up data. Results: From July 2017 to June 2020 in 171 FEC-PET&4D-CTs 159 (92.9%) PAs were suggested. 147 patients already had surgery, FEC-PET&4D-CT accurately localized in 141; false neg. 4, false pos. 2, global sensitivity 0.97; accuracy 0.96, PPV 0.99. All of the 117 patients that already have completed their 12-month postoperative follow up had normal biochemical parameter, i.e., no signs of persisting disease. However, two cases may have a potential for recurrent disease, for a cure rate of at least 98.3%. Conclusion: FEC-PET&4D-CT shows unprecedented results regarding the accuracy localizing PAs. The one-year-follow-up data demonstrate a high cure rate. We, therefore, suggest FEC-PET-CT as the relevant diagnostic tool for the localization of PAs when US fails to localize PA, especially after previous surgery to the neck.

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.

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.

Management of deep neck infections from cervical esophageal perforation caused by foreign body: A case series study

PurposeEsophageal perforation caused by foreign body is common in Chinese medical institutions, and resultant deep neck infections (DNI) is quite different from typical DNI. The purpose of this article was to share our experience on management of this particular type of DNI. Material and methodsA retrospective review was conducted on a consecutive sample of such patients at Capital Medical University Beijing Friendship Hospital from 2015 to 2019. ResultsIn total, 24 cases were recorded. CT scan of the neck and upper thorax was the most useful tool for early diagnosis. Gas formation was not predictive of a worse clinical course. Eleven patients with minor DNI were treated with antibiotics and foreign body removal; while 13 patients with major DNI were treated with neck incision and drainage, ICU observation, and prolonged usage of antibiotics. Outcome was generally good, but major complications, including sepsis and lingual artery rupture, could occur. ConclusionsConservative management, focusing on prompt extraction of esophageal foreign body and adequate antibiotic coverage, can lead to good outcome for mild cases; while in addition to these measures, neck incision, cervical and superior mediastinal exploration, and high negative pressure drainage, should be performed for severe cases.

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

Objective: Radical hysterectomy with bilateral pelvic lymph node dissection is the standard treatment for early-stage cervical cancer. Until recently, in addition to the standard open approach, the procedure was frequently performed by a minimally invasive (MIS) approach. Randomized control trial data presented in 2018 demonstrated that patients who underwent MIS radical hysterectomy had higher rates of disease recurrence and worse overall survival when compared to open radical hysterectomy. The aim of this study was to examine practice trends in New York state.