Minimally Invasive Parathyroidectomy Research Articles

Is intraoperative parathyroid monitoring during minimally invasive parathyroidectomy still justified?

IntroductionPrimary hyperparathyroidism (PHPT) is the third most common endocrine disease. With parathyroidectomy, a cure rate of over 95% at initial surgery is reported. Localization of the abnormal parathyroid gland is critical for the operation to be successful. The aim of this study is to analyze data of patients with single gland disease (SGD) and positive concordant localization imaging undergoing minimally invasive parathyroidectomy (MIP) and intraoperative parathyroid hormone monitoring (IOPTH) to evaluate if IOPTH is still justified in patients with localized SGD.MethodsA retrospective database analysis of all minimally invasive operations with IOPTH for PHPT and positive concordant localization in ultrasound (US) and 99mTc-sestamibi scintigraphy (MIBI) between 2016-2021. When both US and MIBI were negative, patients underwent either choline or methionine PET-CT. The patients were also analyzed a second time without applying IOPTH.ResultsIn total, 198 patients were included in the study. The sensitivity of US, MIBI and PET-CT was 96%, 94% and 100%, respectively. Positive predictive value was 88%, 89% and 94% with US, MIBI and PET-CT, respectively. IOPTH was true positive in 185 (93.4%) patients. In 13 (6.6%) patients, no adequate IOPTH decline was observed after localizing and extirpating the assumed enlarged parathyroid gland. Without IOPTH, the cure rate decreased from 195 (98.5%) to 182 (92%) patients and the rate of persisting disease increased from 2 (1.0%) to 15 (7.5%) patients.ConclusionDiscontinuing IOPTH significantly increases the persistence rate by a factor of 7.5 in patients with concordantly localized adenoma. Therefore, IOPTH appears to remain necessary even for this group of patients.

Evaluation of Focused Mini-Incision Parathyroidectomy in Primary Hyperparathyroidism

Abstract Background In the era of effective preoperative localization and availability of intraoperative parathyroid hormone (IOPTH) assay, the trend now in parathyroidectomy is shifting from bilateral neck exploration (BNE) into minimal invasive parathyroidectomy (MIP). The concept of MIP is based on the fact that 85% of cases have single adenoma. This study highlights the outcomes of focused mini- incision parathyroidectomy (FMIP) for the treatment of selected cases of primary hyperparathyroidism. Aim of study: To evaluate and assess the outcome and advantages of focused mini-incision parathyroidectomy in parathyroid adenoma of primary hyperparathyroidism. Patients and Methods This cohort study was conducted at endocrine surgery unit, Ain Shams University Hospital, and Sohag Cancer Institute including 22 patients with benign solitary parathyroid adenoma; 17 retrospective cases & 5 prospective cases. These included patients had been operated with focused mini-incision parathyroidectomy within the time period from January 2018 to December 2020 as retrospective cases and from January 2021 to December 2021 as prospective cases. Results In this study, age ranged from 30 to 70 years with mean age 50.23 ± 10.71 years. The preoperative serum calcium level ranged from 10.8 to 14.2 mg/dl (mean 12.28 ± 1.16 mg/dl). The preoperative parathyroid hormone level was elevated ranging from 256 to 2090 pg/mL (mean 970.68 ± 563.97 pg/mL). In this study, the operative time ranged from 55 to 75 minutes with mean 64.36 ± 6.33 minutes, percentage of IOPTH decrease level ranged from 75-95 % with mean percentage 85.72 ± 6.28 %. There were no cases with intraoperative bleeding or recurrent laryngeal nerve (RLN) injury. Hospital stay ranged from 6-16 days with mean 10.77 ± 3.10 days. There is no wound infection in all cases. All cases reached a success rate up to 100% (decrease the IOPTH level ≥ 75 %, and resolution of preoperative hypercalcemic manifestations). Conclusion Depending to the high successful rate, very low intraoperative morbidity and better postoperative recovery and cosmoses of FMIP technique, it should be the first choice for pHPT cases with solitary parathyroid adenoma, provided by the concordance localization study of U/S and MIBI scan preoperative.

Utilizing radiomic features of arterial phase computed tomography for delineating parathyroid adenomas from surrounding anatomical structures

Aim: The study aimed to correlate radiomic data of four-dimensional computed tomography (4D-CT) with pathology-proven parathyroid adenomas to identify and quantitate select dimensional and textural features that predict parathyroid adenomas with a high degree of confidence, with the ultimate goal of improving the reliability of parathyroid adenoma detection so as to facilitate the subsequent unilateral minimally invasive parathyroidectomy (MIP). Methods: A total of 144 subjects with a history of neck 4D-CT, parathyroidectomy, and intraoperative pathology-proven parathyroid adenoma(s) were retrospectively reviewed. Following the exclusion of patients with a thyroidectomy, unsuccessful surgery, or indeterminate localization of the parathyroid adenoma on 4D-CT, a preliminary sample of 20 patients was obtained. Four anatomical structures (carotid artery, internal jugular vein, thyroid, and parathyroid adenoma) were segmented twice on 25-second arterial phase axial sections of a 4D-CT, and radiomic data of the shape, first-order, and second-order classes (106 variables) were extracted from the four structures for each patient. Results: Select radiomic variables among the carotid artery, jugular vein, and thyroid groups exhibited overall significant differences when compared to the parathyroid adenoma data (P < 0.05). Further Tukey’s post hoc analysis revealed that, when the parathyroid adenoma group was treated as the reference, 11/16 shape class, 16/18 first-order class, and 46/69 second-order class variables significantly differ from the carotid artery, jugular vein, and/or thyroid group(s). In addition, we found that the thyroid has distinct textural features compared to the parathyroid group, with 1/18 first-order and 19/69 second-order variables differing significantly between the two (P < 0.05). Notably, the texture variables such as dependence non-uniformity, long run emphasis, run percentage, run variance, and busyness exhibited the highest level of differences between the two groups (P < 0.0001). Conclusion: The parathyroid adenoma group is associated with a unique set of radiomic variables in comparison to surrounding anatomy such as the carotid artery, internal jugular vein, and thyroid. Relevance for Patients: The distinct, quantifiable differences in dimensional and textural features serve as a set of signature markers distinguishing parathyroid adenomas from their surrounding structures in 4D-CT. These attributes obviate the need for invasively locating parathyroid adenomas preoperatively, thereby enhancing the utilization rate of MIP, which has a favorable implication in the overall clinical outcomes.

Utility of 99mTc-Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT Single Imaging Strategy in the Preoperative Localization of Parathyroid Adenoma.

Background Primary hyperparathyroidism is an endocrinopathy associated with dysregulated calcium homeostasis. The most common etiology is a parathyroid adenoma most definitely managed via a parathyroidectomy. The two main surgical approaches include a minimally invasive parathyroidectomy (MIP) and open four-gland exploration (4-GE). MIP is the preferred operative strategy since it is associated with less postoperative complications. Accurate preoperative imaging is essential in informing the optimal approach to surgery. MIP is only considered if adenoma is able to be localized precisely. The most commonly used imaging modality includes ultrasound and sestamibi single-photon emission computed tomography (SPECT)/CT, either as a singleor combination strategy. Other options include MRI, PET, and 4D CT. There is no universally accepted preoperative imaging strategy. The literature is discordant and recommendations proposed by existing guidelines are incongruous. Objectives This study aimed to evaluate currently utilized preoperative parathyroid imaging modalities at our institution and correlate them with surgical and histological findings to determine the most efficient imaging strategy to detect adenomas for our patient cohort. This will ultimately guide the best surgical approach for patients receiving parathyroidectomies. Methods This is a retrospective observational study of all patients undergoing first-time surgery for biochemically proven primary hyperparathyroidism at our institution over the past five years. Multiple data points were collected including modality of preoperative disease localization, operation type, final histopathology, biochemical investigations, and cure rate. Patients were categorized into one of three groups based on the method of disease localization. Results A total of 244 patients had parathyroidectomies performed at our institution in the past five years from January 2018 to December 2022. Ninety-six percent (n=235) of all patients received dual imaging preoperatively with SPECT/CT and ultrasound performed on the same day and therefore included in this study. A total of 64.3% (n=151) underwent MIP. Eighty percent (n=188) of all histopathology revealed adenomas and 26.8% (n=63) of patients had adenoma localized on SPECT/CT only (sensitivity: 58.1%, specificity: 71%, and positive predictive value {PPV}: 85.7%). A total of 9.8% (n=23) had adenoma localized on ultrasound only (sensitivity: 15.6%, specificity: 73.3%, and PPV: 65.2%). A total of 45.1% (n=106) were dual localized on both SPECT/CT and ultrasound (sensitivity: 75.6%, specificity: 46.6%, and PPV: 84.9%). The cure rate was 91.5% in the dual-localized group, 86% in the dual-unlocalized group, and 96.5% when localized with SPECT/CT alone. Conclusion A dual-imaging modality with SPECT/CT and ultrasound should remain the first-line imaging strategy. This approach has higher sensitivity rates and poses no inherent patient or surgical-related risks. Patients with disease unlocalized on SPECT/CT alone had a positive predictive value, specificity, and likelihood ratio for adenoma detection comparable to dual-localized patients. Therefore, SPECT/CT alone is sufficient for directing MIP in the presence of a negative ultrasound.

Role of four-dimensional computer tomography (4D-CT) in non-localising and discordant first-line imaging in primary hyperparathyroidism.

Accurate preoperative localisation of parathyroid adenoma is imperative for the success of minimally invasive parathyroidectomy (MIP). Our study aimed to evaluate the role of four-dimensional computer tomography (4D-CT) scan as an imaging modality in patients with failed and discordant localisation reported in the first-line imaging modalities (ultrasonography and 99mTc-MIBI-SPECT/CT). This is a prospective cohort study performed at a university teaching centre from March 2013 to July 2021. All patients with primary hyperparathyroidism who had failed localisation by ultrasonography and 99mTc-MIBI-SPECT/CT (SpCT), or discordance between them, had 4D-CT performed in this study. One hundred and two sporadic cases of pHPT with failed/discordant first-line imaging had 4D-CT imaging prior to parathyroidectomy. In 102 patients, 105 parathyroid adenomas were reported on histopathology. 4D-CT was able to localise 78% of them to the correct side and 64% to the correct quadrant in 102 patients, as compared with US (correct side 21%, correct quadrant 16%) and 99mTc-MIBI-SPECT/CT (correct side 36%, correct quadrant 31%). 4D-CT had a sensitivity, precision, accuracy and F1 score for correct quadrant localisation as 79%, 81%, 66% and 80%; and for correct side localisation as 82%, 98%, 80% and 89%, respectively. 4D-CT was able to identify three ectopic adenomas (two in superior mediastinum and one in the oesophageal wall) which were not detected on US or SpCT. 4D-CT was found to be sensitive and accurate in preoperative localising of the diseased parathyroid glands after failed/discordant US and SpCT. This led to more patients being offered MIP as the primary surgery and improved operative outcomes.

Results of a prospective strategy for focused Minimally Invasive Parathyroidectomy (MIP)

Neck exploration for primary HPT is the standard operation in which 4 parathyroid glands are identified and one abnormal parathyroid gland is removed. This is recommended for all patients with primary HPT. We hypothesized that most patients with primary HPT have a single abnormal parathyroid gland (adenoma) and parathyroid imaging studies will identify it and support a focused minimally invasive parathyroidectomy (MIP). This can be combined with ioPTH monitoring making bilateral exploration unnecessary. This paper reports a 93.4% success rate in 249 consecutive prospective patients with primary HPT over a 15-year period with a short operating time and few complications. The findings suggest that this alternate surgical MIP approach should be the procedure of choice for HPT patients.

18F-fluorocholine PET/MRI versus ultrasound and sestamibi for the localization of parathyroid adenomas.

Accurate preoperative localization is imperative to facilitate a minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (pHPT). This study aims to compare the diagnostic value of standard-of-care localization techniques (ultrasound [US] and 99mTechnetium (99mTc) -sestamibi scintigraphy) to [F-18]-fluorocholine positron emission tomography/magnetic resonance imaging (FCH-PET/MRI) to determine the additional clinical usefulness of PET/MRI in a Canadian cohort. We conducted a prospective, appropriately powered, study to compare the diagnostic value of -FCH PET/MRI to that of the US and 99mTc-sestamibi scintigraphy for localization of parathyroid adenomas in a patient with pHPT. The primary outcome was the per-lesion sensitivity and positive predictive value (PPV) of FCH-PET/MRI, US, and 99mTc-sestamibi scintigraphy. Intraoperative surgeon localization, parathormone levels, and histopathological findings were used as reference standards. Forty-one patients underwent FCH-PET/MRI of which 36 patients had parathyroidectomy. In these 36 patients, 41 parathyroid lesions were histologically confirmed as adenomas or hyperplastic glands. Per-lesion sensitivity of FCH-PET/MRI was 82.9% and of US and 99mTc-sestamibi scintigraphy combined at 50.0%, respectively. The sensitivity of FCH-PET/MRI was superior to that of US and 99mTc-sestamibi scintigraphy (p = 0.002). In the 19 patients in whom both US and 99mTc-sestamibi scintigraphy were negative, PET/MRI correctly identified the parathyroid adenoma in 13 patients (68%). FCH-PET/MRI is a highly accurate imaging modality for localization of parathyroid adenomas in a tertiary center in North America. It is a superior functional imaging modality to 99mTc-sestamibi scintigraphy alone and more sensitive for localization of parathyroid lesions than US and 99mTc-sestamibi scintigraphy combined. This imaging modality could become the most valuable preoperative localization study given its superior performance in localizing parathyroid adenomas.

Dual-tracer 99mTc-sestamibi/ 123I imaging in primary hyperparathyroidism.

Surgery is the only curative treatment for primary hyperparathyroidism (PHPT). Preoperative imaging is always recommended. 99mTc-sestamibi scintigraphy is often used in combination with neck ultrasonography as first-line imaging. 99mTc-sestamibi scintigraphy plays a major role in depicting ectopic parathyroid lesions, as well as in guiding a targeted, minimally invasive parathyroidectomy (MIP). Detecting multiple gland disease (MGD) is important to reduce the risks of surgical failure or unplanned conversion to bilateral surgery. However, the ability to recognize MGD varies greatly depending on the 99mTc-sestamibi imaging protocol that is used. Dual-tracer 99mTc-sestamibi/123I highly improves MGD detection compared to single-tracer "dual-phase" 99mTc-sestamibi imaging. It can thus improve patient selection for MIP. The main requirements for successful dual-tracer imaging are: 1) to acquire 99mTc-sestamibi and 123-iodine images simultaneously, thus avoiding motion artifacts on subtraction images; to use neck pinhole imaging, in addition to planar imaging, to improve resolution and MGD detection; to follow with dual-tracer SPECT/CT imaging to better define anatomic position of detected parathyroid lesions. If dual-tracer 99mTc-sestamibi/123I and neck ultrasonography are negative or inconclusive, the second-line imaging in our practice is 18F-fluorocholine PET/CT. The CT component of 18F-fluorocholine PET/CT is performed as non-enhanced acquisition plus a contrast-enhanced arterial phase acquisition, to minimize the risk from false-positives due to choline uptake in inflammatory lymph nodes. We use the same strategy of first-line dual-tracer 99mTc-sestamibi/123I plus neck ultrasonography, followed if necessary by second-line contrast-enhanced 18F-fluorocholine PET/CT, in patients requiring reoperation for persistent or recurrent PHPT. Additional localization techniques are now rarely necessary.

Comparison of 4D computed tomography and F-18 fluorocholine PET for localisation of parathyroid lesions in primary hyperparathyroidism: A systematic review and meta-analysis.

Minimally invasive parathyroidectomy (MIP) is the standard of care for primary hyperparathyroidism (PHPT). Four dimensional computed tomography(4DCT) and F-18 Fluorocholine positron emission tomography/computed tomography (FCH PET/CT) localize adenomas accurately to perform MIP. We aimed to conduct a systematic review and metanalysis to evaluate the diagnostic performance of 4DCT and FCH PET/CT scan for quadrant wise localisation in PHPT patients and to do head-to-head comparison between these two modalities. DESIGN, PATIENTS AND MEASUREMENT: After searching through PubMed and EMBASE databases, 46 studies (using histology as a gold standard) of 4DCT and FCH PET/CT were included. RESULTS: Total number of patients included were 1651 and 952 for 4DCT scan (studies n = 26) and FCH PET/CT scan (studies n = 24) respectively. In per patient analysis, FCH PET/CT and 4DCT had pooled sensitivities of 92% (88-94) and 85% (73-92) respectively and in per lesion analysis, 90% (86-93) and 79% (71-84), respectively. In the subgroup with negative conventional imaging/persistent PHPT, FCH PET/CT had comparable sensitivity to 4DCT (84% [74-90] vs. 72% [46-88]). As per patient wise analysis, FCH PET/CT had better detection rates than 4DCT ([92.4 vs. 76.85], odds ratio -3.89 [1.6-9.36] p = .0024) in the subpopulation where both FCH PET/CT and 4DCT were reported. CONCLUSION: Both 4DCT and FCH PET/CT scan performed well in newly diagnosed patients, patients with persistent disease and in those with inconclusive conventional imaging results. FCH PET/CT scan had a higher pooled sensitivity than 4DCT in detecting patients with PHPT in head to head comparison.

The Accuracy of Pre-Operative Ultrasonography in Localizing Parathyroid Adenoma for Minimally Invasive Parathyroidectomy (MIP)

OBJECTIVES To determine the sensitivity of pre-op ultrasonography in localizing parathyroid adenoma for minimally invasive parathyroidectomy (MIP) technique. METHODOLOGY The study was conducted at the department of ENT and Head & Neck Surgery, MTI Hayatabad Medical Complex Peshawar. It included a retrospective analysis of records of patients who underwent MIP from Jan 1, 2019, to July 31, 2022. All patients had pre-operative meta-iodobenzylguanidine (MIBG) scans, and serum PTH, Serum calcium levels were determined. A pre-op ultrasound scan was acquired to mark the site of the parathyroid adenoma. MIP was carried out using a 3.5 to 4 cm transverse skin incision over the marked site to expose the thyroid gland. If the marked parathyroid gland was identified without using any other aids, the result was labelled as "True positive". The sensitivity of pre-op ultrasonography was calculated using SPSS v 26.0. RESULTS A total of 53 cases were included in the study. The male: female ratio was 1:1.8. The ages of patients ranged from 23-70 years with a mean age of 48.49 years with a standard deviation of +_ 10.818. Pre-op ultrasonography accurately localizes the site of parathyroid adenoma in 49 patients. Statistical analysis showed this to be a significant finding. CONCLUSION Pre-op ultrasonography is significantly helpful in localizing the parathyroid adenoma. Therefore its routine use is recommended to help localize the adenoma in minimally invasive parathyroidectomy.

The Role of 4D-CT for Pre-Operative Localization in Patients with Primary Hyperparathyroidism with Negative Ultrasonography and/or Sestamibi SPECT/CT.

The major cause of primary hyperparathyroidism (pHPT) is parathyroid adenoma. Today, minimally invasive parathyroidectomy (MIP) has become the standard treatment for patients in whom the pathological gland can be localized with pre-operative imaging methods. In this study, we aimed to evaluate the role of 4D-CT in pre-operative localization in patients with pHPT who are negative for ultrasonography (USG) and/or sestamibi single-photon emission computed tomography/CT (SPECT/CT) and will undergo primary surgery. Patients whom were operated between 2018 and 2023 were included to this study. 4D-CT results of patients with one- or two-negative USG and SPECT/CT results were evaluated retrospectively. In this study, 19 patients (5 men and 14 women) with a mean age of 57.1±8.5 years were evaluated. Pathology results were consistent with parathyroid adenoma in 18 patients (94.7%) and parathyroid hyperplasia in 1 patient (5.3%). USG was negative in six patients, SPECT/CT was negative in 14 patients, and both were negative in four patients. In 4D-CT, positive images were detected in 15 patients and these results were finalized as true positive in 14 patients and false positive in 1 patient. The sensitivity of 4D-CT was 82.4% (95% CI: 60.4-95.3%), positive predictive value was 93.3% (95% CI: 73.8-99.6%), accuracy was 78.9%, and localization rate was 73.7%. In 14 (73.7%) patients, the pathological glands were removed by MIP. In approximately 75% of patients with negative USG and/or SPECT/CT, the pathological gland can be localized with 4D-CT and MIP can be applied in these patients.

Minimally Invasive Parathyroidectomy as the Surgical Management of Single Parathyroid Adenomas: A Tertiary Care Experience.

The aim of our study is to assess the feasibility, safety and adequacy of focused parathyroidectomy for single parathyroid adenoma accurately localized preoperatively by ultrasound neck and Tc99m sestamibi scan. The study was conducted in the department of Otorhinolaryngology of SMS Medical College and Hospital, Jaipur on 116 patients of primary hyperparathyroidism who underwent minimally invasive parathyroidectomy (MIP) for single gland adenoma localized by USG neck and tc99m sestamibi scans. S. Calcium and S. PTH followed up on day 1, 6th week and 6th month. Outcomes were determined on the basis of cure rate, duration of hospitalization, complication rates and disease persistence/recurrence rate. 82 (70.68%) females and 34 (29.31%) males belonging to the age group of 21-67years (43.02 ± 14) formed the basis of our study. Skeletal (73.27%) and renal (62.93%) were the most common presentations. Accuracy of USG and sestamibi accurately was 93.10% and 96.55% respectively with combined accuracy of 100%. Preoperative serum calcium levels of 10.7-16.03mg/dl (13.09 ± 2.11) and serum PTH 127-2196pg/ml (846.57 ± 776.55) were observed. Cure rate of MIP was 99.13%. No permanent complications seen. MIP can be used as the surgical procedure of choice for PHPT caused by single gland adenoma aided by USG and sestamibi scan. The cure rates are equivalent to the bilateral neck exploration (> 95%) with minimal morbidity and complications. Hence, it is a more feasible, safe and effective treatment option.

Contribution of intraoperative parathyroid hormone monitoring to the surgical success in minimal invasive parathyroidectomy.

BackgroundThe contribution of intraoperative parathyroid hormone monitoring to minimally invasive parathyroidectomy remains controversial. We aimed to evaluate whether intraoperative parathyroid hormone monitoring monitoring could contribute to minimally invasive parathyroidectomy in these patients.MethodsThe data of the patients whose preoperative ultrasonography and technetium-99 m sestamibi scintigraphy imagings were positive and concordant for one gland and who underwent minimally invasive parathyroidectomy between 2003 and 2018 in our clinic, were evaluated retrospectively. Blood samples were collected at pre-excisional period, and at post-excisional 10 and 20 min; the intaoperative parathyroid hormone was measured, and the surgery was terminated without waiting for the result. Patients were divided into 2 groups according to the postoperative results, as those with normocalcemia (Group 1) and those with persistence (Group 2).ResultsThere were 195 patients in Group 1 and 14 patients in Group 2. The cure rate at the first surgery was 93.3%. Cure was achieved after the second operation in all patients in Group 2. Recurrent disease developed in 1 patient in group 1 and the overall cure rate was 99.5%. If intraoperative parathyroid hormone had been evaluated, cure could have been achieved at the first surgery with additional exploration, in 10 (71.4%) of 14 patients according to the insufficient decrease in parathyroid hormone value at the 10 min in Group 2, and in 9 (64.3%) of 14 patients according to the parathyroid hormone value at 20 min. However, due to insufficient decrease (false negative) in the parathyroid hormone value at the 10 and 20 min the rate of false negatives and unnecessary exploration would be 9.5% and 2.5%, respectively. With additional exploration, the cure rate in the first surgery could be increased by 4.3%–97.6% according to the 20 min intraoperative parathyroid hormone value.ConclusionThe cure rate in minimally invasive parathyroidectomy can be increased by minimizing unnecessary conversion to bilateral neck exploration, by evaluating intraoperative parathyroid hormone at 10 min in patients with positive and concordant scans, and intraoperative parathyroid hormone at 20 min in patients with inadequate decrease at 10 min intraoperative parathyroid hormone.

Diagnostic Rechallenge with 18F-FCH PET/CT Often Allows Minimally Invasive Parathyroidectomy While Maintaining Exceptional Cure Rates.

Minimally invasive parathyroidectomy(MIP) has gained acceptance as thepreferred surgical procedure for management of primary hyperparathyroidism (pHPT). Appropriate selection of patients for a MIP is a crucial step in its utilization. The aim of the study was to evaluate the role of 18F-FCH PET/CT as second-line imaging for accurately directing MIP. This is a retrospective single-center study. Seventy-two patients with biochemical evidence of pHPT and a non-conclusive or negative first-line imaging (ultrasound and dual isotope subtraction scintigraphy) received 18F-FCH PET/CT between January 2018 and February 2020. All imaging studies were performed at our institution. Assessment of therapeutic changes and outcomes was performed. of the 72 patients imaged with 18F-FCH PET/CT, 54 subsequently underwent parathyroidectomy. When considering the ability of 18F-FCH PET/CT alone to predict a uniglandular disease, the sensitivity, specificity, PPV and NPV were 92.7% (95%CI: 80.1-98.5), 46.2% (19.2-74.9), PPV 87.3% (80.5-92) and NPV 61.2% (31.4-84.5), respectively. When we combined the data provided by 18F-FCH PET/CT with the data already collected from 1st line imaging we were able to complete a minimally invasive surgery in 38 of the 41 (92%) patients with a uniglandular disease. Thirteen patients (24%) had a multiglandular disease, all of them except one underwent bilateral neck exploration based on the data collected by all imaging modalities combined. Overall, cure was achieved in 53 (98%) patients. 18F-FCH PET/CT, interpreted along with first-line imaging results in selected patients, can better facilitate utilization of MIS while maintaining exceptional cure rates.

Factors associated with the degree of 99mTc-MIBI accumulation in parathyroid glands neoplasms during planar scintigraphy and SPECT/CT in primary hyperparathyroidism

Background: Primary hyperparathyroidism (PHPT) is the third most common endocrine disease, after diabetes mellitus and thyroid gland disorders. Surgical removal of the hyperfunctioning parathyroid glands is the only radical treatment. Various methods of preoperative imaging and intraoperative navigation are developed. Planar scintigraphy with 99mTc-MIBI is used for visualization and it is the most frequently performed radionuclide study in PHPT, while it has a relatively low sensitivity and specificity. SPECT/CT can reduce false-negative and false-positive results, and combines the advantages of radionuclide diagnostic methods and computed tomography. However, the factors that prevent the accumulation of 99mTc-MIBI in patients with PHPT are not clear enough.
 Aim: To identify the factors associated with the degree of accumulation (uptake rate) of 99mTc-MIBI in the parathyroid glands during planar scintigraphy and SPECT/CT.
 Materials and methods: The cross-sectional comparative study included 186 patients with PHPT who underwent planar scintigraphy and SPECT/CT for topical diagnosis of parathyroid glands and minimally invasive parathyroidectomy (MIP) followed by histological and immunohistochemical examination of parathyroid glands. The patients were divided into 3 groups depending on the accumulation of 99mTc-MIBI. The accumulation of 99mTc-MIBI was assessed by the expert as low-, moderate-, and high-intensity.
 Results: The association between the volume of the parathyroid glands on ultrasound and the intensity of the capture of the radiopharmaceutical was revealed, and 80% of low uptake is observed if volume is less than 0,215 cm3 (it corresponds to the linear size of the parathyroid gland 5 mm). Next factor that complicate the interpretation of the results of planar scintigraphy and SPECT/CT in patients with PHPT is thyroid diseases. The associations of the level of PTH, calcium in the blood, the localization and cellular composition of the parathyroid glands, the index of proliferative activity (Ki67), the expression of PTH, P-glycoprotein, cyclin D1 in the PTG tissue with the intensity of 99mTc-MIBI accumulation were not found.
 Conclusions: The main factor that positively associates with the degree of 99mTc-MIBI accumulation with planar scintigraphy and SPECT / CT is the volume of the parathyroid glands according to ultrasound data. Comorbidity of the thyroid gland has tendency to be associated with a negative result of radionuclide diagnostics, thus based on the ultrasound data of the thyroid and parathyroid glands it is possible to choose the second preferable method of imaging (SPECT/CT or contrast enhanced CT).

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.

Long-term Cure of Primary Hyperparathyroidism After Scan-Directed Parathyroidectomy: Outcomes From A UK Endocrine Surgery Unit.

Two-decades ago, the advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP) in most surgical centres. More recently, concerns have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism in 2020s. A departmental database was used to identify patients who had MIP after concordant dual localisation with sestamibi scintigraphy and ultrasound scans. Long-term follow-up data were obtained from electronic patient records to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded from analysis. Between June 2001 and August 2014 a total of 404 patients (108M:296F, median age 63years, range 17-90years) underwent MIP and had normalisation of calcium in first 6weeks after the operation. Information on electronic patient records were missing in 14 patients; therefore, data on 390 patients were analysed. During median follow-up of 78months (IQR: 21.25-111.75months), 375 patients had normocalcaemia (2.36mmol/L, IQR: 2.29-2.44mmol/L) at a median 75months, (IQR: 20-118months) after their operation. Overall, 15 (3.85%) patients had biochemical evidence of recurrent disease (2.70mmol/L IQR: 2.63-2.75mmol/L) at 92months (Range: 6-196) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure. Recurrence after scan-directed unilateral neck exploration occurred in 4% of patients after a long disease-free interval. Only one patient had recurrent disease within 1-year of primary surgery. The data suggest that bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to have uncovered multi-gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.

Minimally Invasive Parathyroidectomy: Can Intraoperative Parathyroid Hormone Monitoring be Omitted?

Intraoperative PTH (ioPTH) monitoring has become widely accepted in the era of minimally invasive parathyroidectomy (MIP). The purpose of this study was to evaluate the need for ioPTH during parathyroidectomy in patients with positive preoperative imaging. The charts of patients who underwent parathyroidectomy at three tertiary centers between the years 2012 and 2021 were retrospectively reviewed. Patients were defined as MIP candidates with either concordant preoperative imaging or a single positive imaging. Patients with negative or discordant imaging, concomitant thyroidectomy, or previous neck surgery were excluded. Of a total of 1013 patients who underwent parathyroidectomy, 535 (52.8%) were defined as MIP candidates and were included in the statistical analysis. Surgical success was achieved in all patients. A single adenoma that corresponded to the preoperative imaging was identified and resected in 517 (93.8%) patients. In only 18 (3.3%) patients, the ioPTH correctly changed the operative management where additional pathologic glands were identified and excised. Patients with additional lesions were significantly more likely to have decreased index adenoma size as indicated either by preoperative imaging or by intraoperative findings (15.5 ± 6.6 vs. 8.3 ± 2.5mm, p < 0.001). None of the patients with an adenoma size greater than 13mm had an additional pathologic gland. Our findings suggest that the routine use of ioPTH in MIP candidates may be omitted in patients with an index adenoma greater than 13mm, even with only a single positive preoperative imaging study, without compromising surgical success.

Shifting from open to video-assisted parathyroidectomy: effect of the adjustment period on safety, clinical outcomes and cost.

Bilateral neck exploration (BNE) has been the gold standard for the treatment of primary hyperparathyroidism (PHPT). Minimally invasive parathyroidectomy (MIP) has emerged as an alternative procedure for localised solitary adenomas. The most popular MIP techniques are the open MIP (OMIP) and the minimally invasive video-assisted parathyroidectomy (MIVAP). This study aims to assess whether we achieved a smooth transition from OMIP to MIVAP without compromising the results or increasing the cost. A parathyroid adenoma was successfully localised preoperatively in 77/86 patients with PHPT. MIP was contraindicated in 27/86 cases. For MIVAP, a 5mm, 30 degree camera was employed, along with special instruments. Median preoperative parathyroid hormone (PTH) level was 145.9pg/dl (59-2,151) and median calcium (Ca) was 10.8mg/dl (9.3-19). Comparing MIVAP (N=31) with OMIP (N=28), there was no significant difference in the age, sex, location of the adenoma, preoperative PTH and Ca levels as well as in all the other factors compared, apart from the size of adenomas, which were bigger in the OMIP group (1.85cm vs 1.4cm, p=0.032). Moreover, cure rates, operating time, hospital stay and rates of postoperative normocalcaemia were similar between the two groups. Despite the learning curve, MIVAP was not found to be inferior to OMIP for localised adenomas. The final cost was no higher for MIVAP than OMIP with the use of common reusable instruments. This, along with surgeons' experience in parathyroid and endoscopic surgery facilitates a smooth and cost-effective transition from OMIP to MIVAP.

Long-term cure of primary hyperparathyroidism after scan directed parathyroidectomy

Abstract Background The advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP). Recently, doubts have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism. Methods A departmental database was used to identify patients who had MIP after concordant dual localisation. Long-term follow-up data was obtained to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded. Results Between June 2001 – August 2014 a total of 404 patients (108M:296F, median age 63 years, range 17–90 years) underwent MIP and had normalisation of calcium in first 6 weeks after the operation. Data were missing in 14 patients therefore data on 390 patients was analysed. During follow-up, 375 patients remained normocalcaemic (2.36mmol/L IQR: 2.29–2.44 mmol/L) at a median 75 months (IQR: 20–118months). Only 15 (3.85%) patients had biochemical evidence of recurrent hypercalcaemia (2.70mmol/L, IQR: 2.63–2.75 mmol/L) at 92 months (IQR: 6–196 months) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure. Conclusion Recurrence after scan-directed unilateral neck exploration occurred in 4% of patients after a long disease-free interval. Only one patient had recurrent disease within 1 year of primary surgery. Bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to had uncovered multi-gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.