Parathyroid Pathology Research Articles

Papillary thyroid carcinoma coexisting with benign thyroid and parathyroid pathology: clinical and pathomorphological features

Background. Papillary thyroid carcinoma (PTC) is the most frequent malignant neoplasm originating from follicular cells of thyroid gland. PTC is often coexisting with other benign thyroid pathology such as chronic lymphocytic thyroiditis, follicular thyroid adenoma, toxic thyroid adenoma, Graves’ disease, non-toxic multinodular goiter. PTC can be diagnosed in patients undergoing surgical treatment for hyperparathyroidism. However, the clinical and pathomorphological features of PTC in the presence of other benign thyroid or parathyroid pathology, as well as possible differences in surgical tactics, remain relevant as evidenced by previously published reports. The purpose of the study is to assess the prevalence and determine the differences in the clinical and pathomorphological parameters of PTC in the presence of benign thyroid and parathyroid pathology. Materials and methods. There were identified 91 patients with PTC, who underwent surgical treatment at the clinical bases of the Department of Surgery of the NSC “Institute of Biology and Medicine” of Taras Shevchenko National University of Kyiv. Results. In the studied PTC cohort, 31 (35 %) patients were without coexisted benign thyroid pathology and 60 (35 %) patients had it (PTC/coexisted). A statistically significantly higher number of mitoses per 10 high power fields in the PTC group were identified in 3 (10 %) patients, as compared to the absence of this pathohistological parameter in the PTC/coexisted (p = 0.037). Further analysis of these 3 cases showed that 4 mitotic figures were found in one PTC, and one mitotic figure in the other two cases per 10 high power fields (400×). Conclusions. Papillary thyroid carcinoma in patients with other benign thyroid pathology is associated with lower biological aggressiveness than PTC without comorbidity as evidenced by a lower frequency of mitotic figures per 10 high power fields. The presence of concomitant benign thyroid pathology can be considered as a favorable prognostic factor for patients with PTC.

Surgery for Sporadic Primary Hyperparathyroidism: Evolution over the Last Twenty Years in a Monocentric Setting.

The sporadic parathyroid pathology of surgical interest is primarily limited to lesions that are the cause of hormonal hyperfunction (primary hyperparathyroidism). In recent years, parathyroid surgery has evolved significantly, and numerous minimally invasive parathyroidectomy techniques have been developed. In this study, we describe a single-center and well-documented case series of sporadic primary hyperparathyroidism, surgically treated by a single operator in the Endocrine Surgery Unit of the Surgical Clinic of the University of Florence-Careggi University Hospital, recorded and updated in a dedicated database that embraces the entire evolutionary timeframe of parathyroid surgery. From January 2000 to May 2020, 504 patients with a clinical and instrumental diagnosis of hyperparathyroidism were included in the study. The patients were divided into two groups, based on the application of intraoperative parathyroid hormone (ioPTH). The analysis shows that the use of ioPTH with the rapid method could be ineffective in helping surgeons in primary operations, especially when ultrasound and scintiscan are concordant. The advantages obtained by not using intraoperative PTH are not only economic. In fact, our data shows shorter operating and general anesthesia times and hospital stays, having an important impact on patient biological commitment. Furthermore, the significant reduction in operating time makes it possible to almost triple the volume of activity in the same unit of time available, with an undeniable advantage for the reduction of waiting lists. In recent years, minimally invasive approaches have allowed surgeons to reach the best compromise between invasiveness and aesthetic results.

Evaluation of Surgeon-Performed Ultrasonography With or Without Contrast Enhancement vs Scintigraphy in Patients With Primary Hyperparathyroidism

Scintigraphy and ultrasonography are common imaging modalities for the preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism. When comparing the 2 modalities, the benefits of ultrasonography in terms of convenience, patient comfort, duration, cost, and lack of radiation should be taken into account. To investigate whether surgeon-performed ultrasonography, with or without contrast-enhanced ultrasonography (CEUS), is noninferior to scintigraphy for localizing pathological parathyroid glands in patients with primary hyperparathyroidism. Prospective, paired, noninferiority cohort study performed at a high-volume tertiary referral center for parathyroidectomy with blinded examiners and a 6-month follow-up. Participants were adults (age ≥18 years) referred for parathyroidectomy due to primary hyperparathyroidism. Of 207 eligible patients, 35 were excluded, leaving 172 enrolled in the study. Inclusion lasted from September 2019 until February 2021. Follow-up ended in December 2021. 99mTechnetium-pertechnetate/99mtechnetium-sestamibi subtraction scintigraphy with 99mtechnetium-sestamibi single-photon emission computed tomography/computed tomography, followed by surgeon-performed ultrasonography and CEUS. The sensitivity of each imaging modality in localizing pathological parathyroid glands, calculated on a per-quadrant and a per-patient basis, respectively. The a priori noninferiority margin was a lower 95% confidence limit for the difference in sensitivity not falling below -10%. Out of 172 participants, 139 (80.8%) were women, the median (range) age was 65 (24-87) years, and the median (IQR) follow-up was 200.5 (181-280.25) days. Quadrant sensitivity (95% CI) was 70.9% (63.2%-78.5%) for ultrasonography, 68.4% (60.4%-76.5%) for ultrasonography plus CEUS, and 67.0% (60.0%-74.0%) for scintigraphy. The sensitivity difference (95% CI) compared with scintigraphy was 3.9% (-4.1% to 11.8%) for ultrasonography and 1.5% (-6.4% to 9.3%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Per-patient sensitivity was 81.4% (74.8%-86.9%) for ultrasonography and 79.1% (72.2%-84.9%) for both scintigraphy and ultrasonography plus CEUS. The sensitivity difference compared with scintigraphy was 2.3% (-6.8% to 11.4%) for ultrasonography and 0.0% (-9.1% to 9.1%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. In this cohort study, conventional ultrasonography by an experienced parathyroid surgeon-sonographer was noninferior to scintigraphy and may constitute a valid first-line imaging modality in patients with primary hyperparathyroidism, even without the addition of CEUS. Further imaging should be reserved for cases that are equivocal or nonlocalizing on ultrasonography.

Surgical treatment of hyperparathyroidism with a pathologically changed parathyroid gland found in the mediastinum.

The most common indication for surgical treatment of parathyroid gland pathology is primary hyperparathyroidism where extirpation of the pathologically changed parathyroid gland is the first-choice treatment. Embryonic development of the lower pair of parathyroid glands is quite complex and is closely related to the tissue of the thymus; for this reason it is not uncommon for a parathyroid adenoma to be located in the mediastinum or directly in the tissue of the thymus. The treatment of primary hyperparathyroidism is becoming a multidisciplinary issue in which radiodiagnostics and nuclear medicine methods play a significant role as they are needed to accurately localize the affected gland and to plan an adequate surgery. In case of intrathoracic localization of parathyroid adenoma, the therapy belongs in the hands of thoracic surgery. At our department, the endocrine surgery program, including parathyroid gland surgery, has a long tradition, and complicated patients are concentrated here, often patients with refractory hyperparathyroidism after a previous procedure. In the last 10 years, almost 2,300 procedures for parathyroid pathology have been performed at the IIIrd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital in Motol, of which some pathologies with mediastinal localization were managed using minimally invasive methods, i.e. videothoracoscopy or robotic-assisted surgery.

The Relationship of Negative Imaging Result and Surgical Success Rate in Primary Hyperparathyroidism.

In present, the effect of pre-operative negative imaging results on surgical outcomes of primary hyperparathyroidism (pHPT) is still controversial. In this study, we aimed to evaluate the effect of pre-operative imaging on surgical outcomes. The data of pHPT patients who were operated between 2009 and 2018 were evaluated retrospectively. Patients were divided three groups according to scintigraphy and/or ultrasonography results: Group 1; both imaging positive, Group 2; single imaging positive, and Group 3; patients in whom both imaging modalities are negative. Pre-operative biochemical characteristics, parathyroid pathologies, diameter and volume of the pathological gland, surgery rates, persistence, and recurrent disease rates of the groups were compared. Of 311 patients (258F, 53M) with a mean follow-up period of 24.7±18 months and a mean age of 54.1±12.9 years; 161 were in Group 1, 111 were in Group 2, and 39 were in Group 3. The diameter of pathological gland (2.1±0.8, 1.6±0.9, 1.5±0.7 cm; p<0.001; in Group 1,2,3 respectively) and the volume of pathological gland (2±3.2, 1.4±2.9, 1.1±2.2 cm3; p<0.001; in Group 1,2,3, respectively) in Group 1; the rate of multi gland disease (5.7%, 11%, 21%; p=0.024; in Group 1, 2, 3, respectively) in Group 3 were significantly higher. In the 1, 2, 3 group; bilateral exploration rates were 93.2%, 48.6%, and 5.1%, and focused surgery or unilateral exploration rates were 6.8%, 51.4%, and 94.9%, respectively, with a significant difference (p<0.001). After the first surgery, the cure rate was 91.3%, 93.7%, and 89.7%, and the persistent patient rate was 7.5%, 3.6%, and 10.3% in Groups 1,2,3, respectively, and there was no significant difference. At the end of the follow-up period after secondary intervention applied in persistent and recurrent patients, the overall cure rate was 97.4%, 96.4%, and 97.4%, persistent disease rate 1.3%, 1.8%, and 2.6%, recurrent disease rate 1.3%, 1.8%, and 0%, respectively. In imaging-negative patients with pHPT, the possibility of multi gland disease and smaller pathological glands should be considered at the time of surgery. Surgery in imaging-negative patients can be performed with a similar and acceptable cure rate to imaging-positive patients.

Mandibular brown tumor revealing an ectopic parathyroid adenoma

The case report presents a 47-year-old female patient. She was suffering a painful clinical mandibular lesion. The histological diagnosis returned in favor of a brown tumor (osteitis fibrosa cystica). The patient did not present any signs of hypercalcemia. The biology report shows an hypercalcemia and an elevated parathyroid hormone (PTH) levels. The Sestamibi (methoxyisobutylisonitrile) scintigraphy returned in favor of an ectopic pathological parathyroid tissue in the upper mediastinal zone. The excision of this tissue revealed a parathyroid adenoma, which normalized the metabolic state and regressed the mandibular lesion. This case study highlights the importance of the dosage of parathyroid hormones and the calcemia in identifying the origin of osteitis fibrosa cystica.

Brown Adipose Tissue Biodistribution and Correlations Particularities in Parathyroid Pathology Personalized Diagnosis.

Brown adipose tissue (BAT) participates in the regulation of whole-body metabolism by producing a variety of adipokines. This study investigates into the BAT pattern and the clinical aspects of overweight and obese (OOB) vs. non-obese (NO) hyperparathyroidism (HPT) patients with the aim of assessing the impact of BAT and obesity on HPT. Parathyroid scans performed on 441 HPT patients between 2015 and 2020 were retrospectively analyzed in order to select the images with active BAT. Based on their BMI, the patients with active BAT were divided into OOB vs. NO. The results showed that BAT was present in cervical and supraclavicular regions, with a single localization especially among NO vs. multiple sites among OOB. The (total counts/pixels)BAT/(total counts/pixels)non-BAT ratio in the right cervical localization showed a significant difference between the groups with higher values in OOB. BMI, PTH, FT4, vitamin D, magnesium, creatinine, and urea had significant correlations with BAT ratios. The predictive values showed that right cervical ratios higher than 1.52 and right supraclavicular ratios lower than 1.15 indicated an increased probability of being OOB. The significant correlations between BAT activation in OOB vs. NO and HPT clinical parameters could be useful for developing potential treatments based on this tissue.

Advances and Updates in Parathyroid Pathology.

Hyperparathyroidism is a common endocrine disorder characterized by elevated levels of parathyroid hormone and hypercalcemia and is divided into 3 types: primary, secondary, and tertiary. Distinction between these types is accomplished by correlation of clinical, radiologic, and laboratory findings with pathologic features. Primary hyperparathyroidism occurs sporadically in 85% of cases with the remaining cases associated with multiple familial syndromes. The pathologic manifestations of primary hyperparathyroidism include parathyroid adenoma, parathyroid hyperplasia, and parathyroid carcinoma. Recent advances in the understanding of the pathogenesis of parathyroid disease has helped to refine the diagnosis and classification of parathyroid lesions. The identification of multiple clonal proliferations in traditional multiglandular parathyroid hyperplasia has led to the adoption by the World Health Organization (WHO) of the alternate term of primary hyperparathyroidism-related multiglandular parathyroid disease. Additional nomenclature changes include the adoption of the term atypical parathyroid tumor in lieu of atypical parathyroid adenoma to reflect the uncertain malignant potential of these neoplasms. Clinical and morphologic features characteristic of familial disease have been described that can help the practicing pathologist identify underlying familial disease and provide appropriate management. Use of ancillary immunohistochemistry and molecular studies can be helpful in classifying parathyroid neoplasms. Parafibromin has proven useful as a diagnostic and prognostic marker in atypical parathyroid tumors and parathyroid carcinomas. This review provides an update on the diagnosis and classification of parathyroid lesions considering the recent advances in the understanding of the molecular and clinical features of parathyroid disease and highlights the use of ancillary studies (immunohistochemical, and molecular) to refine the diagnosis of parathyroid lesions.

Comparison of [18F]fluorocholine PET/CT with [99mTc]sestamibi and ultrasonography to detect parathyroid lesions in primary hyperparathyroidism: a prospective study

Primary hyperparathyroidism is a common endocrine disorder produced by the increase of parathyroid hormone (PTH) due to a benign adenoma of a single parathyroid gland, or as multiple gland hyperplasia, or as a rare malignant tumor. Preoperative imaging scans are frequently necessary for the minimally invasive parathyroidectomies to identify the location of enlarged parathyroid glands and to design the procedure. The diagnostic reliability of [18F]fluorocholine positron emission tomography/computed tomography (FCH PET/CT), [99mTc]sestamibi [multiplexed ion beam imaging (MIBI)] and cervical ultrasonography was analyzed in 37 patients diagnosed with primary hyperparathyroidism undergoing minimally invasive parathyroidectomy. The three preoperative imaging techniques were correlated with intraoperative and histopathological findings as well as changes in biochemical parameters (serum PTH and calcium levels). Statistical analysis was carried out with SPSS version 24.0. In 30 of 37 patients (81.1%), FCH PET/CT correctly localized the pathological gland. In 3 cases of ectopic adenomas, the accuracy of the techniques was 100% (3/3) for FCH PET/CT, 66.7% (2/3) for MIBI, and 33.3% (1/3) for neck ultrasonography. Neither neck ultrasonography nor MIBI were able to locate pathological parathyroid glands in those patients with multiglandular disease, while FCH PET/CT correctly located one patient (1/3, 33.3%) with two adenomas and 3 patients (3/6, 50.0%) with hyperplasia. The three imaging techniques, FCH PET/CT, MIBI and neck ultrasound yielded a sensitivity of 92.1%, 57.9% and 32.4%, a positive predictive value of 94.6%, 84.6% and 78.6%, and a diagnostic accuracy of 96.4%, 85.7% and 79.0%, respectively. In this group of patients diagnosed with primary hyperparathyroidism, FCH PET/CT was superior to MIBI and neck ultrasound in detecting adenomas, particularly in the presence of ectopic glands or multiglandular disease.

ODP086 Detecting Primary Hyperparathyroidism with Image Discordant Findings

Abstract Introduction Primary hyperparathyroidism is a common cause of hypercalcemia, with 80-85% of cases being due to a single gland adenoma. The sensitivity of imaging modalities varies, with ultrasound at 76%, sestamibi scintigraphy at 63%, and 4-dimensional computed tomography (CT) scan at 89%. Clinical Case A 48-year-old woman with a remote history of iron deficiency anemia presented with 2 weeks of dry cough. She reported associated body aches and fatigue, but review of systems was otherwise negative. Family history was notable for a maternal grandmother with an unknown thyroid disease. On presentation, her blood pressure was 115/74 mm Hg, temperature was 37.1 Celsius, pulse was 64 beats per minute, with a respiratory rate of 16 breaths per minute, and oxygen saturation of 100 percent on room air. On exam, there was no thyromegaly, and there were decreased breath sounds. Initial labs were notable for calcium of 11.4 mg/dL (reference range: 8.4-10.2 mg/dL). Her rapid Covid antigen test was negative. A chest x-ray showed bilateral opacifications, suggestive of community acquired pneumonia. She was started on isotonic intravenous (IV) fluids, as well as ceftriaxone and azithromycin. The calcium remained persistently elevated and peaked at 12.6 mg/dL. Creatinine levels remained between 0.7-1. 0 mg/dL (reference range: 0.5-1. 0 mg/dL). Phosphorus level was 3.6 mg/dL (reference range: 2.5-4.5 mg/dL). Parathyroid hormone level was 174.6 pg/mL (reference range: 37.87-83.87 pg/mL). 24-hour urinary calcium was 660 mg (reference range: 0-320 mg). Ultrasound of the neck showed multiple mildly suspicious thyroid nodules, but no notable findings for the parathyroid gland. Subsequent nuclear medicine sestamibi scan revealed no discrete parathyroid adenomas. The 4-dimensional CT scan did not mention parathyroid pathology on the report. However upon review by a head and neck surgeon, a suspicious lesion was identified adjacent to the right thyroid lobe. Intervention was indicated given her age (&amp;lt;50), serum calcium &amp;gt; 1 mg/dL above the upper limit of normal, and 24-hour urinary calcium &amp;gt; 400 mg. The patient underwent a right neck exploration, and a right superior parathyroidectomy was performed. Conclusion The patient met the criteria for primary hyperparathyroidism based on her normal kidney function, elevated serum calcium, and elevated parathyroid hormone. While imaging is frequently ordered, it is important to note that it does not have a role in confirming or ruling out the diagnosis of primary hyperparathyroidism. It should instead be used to localize abnormal parathyroid glands for operative planning. This case highlights the importance of surgical consultation in primary hyperparathyroidism, especially in the setting of negative or conflicting imaging results. Presentation: No date and time listed

PSUN76 Massive Four-Gland Parathyroid Hyperplasia: The Case of the Missing Glands

Abstract Introduction Parathyroid adenoma (PA) and parathyroid hyperplasia (PH) are common causes of primary hyperparathyroidism (PHPT) for which the only definitive treatment is surgical removal. Surgery is often preceded by imaging for localization, including by ultrasound (US), Sestamibi scan (MIBI), positron emission tomography/computer tomography (PET/CT), and four-dimensional computed tomography (4D-CT). While it is common for parathyroid pathology to not be visualized on imaging, non-visualization is more typical of adenomas and hyperplasia of smaller size. Clinical Case A 65-year-old male without history of kidney dysfunction or family history of parathyroid disease was referred to surgery for parathyroidectomy to manage longstanding PHPT. Serology showed a parathyroid hormone (PTH) level of 581 pg/mL (reference range: 12-65 pg/mL) and calcium of 11.8 mg/dL (reference range: 8.6-10.5 mg/dL). Preoperative parathyroid localization US revealed a large well-defined 1.5 cm PA. The patient underwent parathyroidectomy, which detected a large right inferior parathyroid gland, confirmed with pathology to be an atypical parathyroid adenoma weighing 1800 mg. Postoperative PTH level was 550 pg/mL and calcium was 12.6 mg/dL. MIBI did not display any definite parathyroid adenoma or ectopic parathyroid tissue. Further evaluation with PET/CT did not demonstrate any evidence of metabolically active residual or ectopic parathyroid adenoma or metastatic disease, and repeat US showed did not reveal evidence of any abnormal parathyroid tissue. Ultimately, 4D-CT detected a multiglandular parathyroid with a 1.8×1.4×3.0 cm right superior adenoma weighing approximately 3931 mg, 1.2×0.8×2.1cm left superior adenoma weighing approximately 1048 mg, and a 0.3×0.4×0.4cm left superior adenoma weighing approximately 25 mg. The patient underwent re-exploration parathyroidectomy with removal of the right superior adenoma weighing 3105 mg and left superior adenoma weighing 1100 mg. The remaining left inferior gland was biopsied and the majority of it was implanted into the arm. Repeat serology one week post-operatively showed improvement of PTH level to 5 pg/mL and of calcium to 8.9 mg/dL and serology one year post-operatively showed a PTH level of 82 pg/mL and a calcium of 9.4 mg/dL. Conclusion We present a patient with massive four-gland PH who initially presented with findings more typical of PA, but ultimately had additional hyperplasic glands that were identified after removal of the adenomatous gland. These glands were unusually large to be seen in PH and yet still be undetected on multiple imaging modalities; no previously reported non-ectopic hyperplastic glands of this size have been documented that were not detected on US or MIBI. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Normocalcemic non-renal hyperparathyroidism

Parathyroid hormone (PTH) is produced by the parathyroid glands, which are the main regulators of calcium and phosphorus metabolism. Hyperparathyroidism is a clinical condition associated with an increase in serum PTH content. The state of parathyroid glands depends very much on the amount of vitaminD, magnesium and boron in the blood because, according to official data, substantiated by a number of scientific studies, the majority of the world population (80%) has a lack/deficiency of vitamin D. This fact explains the high prevalence of thyroid diseases (hyperplasia, adenoma, hyperparathyroidism) and associated pathology. Previous studies have shown that a deficiency/lack of vitaminD was found in 85–94% of Ukraine population. A deficiency/lack of vitamin D compensatorily stimulates an increase in PTH synthesis. Doctors very rarely determine the level of PTH, which prolongs the progression of hyperparathyroidism, and they detect it only with severe associated changes in other systems. Hyperparathyroidism occurs when one or more of the parathyroid glands become hyperactive, gradually leading to elevated serum parathyroid hormone levels and hypercalcemia. The diagnostic criteria for hyperparathyroid conditions are very vague, which is confusing and leads to unnecessary surgeries instead of simple vitamin D and boron therapy. Normocalcemic primary hyperparathyroidism is a diagnosis of exclusion, and it can be considered only after careful assessment of the causes of secondary hyperparathyroidism, including that associated with a lack of vitamin D. The most common form of hyperparathyroidism is normocalcemic non-renal hyperparathyroidism. Prophylactic use of vitamin D in the correct individualized doses (25(OH)D range of 100–150 nmol/l or 40–60 ng/ml) should reduce the risk of parathyroid pathology but only 10% of the population receives such therapy, others do not know that it is useful. The only way to eliminate the gradual progression of parathyroid disorders is to administer individual prophylactic or therapeutic doses of vitaminD.

Comparison of Planar Imaging Using Dual-phase Tc-99m-sestamibi Scintigraphy and Single Photon Emission Computed Tomography/Computed Tomography in Hyperparathyroidism.

Objectives:The aim of this study was to compare Technetium-99m (Tc-99m)-sestamibi dual-phase planar imaging method and delayed phase single photon emission computed tomography/computed tomography (SPECT/CT) imaging in patients with primary hyperparathyroidism and to evaluate the accuracy of scintigraphy with histopathological results.Methods:Thirty-six patients with a prediagnosis of hyperparathyroidism, who had not been operated on the neck region before, and were not followed up for any other malignancy, and has confirmed histopathologic and biochemical diagnosis after parathyroidectomy, were retrospectively scanned and included in the study. The images of 36 patients who underwent dual-phase Tc-99m-sestamibi planar scintigraphy at the 20th and 120th minutes in the nuclear medicine clinic and delayed phase SPECT/CT imaging immediately after the 120th minute planar imaging were evaluated visually by two nuclear medicine specialists as positive or negative lesion. Dual-phase planar and SPECT/CT images were statistically compared in terms of sensitivity, specificity, positive predictive value, negative predictive value, and accuracy.Results:Thirty-six patients with 41 lesions were evaluated. Comparing dual-phase planar imaging and delayed phase SPECT/CT revealed, sensitivity 84.21%-94.74%, specificity 66.67%-66.67%. Positive predictive value 96.97%-97.30%, negative predictive value 25%-50.0%, accuracy 82.93%-92.68% respectively. There was a statistically significant difference between planar imaging and SPECT/CT; SPECT/CT localized the lesion more accurately (p<0.05).Conclusion:SPECT/CT is superior to planar imaging in determining the anatomical details and localization of the lesion, especially in determining the depth of the lesions in the neck and whether it is ectopic. In patients with hyperparathyroidism, SPECT/CT should be used routinely to detect parathyroid pathologies because it has a lower rate of error and higher accuracy rate.

Application value of contrast-enhanced ultrasound in preoperative localization of microwave ablation for primary hyperparathyroidism.

Ultrasonography (US) and 99m Technetium-sestamibi scintigraphy (99m Tc-MIBI) are currently first-line imaging modalities to localize parathyroid adenomas with sensitivities of 80% and 84%, respectively. Therefore, finding other modalities to further improve the diagnostic accuracy for preoperative localization is critically needed. To evaluate the application value of contrast-enhanced ultrasound (CEUS) in the preoperative localization of microwave ablation (MWA) for primary hyperparathyroidism (PHPT). Between December 2012 and May 2021, 100 PHPT patients (34 males and 66 females; mean age, 56.31±13.43 years; age range, 25-85 years) with 130 suspected parathyroid nodules were enrolled. US, CEUS, and 99m Tc-MIBI were performed for the localization of pathological parathyroid glands. All patients were performed MWA under ultrasound guidance. All the suspected parathyroid nodules underwent core needle biopsy under ultrasound guidance during MWA to confirm the pathology. The diagnostic performance of all the imaging tests was analyzed in comparison with the pathological results. A total of 130 nodules suspected to be of parathyroid origin from preoperative localization images were confirmed by pathological results, of which 116 were of parathyroid origin, and 14 were not of parathyroid origin. The sensitivity, specificity, accuracy, and the area under receiver operating characteristic curve of CEUS in the localization of pathological parathyroid glands were 100%, 92.86%, 99.23%, and 0.964, which were significantly higher than those of US (93.10%, 42.86%, 87.69%, and 0.680) and 99m Tc-MIBI (81.90%, 42.86%, 77.69%, and 0.624) (p<0.05). The sensitivity and accuracy of CEUS were 100% and 97.22%, which were higher than those of 99m Tc-MIBI (65.62% and 63.89%) or US (75.00% and 72.22%) in patients with multiple parathyroid glands (p<0.05). For smaller parathyroid adenomas (≤2cm in diameter), the sensitivities of CEUS in locating hyperfunctioning parathyroid glands were 100%, which was significantly higher than that of 99m Tc-MIBI (73.68% and 84.31%, p<0.05). CEUS is a valuable preoperative localization method for PHPT patients performed MWA, especially for the patients with smaller pathological parathyroid gland and multiple glandular lesions.

Smaller parathyroids have higher near-infrared autofluorescence intensity in hyperparathyroidism

BackgroundIntraoperative parathyroid gland identification can be challenging. Parathyroid glands have an intrinsic autofluorescence when excited by wavelengths in the near-infrared region. Studies using near-infrared cameras to detect parathyroid gland near-infrared autofluorescence have suggested improved identification. The pathologic parathyroid glands in primary hyperparathyroidism have variable near-infrared autofluorescence intensity, but how this correlates with different characteristics of hyperparathyroidism is unknown. Our objective was to correlate the fluorescent intensity of excited glands with clinical variables to enhance a surgeon’s ability to identify parathyroid glands. MethodsThe data on patients undergoing surgery for primary hyperparathyroidism were collected. The images were collected intraoperatively with a handheld near-infrared device and analyzed. The data consisted of the ratio of mean parathyroid gland near-infrared autofluorescence over background (white gauze) near-infrared autofluorescence. The variables assessed for correlation with autofluorescence intensity were gland volume and weight, preoperative serum calcium and parathyroid hormone, age, body mass index, and sex. The images were quantified by Image J software (National Institutes of Health, Bethesda, MD). The lasso regression was analyzed by R version 4.1.3 to calculate adjusted P values (R Foundation for Statistical Computing, Vienna, Austria). ResultsFrom 2017 to 2021, 131 patients with primary hyperparathyroidism underwent parathyroidectomies of 151 parathyroid glands. The mean near-infrared autofluorescence intensity of parathyroid glands had a negative correlation with weight with lighter glands fluorescing more (P = .019) and a positive correlation with age with glands from older patients fluorescing more (P = .013). There were no significant correlations with preoperative serum calcium and parathyroid hormone, body mass index, and sex (P > .05). ConclusionIn patients with primary hyperparathyroidism, we found that autofluorescence intensity correlated with parathyroid gland weight and patient age. This suggested that near-infrared camera use may be particularly helpful in identifying smaller adenomas and in older patients.

The short test with hydrochlorothiazide in differential diagnosis between primary normocalcemic and secondary hyperparathyroidism for inpatient treatment

Differential diagnosis between the normocalcemic primary hyperparathyroidism (nPHPT) and secondary hyperparathyroidism (SHPT) due to hypercalciuria remains a challenge. The aim of this study was to investigate the capability of short test with hydrochlorothiazide for the differential diagnosis of nPHPT and SHPT. A retrospective study was conducted with the participation of 28 patients who underwent a functional test with thiazide diuretics during hospitalization in the Department of parathyroid glands pathology and mineral disorders of the Endocrinology Research Centre, Russia. Parameters of mineral metabolism were evaluated before and 3-5 days after taking hydrochlorothiazide 50 mg/day. According to baseline and dynamic biochemical evaluation patients were divided into 3 groups. Group 1 (n=21) included patients with confirmed PHPT, who reached hypercalcemia accompanying with an elevated level of iPTH (n=19) or an increased level of iPTH accompanying with normocalcemia (n=2). In group 1, baseline Caadj. was 2.48 mmol/l [2.47; 2.52], iPTH 107.5 pg/ml [86.8; 133.0], after short test - 2.63 mmol/l [2.59; 2.66] and 102.1 pg/ml [95,7; 124,1]. Group 2 included only one who was diagnosed with SHPT, a normal value of iPTH with concomitant normocalcemia was achieved after 4 days of hydrochlorothiazide therapy (baseline Caadj. 2.35 mmol/l, iPTH 74.5 pg/ml vs at 2.27 mmol/l and 50.7 pg/ml respectively). Patients with doubtful results of the test entered in group 3 (n=6), they did not achieve significant changes in the calcium and iPTH levels, so it was recommended to continue the test on an outpatient basis (baseline Caadj. 2.39 mmol/l [2.33;2.45], iPTH 97.0 pg/ml [83.1;117.0]); after short test - 2.47 mmol/l [2.42; 2.48] and 91.3 pg/ml [86.9; 124.0] respectively). Groups with PHPT and SHPT and doubtful results significantly differed from each other in Caadj (р=0.003, U-test, Bonferroni correction Р0=0.006), but not in iPTH, daily calciuria, eGFR, and phosphorus. There were no significant differences in the incidence of classical complications of PHPT. The diagnosis of PHPT was confirmed in 21/28 patients 3-5 days after taking hydrochlorothiazide 50 mg/day. The obtained results are significant for the differential diagnosis in hospitalized patients with an unspecified genesis of hyperparathyroidism.

Changes of metabolic parameters in patients with primary hyperparathyroidism of different age groups

BACKGROUND: Studies have shown a high incidence of metabolic disorders and cardiovascular diseases in patients with primary hyperparathyroidism (PHPT). PHPT is usually diagnosed in people of age over 50 years and therefore age-associated changes of metabolism should be excluded. Researching predictors of cardiovascular pathology contributes to choosing optimal approaches to personalized patient management.AIM: To determine the features of metabolic disorders in patients of various age groups with confirmed active stage of PHPT.MATERIALS AND METHODS: A single-center observational retrospective comparative study of patients with active PHPT at the age of 18-49 years (Group 1, n=66) and over 50 years (Group 2, n=290) was carried out. The exclusion criteria for both groups were: persistent PHPT or recurrence after surgical treatment of the disease in history; clinical/genetically confirmed multiple endocrine neoplasia syndrome; for Group 1 — pregnancy, lactation. The assessment of laboratory parameters of mineral, carbohydrate, fat and purine metabolism obtained during a hospital examination was carried out, the frequencies of various metabolic disorders were determined and compared between age groups.RESULTS: There were no significant differences in parathyroid hormone and serum calcium levels between age groups, however, there were more severe hypercalciuria, a tendency to active bone metabolism and lower vitamin D level in Group 1. Patients of Group 2 had statistically significantly lower glomerular filtration rate and a higher frequency of bone complications. In the same group glycaemia and triglycerides levels were higher (the latter difference has the level of a statistical tendency). These patients also had a higher body mass index and, as a result, a higher incidence of obesity (37% vs 20%, p=0.006) and diabetes mellitus type 2 (12.5% vs 3%, p=0.013). At the same time, patients did not significantly differ in the rates of hypercholesterolemia (62% in Group 1 vs 70% in Group 2, p=0.228), hypertriglyceridemia (27% vs 32%, p=0.433) and hyperuricemia (42% vs 50%, p=0.302), significantly exceeding similar indicators in the general Russian population.CONCLUSION: Carbohydrate disorders are more often observed in patients older than 50 years, providing an increased prevalence of diabetes mellitus type 2 among patients with PHPT compared with the general population. The high incidence of various types of dyslipidemia and hyperuricemia in the primary parathyroid pathology has no age specific features. Thereby these disorders are significant risk factors of cardiovascular diseases, even in young people with PHPT.

Pathological uptake with 18-Fluorocholine versus 99mTc-MIBI in the location of the parathyroid glands in hyperparathyroidism. Systematic review and meta-analysis

Introduction: The location of the pathological parathyroid glands in hyperparathyroidism is usually carried out by means of 99mTc-sestamibi scintigraphy, which increases its precision by adding the ultrasound examination. The non-localization of the parathyroid glands increases the difficulties for surgical removal. To increase the detection of pathological glands, other radioactive tracers are used, such as methionine, fluorocholine or 18F-flurpiridaz. Objective: To establish if PET / CT with 18-Fluorocholine in patients with hyperparathyroidism increases the number of uptakes compared to the 99mTc-sestamibi scan. Method: Systematic review and meta-analysis. Two subgroups were analyzed. Subgroup 1: trials comparing both techniques as an initial exploration. Thirteen studies including 1131 examinations were selected (596 PET / CT with 18-Fluorocholine vs. 535 scintigraphy with 99mTc-sestamibi). Meta-analysis was performed following the random effects model and the odds ratio was calculated. Subgroup 2: studies that include 18-Fluorocholine as a rescue examination in patients with a previous negative study with a 99mTc-sestamibi scan. 17 articles including 412 examinations with 359 patients in which there was at least one uptake were selected. Meta-analysis of the prevalence of the number of patients in whom there was at least one uptake was performed using the random effects model. Results: Subgroup 1: The number of patients in which at least one uptake occurs is significantly higher with the 18-Fluorocholine examinations (OR 4.264, 95% CI 2.400-7.577). The prevalence of uptake with 18-Fluorocholine is 0.91 [0.86, 0.95] and with sestamibi 0.68 [0.56, 0.80]. Subgroup 2: the prevalence of uptake among patients with previous negative MIBI studies was 0.90 [0.87, 0.94]. The probability of detection of both techniques in this group reaches 0.98. Publication bias in the meta-analyzes is low. Discussion: 18-Fluorocholine protocols provide higher precision, clearer images, with faster acquisition as well as being readily available for most PET / CT centers. Conclusion: The PET / CT study with 18-Fluorocholine can be recommended as a study for the location of pathological parathyroid glands after studies with negative MIBI.

Parathyroidectomy for primary hyperparathyroidism: A retrospective analysis of localization, surgical characteristics, and treatment outcomes

ObjectiveTo evaluate parathyroidectomy for primary hyperparathyroidism (PHPT) regarding localization, surgical characteristics, and treatment outcomes. MethodsSeventy-eight patients who underwent parathyroidectomy for PHPT were retrospectively reviewed. The results were analyzed according to intraoperative localization technique (IOLT), intraoperative parathyroid hormone (IOPTH) monitoring, and intraoperative nerve monitoring (IONM). The localization accuracy of ultrasonography (US), computed tomography (CT), and single-photon emission computed tomography (SPECT)-CT with sestamibi Tc99m was evaluated. ResultsParathyroidectomy was successfully completed in all 78 patients, achieving 100% surgical cure. For 60 patients with IOPTH monitoring, 10-min IOPTH decreased >50% from baseline in 57 (95.0%), and they achieved surgical cure. In the remaining three (5.0%) patients with ≤50% decrease in 10-min IOPTH, 20-min IOPTH decreased >50% from baseline in two (3.3%) patients, achieving surgical cure without additional neck exploration. There were no differences in surgical cure and complications as a function of IOLT use or IOPTH monitoring. Operating time was significantly shorter with IOLT and IOPTH monitoring than without (IOLT: 70.9 min vs. 88.0 min, p = 0.013; IOPTH: 74.9 min vs. 91.9 min, p = 0.037). All 78 patients had adenoma including one patient with a double adenoma. Vocal cord paralysis was not observed in our series, regardless of IONM. US, CT, and SPECT-CT localized the pathological parathyroid gland accurately in 88.1%, 85.5%, and 86.8% of patients, respectively (p = 0.894). ConclusionThe surgical outcomes of parathyroidectomy for PHPT were excellent regardless of IOLT and IOPTH monitoring. However, these techniques can maximize the performance of parathyroid surgery by reducing operating time and rescuing challenging cases.

Parathormone concentration in the fluid of fine-needle parathyroid biopsy for assessing the effectiveness of surgical treatment of patients with primary hyperparathyroidism.

The aim of the work was to evaluate the usefulness of intraoperative determination of parathyroid hormone (PTH) concentration in the fluid of fine-needle biopsy lesions of pathologically parathyroid glands for their identification and evaluation of the effectiveness of surgical treatment of primary hyperparathyroidism (PHP). The study group comprised 75 patients: 65 women and 10 men, aged 33-78 years (mean 57.5), operated in the years 2019-2020 due to PHP. Seventy-nine biopsies of fine-needle aspiration lesions were assessed intraoperatively as pathological parathyroid glands were collected, and the concentration of PTH was determined in their lavage fluid. The results were compared with a control group of 20 patients operated at that time for various forms of goitre, without concomitant parathyroid disease. In 79 biopsies, the presence of the parathyroid gland was confirmed 72 times. The concentration of PTH in the biopsy fluid exceeded the value of 5000 pg/mL 70 times, 1 was 3733 pg/mL, and 1 was 1985 pg/mL. Seven times (8.9%), the biopsy was for a colloidal nodule instead of the parathyroid gland. The concentration of PTH in the fluids of these biopsies was low and ranged from 5.3 to 500 pg/mL. In the control group, the concentration of PTH in postoperative thyroid biopsies was low and did not exceed the reference value range of up to 64 pg/mL. Comparison of the results of the study group with the control group shows significantly higher PTH values in parathyroid biopsies compared to biopsies of thyroid specimens (p = 0.017), with a sensitivity of 100% and a specificity of nearly 93%. Intraoperative determination of PTH concentration in the fluid of fine-needle biopsy lesions with diseased parathyroid glands allows for their identification and evaluation of the effectiveness of surgical treatment of PHP. Testing the concentration of PTH in the biopsy fluid of dissected parathyroid glands is characterized by high sensitivity and specificity of the method. The value of PTH concentration in fluid from parathyroid biopsies does not depend on the cause of PHP.