Radioguided Parathyroidectomy Research Articles

AB130. SOH24AB_066. Evaluating the combined approach of three intra-operative adjuncts in localizing parathyroid adenomas during minimally invasive radio-guided parathyroidectomy: a single center retrospective analysis

AB130. SOH24AB_066. Evaluating the combined approach of three intra-operative adjuncts in localizing parathyroid adenomas during minimally invasive radio-guided parathyroidectomy: a single center retrospective analysis

Intraoperative freehand SPECT as an alternative imaging technique for use in radioguided parathyroidectomy.

Freehand single photon emission computed tomography (fhSPECT) is a technique that is used to monitor body's radioactivity intraoperatively. Accordingly, in this study, the feasibility of using fhSPECT for intraoperative 3D mapping in radioguided parathyroidectomy has been assessed. Patients, who were diagnosed with primary hyperparathyroidism consecutively, were scanned intraoperatively using fhSPECT to locate parathyroid adenomas before surgical procedure. The fhSPECT images were acquired intraoperatively using a declipse®SPECT device (SurgicEyeTM). The fhSPECT protocol could not be completed due to the technical problems in one patient. Parathyroid adenoma was located in the first patient with no lateral deviation. Nevertheless, a deviation of 8mm was detected in the depth of the parathyroid adenoma, which is the distance of parathyroid adenoma from the skin. A 20mm lateral deviation and a 10mm deviation in depth were detected in the second patient. In the third patient, as was the case in the first patient, parathyroid adenoma was located with no lateral deviation. However, there was a 15mm deviation in the depth of the parathyroid adenoma. A 5mm lateral deviation was detected in the fourth patient yet with no deviation in the depth of parathyroid adenoma. Finally, neither lateral nor vertical deviation was detected in fifth patient. Based on the findings of this study, it was concluded that the fhSPECT technology can be helpful to a certain degree in locating the parathyroid adenoma. However, further studies are needed to support the findings of this preliminary study.

Utility of intraoperative digital scintigraphy in radioguided parathyroidectomy.

Intraoperative scintigraphy (IoS) has been proposed as a tool for real-time intraoperative decision-making regarding parathyroid adenoma localization and confirmation of excision. Retrospective review of patients who underwent minimally invasive parathyroidectomies with scintigraphy performed intraoperatively. Preoperative neck ultrasound, 4D computed tomography, as well as intraoperative parathyroid hormone (IOPTH) and gamma probe measurements were conducted per standard practice. IoS images were obtained prior to and following parathyroid excision. Cases were reviewed to determine accuracy of IoS for localizing parathyroid pathology and confirming successful excision. Fifty-six cases met the inclusion criteria. Twenty-nine patients (51.8%) showed confirmation of excision of an abnormal gland on post-excision IoS. There were no significant differences in IOPTH reduction and postoperative laboratory values between patients with IoS-identified resolution and those without IoS-identified resolution. With low accuracy in correctly localizing abnormal glands and confirming their excision, there is no appreciable benefit of IoS at this time.

O62: INTRA-OPERATIVE ADJUNCTS IN MINIMALLY INVASIVE RADIO-GUIDED PARATHYROIDECTOMY AT A SPECIALIST ENDOCRINE SURGERY CENTRE

Abstract Introduction Primary Hyperparathyroidism (PH) is common cause of hypercalcaemia (0.3% of the population). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e. sestamibi scans allowing localisation of areas of parathyroid hyperactivity. Method Due to the disagreement in the literature regarding which intra operative adjunct is best used in MIRP surgery to decrease recurrence, the rationale for this study is to examine and compare the performance of these adjuncts in consecutive patients i.e. 1. Intra operative PTH assay (IOPTHA) 2. Tc-99m radio-guidance using a gamma probe and the 20% rule 3. Frozen section analysis. Result 45 MIRP procedures were carried out between 01/07/2018 and 30/10/2019. 77.8% were females; mean age was 62 years (range 30 - 79). Final pathology showed that in 43 of the cases parathyroid tissue was correctly removed; thyroid tissue was identified for the other 2 cases. 20% rule was positive in 43 out of the 45 cases and negative in 2 (sensitivity 100%, specificity 100%). A drop in IOPTHA greater than 50% was found in 41 out of the 45 cases but not in 4 (sensitivity 93.9%, specificity 100%). Frozen section was 100% concordant with final pathology (45/45). AUC analysis showed no significant difference in the performance of these tests (p = 0.15) but was around 1 for 20% rule and Frozen section. Conclusion When radio-guidance and frozen sections are added to IOPTHA, the success rate of parathyroidectomy is markedly improved. Using them together will greatly reduce recurrent hyperparathyroidism. Take-home message When radio-guidance and frozen sections are added to Intra-operative PTH assays in Minimally Invasive Radio-Guided Parathyroidectomy, the success rate of parathyroidectomy is markedly improved. Using them together as in our study will greatly reduce the incidence of recurrent hyperparathyroidism and thus recurrent surgery.

Individualised Timing of Radio-Guided Parathyroidectomy Using Multi-Phase SPECT/CT Increases In Vivo Sensitivity and Accuracy and Reduces Operating Time: A Randomised Clinical Trial.

Background: Minimally invasive parathyroidectomy is the preferred treatment for primary hyperparathyroidism. Despite relatively accurate preoperative information, minimally invasive parathyroidectomy can be challenging, especially in the case of small and ectopic adenomas. Radio guidance aids in both in vivo identification and ex vivo confirmation of adenoma. In vivo accuracy is currently not satisfactory. The present study evaluated whether a beneficial effect (increased sensitivity, specificity, accuracy) is obtained with individualised timing of minimally invasive radio-guided parathyroidectomy (MIRGP) using preoperative multi-phase 99mTc-MIBI single photon emission computed tomography (SPECT)/computed tomography (CT). Methods: This randomised clinical trial was conducted from May 2016 to January 2020 in a tertiary referral hospital. Adult patients with primary hyperparathyroidism sent for 99mTc-MIBI SPECT/CT were included consecutively and randomly assigned to conventional (dual-phase) SPECT/CT and conventional MIRGP (group I) or multi-phase SPECT/CT and individualised MIRGP (group II). One hundred of 106 eligible patients were included, and 83 patients underwent complete intervention. Results: A total of 47 patients in group I and 35 patients in group II were analysed. Group II had a shorter operating time (p = 0.003). The in vivo sensitivity and accuracy of radio guidance was 85.1% in group I and 100% in group II (p = 0.046), and 90.4% in group I and 100% in group II (p = 0.021), respectively. We found no difference in the in vivo specificity and ex vivo parameters between groups. Conclusion: Individualised timing increased the in vivo sensitivity and accuracy of radio guidance and reduced operating time, as some parathyroid adenomas rapidly wash out the radionuclide.

Surgical outcome of radioguided parathyroidectomy in primary hyperparathyroidism

Background: Focused parathyroidectomy is the adequate treatment for primary hyperparathyroidism for localised disease. Adequacy of resection is confirmed by the availability of intraoperative parathormone assay (iOPTH). In the absence of availability of iOPTH assay, the radio guided surgery is an option. The aim of this study was to evaluate the feasibility of radioguided parathyroidectomy in tertiary care centre in India and to compare the overall success rate, operative time, hospital stay and postoperative outcome between focused open and radioguided parathyroidectomy.Methods: This was a prospective study which included 30 primary hyperparathyroidism patients with a single gland disease localised on Tc99m Sesta MIBI scan. Patients were randomized into two equal groups, and they underwent focused open or radioguided parathyroidectomy. Patients were followed up for three months.Results: All patients achieved biochemical cure as evident by the normalization of serum calcium and parathormone levels after surgery. The mean incision length, and operative time in this study was significantly better for radioguided parathyroidectomy (p=0.0001, <0.0001 respectively). There was no perioperative complications like recurrent laryngeal nerve injury, gland rupture, or bleeding in either group. However, there seems to be higher grade of pain experience by the patients who underwent open focused parathyroidectomy (p<0.0001).Conclusions: Radioguided parathyroidectomy has excellent cure rate for PHPT with an added advantage of short operative time & incision length and less post-operative pain. Radioguided parathyroidectomy seems to be a good alternative in the absence of availability of iOPTH assay and frozen section.

Cirugía radioguiada en el hiperparatiroidismo primario: revisión de las diferentes técnicas disponibles

Parathyroidectomy has evolved over the years from bilateral neck exploration to a single gland approach using minimally invasive surgery. The precise presurgical localization of the problem gland, using functional techniques, such as double-phase scintigraphy with [99mTc] Tc-MIBI including SPECT-CT and PET-CT with [18F]-Choline and morphological ones, such as ultrasound have played a crucial role in this paradigm's shift. Radioguided surgery techniques have also adapted and grown with new contributions known for their indication in other fields. Thus, we currently have a wide range of techniques that have been added to the minimally invasive radioguided parathyroidectomy with [99mTc] Tc-MIBI, which was the first on the stage and for which more experience exists. Among them, in this update, we will discuss parathyroidectomy using ultrasound-guided ROLL technique as well as with the use of 125I seeds and finally, hybrid techniques that use radiotracer and fluorescence.

Radioguided surgery in primary hyperparathyroidism: a review of the different techniques available

Parathyroidectomy has evolved over the years from bilateral neck exploration to a single gland approach using minimally invasive surgery. The precise presurgical localization of the problem gland, using functional Choline, such as double-phase scintigraphy with [99mTc] Tc-MIBI including SPECT/CT and PET/CT with [18F]-Colina and morphological ones, such as ultrasound have played a crucial role in this paradigm’s shift. Radioguided surgery techniques have also adapted and grown with new contributions known for their indication in other fields. Thus, we currently have a wide range of techniques that have been added to the minimally invasive radioguided parathyroidectomy with [99mTc] Tc-MIBI, which was the first on the stage and for which more experience exists. Among them, in this update, we will discuss parathyroidectomy using ultrasound-guided ROLL technique as well as with the use of 125I seeds and finally, hybrid techniques that use radiotracer and fluorescence.

The use of focused, radioguided parathyroidectomy in geriatric patients with a history of thyroid surgery.

Geriatric patients are often reluctant to undergo parathyroid surgery under general anesthesia because of the major comorbidities. The use of minimally invasive techniques for parathyroid lesions under local anesthesia have been published. Radioguided lesion localization has been known to decrease operative time and reduce the occurrence of positive margins in breast cancer surgery. We hypothesize that it could also be effectively used in focused parathyroid surgery in geriatric patients with in history of thyroid surgery. Our study group consists of geriatric patients with a history of thyroid surgery who underwent focused parathyroid surgery between February 2017 and October 2019. Group-1 included 18 patients who had parathyroidectomy under radioguidance. Group-2, 22 patients who had surgery without it. Patient demographics, operative time, number of frozen sections and length of hospital stay were analyzed. Analyzed data were similar between groups. The mean age of the patients was 72.56±12.65 years (range: 65-88). The operative times for group-1 and group-2, were 65.42±7.78 and 74.63±15.98 minutes, respectively (P=0.002). All patients were discharged uneventfully on postoperative day-2. Radioguidance parathyroidectomy positively affected the operative time and also decreased the need for additional frozen section.

Intraoperative 99mTc-MIBI-Guided Parathyroidectomy Improves Curative Effect of Parathyroidectomy, Bone Metabolism, and Bone Mineral Density.

This study aimed to compare the postoperative effects of total parathyroidectomy plus forearm transplantation and radioguided parathyroidectomy on bone metabolism and bone mineral density (BMD). From June 2013 to October 2017, 67 patients with renal secondary hyperparathyroidism (SHPT) received surgical treatment. The control group included 30 cases of classical total parathyroidectomy plus forearm transplantation for SHPT. In the experimental group, 37 patients underwent 99mTc-MIBI-guided parathyroidectomy. Demographics, parathyroid hormone (PTH) level, blood calcium level, and pathological results were compared between the 2 groups. The curative effect of parathyroidectomy and its effect on BMD were also compared. The BMDs in the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The T scores of the L1-L4 segments and femoral neck in both groups were significantly improved after operation (all P < .05). The improvement in the T score of the L4 in the experimental group was significantly higher than that in the control group (P < .05). No significant differences in the improvement in the L1-L3 segments and femoral neck were found between the 2 groups. Both traditional total parathyroidectomy plus forearm transplantation and 99mTc-MIBI-guided parathyroidectomy can improve PTH level, blood calcium level, phosphorus level, bone metabolism, and BMD to varying degrees in patients with SHPT. Compared with the traditional surgery, 99mTc-MIBI-guided parathyroidectomy can improve blood calcium and phosphorus metabolisms, reduce PTH level, and improve the T scores of L4 to a greater extent.

Occult Primary Hyperparathyroidism: A Case Report and Review of Parathyroid Ultrasonography

To discuss the diagnosis and management of occult primary hyperparathyroidism. We present the biochemical and radiologic evaluation, treatment, and outcome of a woman with occult primary hyperparathyroidism which presented as an unusual neck mass on ultrasound. We also present a relevant literature review. A 52-year-old female presented with Hashimoto thyroiditis and a 1.2-cm, hypoechoic oval nodule in the left upper lateral portion of the thyroid. She returned a decade later with a 2.2-cm, hypervascular mass on ultrasound. Parathyroid hormone was mildly elevated at 90 pg/mL (reference range is 15 to 65 pg/mL), but she had persistently normal levels of total serum calcium at 9.9 mg/dL (reference range is 8.7 to 10.3 mg/dL), phosphorus at 3.5 mg/dL (reference range is 2.1 to 4.5 mg/dL), and albumin at 4.4 g/dL (reference range is 3.6 to 4.8 g/dL). She had elevated ionized calcium of 5.9 mg/dL (reference range is 4.5 to 5.6 mg/dL). Computed tomography with contrast of the neck revealed an enhancing oval lesion abutting the superior pole of the left thyroid with attenuation characteristics similar though slightly different from the thyroid. 99mTc-Sestamibi scan showed increased uptake posterior to the superior aspect of the left thyroid. Bone densitometry showed osteoporosis of the left distal radius and osteopenia of the left femoral neck. Minimally invasive radio-guided parathyroidectomy was performed with normalization of parathyroid hormone. Pathology confirmed a 1.715-g parathyroid adenoma. Despite normal total calcium levels, clinically significant primary hyperparathyroidism may present as a large adenoma which could appear as a hypervascular neck mass on ultrasound. A high index of suspicion based on ultrasound features and measurement of ionized calcium may be helpful in diagnosing occult, but clinically relevant primary hyperparathyroidism.

Minimally Invasive Radioguided Parathyroidectomy

Minimally Invasive Radioguided Parathyroidectomy

AB024. Intra-operative adjuncts in minimally invasive radio-guided parathyroidectomy at a specialist endocrine surgery centre

Background: Primary hyperparathyroidism (PH) is a common cause of hypercalcaemia (0.3% of the population) and is characterized by high concentrations of calcium and parathyroid hormone (PTH). Minimally invasive radio-guided parathyroidectomy (MIRP) has been made possible due to advancements in pre-operative imaging i.e., sestamibi scans that allows localization of areas of parathyroid hyperactivity.

Radio-guided miniinvasive surgery of solitary parathyroid adenoma as a cause of primary hyperparathyroidism

Abstract The function of parathyroid gland is affected by a wide spectrum of diseases, among them primary hyperparathyroidism is the most common. In about 85% of the patients a solitary parathyroid adenoma is the cause of the hyperparathyroidism. Surgical removal of pathologically changed gland is a treatment of choice, usually performed by miniinvasive radio-guided parathyroidectomy. In this article the authors review current knowledge, research state, and present some cases of this operation at the Clinic of Otorhinolaryngology and Head and Neck Surgery, Jessenius Faculty of Medicine, Comenius University and University Hospital Martin, Martin, Slovakia.

Prevalence of Thymic Parathyroids in Primary Hyperparathyroidism During Radioguided Parathyroidectomy.

Background:Radioguided surgery has been an effective tool for identifying hyperfunctioning parathyroid glands during routine parathyroidectomy for hyperparathyroidism. The purpose of this study was to examine the role of radioguided surgery for the identification of intrathymic parathyroid glands.Material and Methods:Between March 2001 and February 2018, 2291 patients underwent parathyroidectomy by 1 surgeon for primary hyperparathyroidism. Of these patients, 158 (7%) were identified to have an ectopic intrathymic parathyroid gland. All patients underwent radioguided parathyroidectomy. Ex vivo radionuclide counts were used to confirm parathyroid excision with specimen radioactivity of >20% of the background level.Results:The mean age was 56 ± 1 years with 74% of the patients being female. Preoperatively, 122 patients underwent sestamibi scan, which correctly identified the affected gland 61% of the time. Mean background radionuclide count was 208 ± 7, mean ex vivo radionuclide count was 127 ± 9, with ex vivo counts of removed glands >20% in all patients. All ectopic parathyroid glands were successfully identified using gamma probe. Ex vivo counts found to be significantly higher in patients with adenomas. Patients with parathyroid adenomas also were older in age and had higher preoperative calcium levels. While 10% of patients with primary hyperparathyroidism have hyperplasia, 42% of patients with thymic parathyroids had hyperplasia.Conclusions:Radioguided parathyroidectomy is useful in detecting ectopic parathyroid glands in the thymus. Patients with hyperplasia disproportionately have clinically significant thymic parathyroid glands.

AB094. 92. Intra-operative adjuncts in minimally invasive radio-guided parathyroidectomy at Cork University Hospital

AB094. 92. Intra-operative adjuncts in minimally invasive radio-guided parathyroidectomy at Cork University Hospital

Parathyroid radionuclide imaging: update

Parathyroid scintigraphy is a well established and effective imaging technique for preoperative detection and localization of parathyroid adenoma. This functional type of imaging has very high specificity for parathyroid adenoma identification with only a small number of reported false results. In clinical practice today, there are many different methodologies used in parathyroid scintigraphy. This article discusses the current role and limitations of scintigraphic imaging, with a focus on different imaging protocols in the evaluation of patients with hyperparathyroidism. In addition, the value of this imaging procedure in the different clinical settings and the role of radio-guided parathyroidectomy are reviewed in this article.

Decrement in bone mineral density after parathyroidectomy in a pediatric patient with primary hyperparathyroidism.

.Primary hyperparathyroidism (PHT) causes increased bone turnover, leading to reduction in bone mineral density (BMD). Parathyroidectomy is a definitive therapy and improves BMD in adult patients with PHT. However, there are no reports regarding alterations of BMD in pediatric or adolescent patients with PHT. Here, we report a case of a 13-yr-old boy with PHT who was referred to our institution for evaluation of hypercalcemia and hyperparathyroidism. Radiological investigation revealed an ectopic parathyroid adenoma below the right thyroid lobe. A minimally invasive radio-guided parathyroidectomy was successfully performed. We followed up the patient’s BMD for three years both before and after parathyroidectomy. Over the course of three years, his BMD was steadily decreased, with z-scores of +0.506 at 13 yr and 9 mo, +0.162 at 14 yr and 9 mo, and –0.411 at 15 yr and 9 mo. BMD usually increases during peak height velocity in an adolescent and improves after parathyroidectomy in adult patients with PHT. However, our patient showed decreased BMD z-scores following parathyroidectomy. Therefore, the patient had an increased risk of fracture after parathyroidectomy and was followed up closely. Both height and BMD should be carefully evaluated after parathyroidectomy in pediatric and adolescent patients with PHT.

Association of Parathyroid Gland Biopsy Excision Technique With Ex Vivo Radiation Counts During Radioguided Parathyroid Surgery

ImportanceParathyroid biopsy represents a means for normal and hyperfunctional glands to be distinguished intraoperatively. However, no data exist to guide surgeons regarding how much of a parathyroid gland must be biopsied to satisfy the 20% rule.ObjectiveTo quantify the relative proportion of a hyperfunctional parathyroid gland that must be evaluated with the gamma probe to satisfy the 20% rule.Design, Setting, and ParticipantsA retrospective review of surgical data for 24 consecutive patients (16 women, 18 men; mean [SD] age, 66.6 [10] years; range, 51-83 years) who underwent surgery for primary hyperparathyroidism between May and October, 2015, in a tertieary academic medical center.Main Outcomes and MeasuresExtirpated parathyroid glands were sectioned into parallel or pie-shaped biopsies and evaluated ex vivo with a gamma probe to determine what percentage of a hyperfunctional gland must be sampled to meet the Norman 20% rule. The hypothesis was formulated during data collection.ResultsIn total, 253 ex vivo biopsy specimens were obtained from 33 surgically removed parathyroid glands. Parathyroid biopsies satisfied the 20% rule with an accuracy that depended on the relative proportion of the parent gland represented: half or more (96.6%; 95% CI, 91.7%-100.0%), a quarter to one-half (87.0%; 95% CI, 79.3%-94.7%), less than a quarter (63.6%; 95% CI, 54.5%-72.8%). When less than a quarter of the gland was removed, pie-shaped biopsies were more likely to satisfy the 20% rule compared with parallel biopsies of the same weight (78.4% vs 56.2%; absolute difference, 22.2%; 95% CI, 4.7%-39.7%).Conclusions and RelevanceUnless half of a parathyroid gland is biopsied during radioguided parathyroidectomy, the 20% rule cannot reliably rule out the presence of a hyperfunctional parathyroid lesion. Pie-shaped biopsies originating from the center of the gland are associated with a lower rate of false-negative results compared with peripheral biopsies of similar size. Pie-shaped biopsies and biopsy of half or more of each nonexcised parathyroid gland for ex vivo counts may increase the risk of remnant devascularization and resultant hypoparathyroidism.

Feasibility and safety of minimally invasive radioguided parathyroidectomy using very low intraoperative dose of Tc-99m MIBI

BackgroundSurgical resection of the abnormal parathyroid glands is the only curative treatment for primary hyperparathyroidism (PHPT). Radioguided parathyroidectomy with technetium-99m (TC-99m) sestamibi has been successfully used in patients with PHPT.This study was designed to evaluate the results of a series of patients with PHPT who underwent minimally invasive radioguided parathyroidectomy (MIRP) using very low dose (1 mCi) of TC-99m sestamibi (MIBI) without application of intraoperative parathyroid hormone (PTH) assay or frozen section analysis. MethodsEighty-seven patients with PHPT were prospectively studied from November 2012 to January 2015. Following neck ultrasound (US) and MIBI scan concordant for single gland disease, patients underwent MIRP using a handheld gamma probe. The technique involved injecting of 1 mCi MIBI in the operative room before the beginning of the intervention. All patients were followed up for a minimum of 6 months postoperatively. ResultsMIRP was successfully performed in 86 out of 87 patients (98.85%). The Gamma probe was particularly useful in detection of ectopic parathyroid adenomas in upper mediastinum. Mean operative time was 23.95 ± 7.982 min and mean hospital stay was 1.44 ± 0.604 days. No major surgical complications were recorded. ConclusionsThe MIRP technique using very low dose (1 mCi) of Tc-99m MIBI without intraoperative PTH assay and frozen section analysis resulted in excellent cure rate for PHPT. This technique involves a radiation exposure to patients and surgical staffs 20 times lower than conventional MIRP using 20 mCi Tc-99m MIBI. Besides, patients with PHPT due to ectopic parathyroid adenoma may especially benefit from MIRP.