Technetium-99m Sestamibi Scintigraphy Research Articles

Surgical treatment of secondary hyperparathyroidism in children with chronic kidney disease. Experience in 19 patients.

Secondary hyperparathyroidism (sHPT) is an important contributor to bone disease and cardiovascular calcifications in children with chronic kidney disease (CKD). When conservative measures are ineffective, parathyroidectomy is indicated. The aim of our study was to evaluate the efficacy and safety of subtotal parathyroidectomy (sPTX) in pediatric and adolescent patients, and to provide a rationale for considering this aggressive treatment in CKD patients with uncontrolled sHPT. We retrospectively analyzed the medical records of 19 pediatric CKD patients on dialysis with refractory sHPT who underwent sPTX at our institution between 2010 and 2020. All patients had clinical, radiological, and biochemical signs of renal osteodystrophy. One year after sPTX, parathyroid hormone (PTH) levels (median and interquartile range (IQR)) dropped from 2073 (1339-2484) to 164 (93-252) pg/mL (p=0.0001), alkaline phosphatase (ALP) levels from 1166 (764-2373) to 410 (126-421) IU/L (p=0.002), and the mean (±SDS) calcium-phosphate (Ca*P) product from 51±11 to 41±13mg2/dL2 (p=0.07). Postoperatively, all patients presented with severe hungry bone syndrome (HBS) and required intravenous and oral calcium and calcitriol supplementation. None of them had other postoperative complication. Histological findings had a good correlation with preoperative parathyroid ultrasound imaging (n: 15) in 100 % and with technetium-99m (99mTc) sestamibi scintigraphy (n: 15) in 86.6 %. Clinical and radiological signs of bone disease improved in all patients. Pediatric sPTX is effective and safe to control sHPT and calcium-phosphate metabolism in children with CKD on dialysis and may mitigate irreversible bone deformities and progression of cardiovascular disease.

Quantitative model for assessment of lower-extremity perfusion in patients with diabetes.

Although diabetic and atherosclerotic vascular diseases have different pathophysiological mechanisms, the screening methods currently used for diabetic lower-extremity vascular diseases are mainly based on the evaluation methods used for atherosclerotic vascular diseases. Thus, assessment of microvascular perfusion is of great importance in early detection of lower-extremity ischemia in diabetes. This cross-sectional study aimed to develop a quantitative model for evaluating lower-extremity perfusion. We recruited 57 participants (14 healthy participants and 43 diabetes patients, of which 16 had lower-extremity arterial disease [LEAD]). All participants underwent technetium-99m sestamibi (99mTc-MIBI) scintigraphy and ankle-brachial index (ABI) examination. We derived two key perfusion kinetics indices named activity perfusion index (API) and basal perfusion index (BPI). This study was registered in ClinicalTrials.gov (URL: https://www. gov, NCT02752100). The estimated limb perfusion values in our lower-extremity perfusion assessment (LEPA) model showed excellent consistency with the actual measured data. Diabetes patients showed reduced lower-extremity perfusion in comparison with the control group (BPI: 106.21±11.99vs. 141.56±17.38, p<0.05; API: 12.34±3.27vs. 14.56±3.12, p<0.05). Using our model, the reductions in lower-extremity perfusion could be detected early in approximately 96.30% of diabetes patients. Patients with LEAD showed more severe reductions in lower-extremity perfusion than diabetes patients without LEAD (BPI: 47.85±20.30vs. 106.21±11.99, p<0.05; API: 7.06±1.70vs. 12.34±3.27, p<0.05). Discriminant analysis using API and BPI could successfully screen all diabetes patients with LEAD with a sensitivity of 100% and specificity of 80.77%. We established a LEPA model that could successfully assess lower-extremity microvascular perfusion in diabetes patients. This model has important application value for the recognition of early-stage LEAD in patients with diabetes.

IS BILATERAL JUGULAR VENOUS SAMPLING A SUITABLE STRATEGY FOR PRIMARY HYPERPARATHYROIDISM CASES WITH PARATHYROID GLANDS THAT CANNOT BE LOCALIZED WITH SESTAMIBI?

Objective: Primary hyperparathyroidism (PHPT) is a common disorder. The surgical excision of all hyperfunctional parathyroid tissues is required to ensure long-term eucalcemia in these patients' curative treatment. This study aimed to evaluate whether parathormone (PTH) measurement via bilateral jugular venous sampling (BJVS) is an appropriate strategy for parathyroid adenoma lateralization in PHPT cases where parathyroid glands cannot be localized by imaging. Method: The study included 22 cases diagnosed with PHPT, which could not be localized by ultrasonography and technetium-99m sestamibi scintigraphy (99mTc-MIBI). The patients’ PTH levels were measured using BJVS, and unilateral neck exploration (UNE) was performed in those detected to have lateralization. Success rate, permanent or temporary recurrent laryngeal nerve (RLN) injury, and hypoparathyroidism were evaluated. Results: Parathyroid adenoma was successfully excised in 21 of 22 patients, and the success rate of PTH determination with BJVS was observed to be 94.5%. RLN injury and persistent hypoparathyroidism were not observed in any patient. Transient hypoparathyroidism was present in 9% of the patients. Conclusions: In PHPT cases where parathyroid glands cannot be localized on ultrasonography and 99mTc-MIBI, UNE can be safely performed after achieving PTH level lateralization with preoperative BJVS without the need for advanced imaging methods.

Persistent Hyperparathyroidism: How Many Cases Can Be Prevented

The need for surgery for persistent or recurrent hyperparathyroidism results from incomplete resection of abnormal parathyroid glands or adenoma of the remaining gland 6 months after successful surgery. Secondary surgeries can cause major problems, such as healthcare costs and surgical complications, some of which can be disastrous. Preventive medicine is one of the most effective ways to avoid these problems. In this study, our aim is to determine the main causes of persistent hyperparathyroidism and recurrent hyperparathyroidism and prevent these secondary surgeries. We reviewed data of patients who had been reoperated on for persistent hyperparathyroidism and recurrent hyperparathyroidism between July 2015 and November 2018 in our clinic. Patients who underwent reoperation for other reasons, patients under 18 years of age, and patients with missing follow-up information were excluded from the study. Thirty-six patients (7 man and 29 women) were included in the study, and the mean age was 56 SD15.2 years. Thirty of them suffered from persistent hyperparathyroidism, and six (16.7%) of them suffered from recurrent hyperparathyroidism. Ultrasonography was used for localization, which was performed by the department of endocrinology, or, alternatively, radiology, technetium 99m-sestamibi scintigraphy, computer tomography, and magnetic resonance imaging were used. Single imaging modality was used for 19 (52.7%) patients, while more than one imaging modality was used for 17 (47.2%) patients. In the first surgery, 21 (58.3%) patients underwent focus parathyroidectomy, while 15 (41.7%) patients underwent conventional bilateral neck exploration parathyroidectomy. In 29 persistent hyperparathyroidism patients, the causes of persistent hyperparathyroidism were pre-op imaging in 18 (62.0%) patients, inexperience of surgeon in 6 (20.6%) patients, and ectopic localization of parathyroid adenoma in 5 (17.4%) patients. Success was achieved in 35 (97.2%) patients after a second surgery, while 1 (2.8%) persistent hyperparathyroidism patient was followed up with medical treatment because no pathological parathyroid adenoma was detected in the imaging studies or in the second exploration. Hyperparathyroidism can persist after a first surgery due to localization discordance in pre-op imaging modalities, inadequate surgical experience, and sometimes because parathyroid adenoma cannot be found despite all efforts. In more than 80% of cases, persistent hyperparathyroidism can be prevented with careful pre-op image studies and surgeries performed by experienced surgeons.

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

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

Performance of F-18 Fluorocholine PET/CT for Detection of Hyperfunctioning Parathyroid Tissue in Patients with Elevated Parathyroid Hormone Levels and Negative or Discrepant Results in conventional Imaging.

ObjectiveOur aim was to assess the diagnostic performance of F-18 fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) in detecting hyperfunctioning parathyroid tissue (HPT) in patients with elevated parathyroid hormone levels with negative or inconclusive conventional imaging results and to compare the findings with those obtained using technetium-99m sestamibi (MIBI) scintigraphy and neck ultrasonography (US).Materials and MethodsImages of 105 patients with hyperparathyroidism who underwent FCH PET/CT, dual-phase MIBI parathyroid scintigraphy (median interval: 42 days), and neck US were retrospectively analyzed. The gold standard was histopathological findings for 81 patients who underwent parathyroidectomy and clinical follow-up findings in the remaining 24 patients. Sensitivities, positive predictive values (PPVs), and accuracies were calculated for all imaging modalities.ResultsAmong the 81 patients who underwent parathyroidectomy, either parathyroid adenoma (n = 64), hyperplasia (n = 9), neoplasia (n = 4), or both parathyroid adenoma and hyperplasia (n = 1) were detected, except 3 patients who did not show HPT. Of the 24 (23%) patients who were followed-up without operation, 22 (92%) showed persistent hyperparathyroidism. FCH PET/CT showed significantly higher sensitivity than MIBI scintigraphy and US in detection of HPT (p < 0.01). Sensitivity, PPV, and accuracy of FCH PET/CT were 94.1% (95/101), 97.9% (95/97), and 92.4% (97/105), respectively. The corresponding values for MIBI scintigraphy and US were 45.1% (46/102), 97.9% (46/47), and 45.7% (48/105) and 44.1% (45/102), 93.8% (45/48), and 42.9% (45/105), respectively. Among the 35 patients showing negative MIBI scintigraphy and neck US findings, 30 (86%) showed positive results on FCH PET/CT. FCH PET/CT could demonstrate ectopic locations of HPT in 11 patients whereas MIBI and US showed positive findings in only 6 and 3 patients, respectively.ConclusionFCH PET/CT is an effective imaging modality for detection of HPT with the highest sensitivity among the available imaging techniques. Therefore, FCH PET/CT can be recommended especially for patients who show negative or inconclusive results on conventional imaging.

Ultrasound and Technetium-99m Sestamibi Scintigraphy Diagnostic Performance as Preferred Localization Techniques in Patients with Primary Hyperparathyroidism: A Literature Review

Ultrasound and Technetium-99m Sestamibi Scintigraphy Diagnostic Performance as Preferred Localization Techniques in Patients with Primary Hyperparathyroidism: A Literature Review

Indocyanine Green Fluorescence Angiography Can Guide Intraoperative Localization During Parathyroid Surgery.

Intraoperative localization of pathologic parathyroid glands is of major importance for the hyperparathyroidism treatment. Based on the small size and the anatomic variability, the localization can be very challenging. The current practice is to compare preoperative ultrasonography with Technetium-99m sestamibi scintigraphy (MIBI) and plan the resection accordingly. In this study, we implemented indocyanine green angiography for the intraoperative localization of parathyroid glands. This is a retrospective analysis of 37 patients with primary, secondary, or tertiary hyperparathyroidism who were operated using indocyanine green angiography for the intraoperative localization of pathological parathyroid glands. An indocyanine green solution of 2.5 mg was were intravenously administered for parathyroid gland visualization. Different fluorescence scores were correlated with changes in postoperative parathyroid hormone levels. Patients were divided into two groups depending on the presence of uniglandular or multiglandular disease. Sixty-four lesions were resected, and the final histopathologic analysis confirmed the parathyroid origin in 62 of them (96.8%). None of the patients with uniglandular disease developed postoperative hypoparathyroidism, whereas three patients in the multiglandular group developed temporary hypoparathyroidism symptoms. Indocyanine green imaging had higher sensitivity for the intraoperative detection of parathyroid glands compared with ultrasonography and MIBI (p < 0.001). Indocyanine green angiography indicated high sensitivity for the intraoperative identification of pathologic parathyroid glands leading to a resection rate of 95.16%. The modality was useful, especially in cases of revisional surgery or ectopic parathyroid glands. Randomized trials have already proven the value of indocyanine green imaging in predicting postoperative hypocalcemia. Our results support the regular use of this method during parathyroid surgery.

MON-LB088 Comparative Study of Single Photon Emission Computed Tomography (SPECT)/CT Imaging Versus Combined Planar Technetium-99m Sestamibi -Ultrasonographic Imaging for Pre-Operative Parathyroid Localisation in Primary Hyperparathyroidism.

Primary hyperparathyroidism is the third most common endocrine disorder in the western world with an estimated prevalence of 1-4 per 1000.The only curative treatment is surgical resection. Minimally invasive surgical techniques are preferred over bilateral neck exploration due to reduced risk of surgical complications (1.2% vs 3%) and seven-fold shorter hospital stay with cost reduction of up to 50% (1); however this requires accurate preoperative localisation. Various imaging modalities evolved over time to identify pathological parathyroid glands pre-operatively. Imaging modality which is non-invasive, accurate and has minimal radiation exposure should be preferred as a first line option. Planar Technetium-99m Sestamibi scintigraphy coupled with Ultrasonography (MIBI/USS) has conventionally been used as the localisation study of choice. Single Photon Emission Computed Tomography (SPECT)/CT has been introduced recently and adopted by our centre as a first line investigation. The aim of the current study was to compare the accuracy of MIBI/USS versus SPECT/CT in localising pathological parathyroid glands preoperatively and assess the influence of imaging modality on surgical outcomes. A total of 135 patients with confirmed primary hyperparathyroidism were studied retrospectively in a tertiary centre over 24 months period. 61 patients underwent MIBI/USS and 74 had SPECT/CT as first line imaging. 82% of patients were female with mean age of 67 years. Preoperatively Sestamibi -SPECT/CT identified the laterality of the adenoma in 78.4% of cases, compared to 49.2% in MIBI/USS (p<0.001). Post operative surgical and histological concordance in terms of laterality and position (inferior or superior) of the hyper-functioning gland SPECT/CT (59.5%) was still superior compared to MIBI/USS (34.4%), p=0.04. There were two cases of intra-thyroidal adenoma of which both were identified by SPECT/CT. Additionally there were two cases of mediastinal parathyroid foci identified on SPECT/CT. None of the patients who underwent MIBI/USS had ectopic foci. Out of the 135 patients, 83.0% had a single parathyroid adenoma, 9.6% had single or multi-gland hyperplasia, 1.4% had ectopic parathyroid adenomas (n=1 mediastinal, n=1 thymus) and there were no cases of parathyroid carcinoma. 16 patients (22.5%) in the SPECT/CT group had bilateral neck exploration versus 24 (39.3%) in the MIBI/USS group (p = 0.04).There was no difference in length of hospital stay (average 1 day) between groups and no significant difference in post operative complications (laryngeal nerve palsy, post-operative hypocalcaemia) between the two groups . There was no statistically significant difference between cure rates with either modality of imaging MIBI/USS or SPECT/CT (93.4% and 93.1% respectively, p=0.93) (1).R.UDELSMAN. 656 consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002;235(5):665-70 Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

Parathyroidectomy for primary hyperparathyroidism: The results of a single institution

Aim: Primary hyperparathyroidism (PHPT) is a clinical entity characterized by an excess synthesis of parathormone due to one or more autonomic parathyroid gland. The present study aims to evaluate the outcomes of parathyroidectomies performed due to PHPT.Material and Methods: The results of 52 parathyroidectomies performed due to PHPT between September 2014 and October 2018 were retrospectively evaluated for demographic, clinical, imaging and pathologic characteristics.Results: Fifty-two patients with primary hyperparathyroidism were included in the study. The mean age of the patients was 50±14.5 years. Forty-three (82.9%) patients were female and 9 (17.4%) were male. The most common complaints at admission were generalized muscle and bone pain in 13 patients (15.3%). In 2 patients (3.8%) osteoporosis and another 2 (3.8%) patients, nephrolithiasis was identified. Thirty- five (67.3%) patients had no complaints. The mean preoperative calcium level was 11.21±0.88 mg/dl. Mean preoperative phosphate level was 2.58±0.72 mg/ dl. Mean preoperative parathormone level was 278.65±317.67 pg/ml. Technetium 99m-sestamibi scintigraphy was obtained for 41 patients. Cervical ultrasonography was performed in 43 patients. The surgical localization of the parathyroid adenoma showed that the accuracy of ultrasonography was 60.4% whereas the accuracy of Technetium 99m-sestamibi scintigraphy was 80.4%. Three of the 12 (25%) patients with no localization in ultrasonography had parathyroid hyperplasia as the pathologic diagnosis. There were two patients in whom ultrasonography and scintigraphy could not localize the pathologic parathyroid tissue and all of them (100%) were found to have parathyroid hyperplasia as the pathologic evaluation. Pathologic evaluation of the surgical specimens showed that there was adenoma in 40 patients (76.9%), hyperplasia in 5 (9.6%), normal parathyroid tissue in 5 (9.6%), tumor with undetermined biologic potential in 1 patient (1.9%) and adenomatous parathyroid tissue in 1 patient (1.9%). In fifteen patients (28.8%) concomitant total thyroidectomy, right lobectomy in 7 patients (13.4%)and left lobectomy in 4 patients (7.6%) were performed.Conclusion: Parathyroid adenoma can be localized in places other than the expected locations; despite the advances in imaging technologies. Surgeons experience and accurate localization before the operation are important for a successful parathyroid operation. If scintigraphy and ultrasonography cannot localize the pathologic parathyroid tissue, hyperplasia should be suspected.

Osteolytic lesions (brown tumors) of primary hyperparathyroidism misdiagnosed as multifocal giant cell tumor of the distal ulna and radius: a case report

BackgroundBrown tumors represent a rare clinical manifestation reported in approximately 3% of patients with primary hyperparathyroidism and correspond to radiologically osteolytic lesions with well-defined borders in different parts of the skeleton.Case presentationWe report the case of a 53-year-old white man who presented to our hospital with osteolytic lesions of his distal ulna and radius, causing pain and swelling of 2-month duration. A subsequent biopsy revealed histological features consistent with giant cell tumor and a complete resection of his distal ulna was followed, along with curettage and cementoplasty of the distal radial metaphysis. Two weeks later, he was re-admitted with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain and multiple osteolytic lesions on plain radiographs. A histopathological examination of the ulna and radius specimens showed similar findings and, given the multifocality, brown tumors related to primary or secondary hyperparathyroidism was included in the differential diagnosis. A laboratory examination showed high total serum calcium (14.5 mg/dl) and low serum phosphorus and 25-hydroxyvitamin D levels. Primary hyperparathyroidism was suspected and confirmed by the elevated parathyroid hormone levels of 1453 pg/mL. At radiological work-up, using computed tomography, ultrasonography, and parathyroid subtraction technetium-99m sestamibi scintigraphy, a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland was detected, displaying extensive uptake in the right lower parathyroid gland. After appropriate medical support including hyperhydration and high doses of diuretics and diphosphonates, his laboratory profile normalized and he underwent total thyroidectomy with removal of the parathyroid glands. Our patient is now recovering 12 months after surgery, with normal values of serum parathyroid hormone and calcium levels. The lytic bone lesions have almost disappeared and no other additional orthopedic intervention was necessary.ConclusionsThe present case report emphasizes the need of inclusion of brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid harmful surgical interventions. Laboratory testing of serum phosphate, calcium levels, and parathyroid hormone levels should always be included in the routine survey of patients with multifocal osteolytic lesions.

Evaluation of the minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: A retrospective cohort study.

IntroductionAn accurate differential diagnosis between single adenoma (SA) and multiglandular disease (MGD) remains difficult in Technetium-99m sestamibi scintigraphy (MIBI)-negative patients with primary hyperparathyroidism (PHPT). The aim of the present study was to evaluate the minimally invasive parathyroidectomy (MIP) in patients with PHPT.MethodsClinical records of 48 patients who underwent neck exploration between November 2002 and June 2012 in Kochi Medical School Hospital were reviewed retrospectively to identify candidates that underwent for MIP which was defined as the selective removal of a SA using less invasive surgery.ResultsThe preoperative detection rate of lesions using ultrasonography, MIBI, computed tomography, and magnetic resonance imaging was 90%, 83%, 76%, and 55%, respectively. Although all 39 patients in the MIBI-positive group were diagnosed with an SA and subsequently underwent curative MIP, 3 patients in MIBI-negative group (n = 6) were MGD, who underwent neck exploration. Preoperative mean intact parathyroid hormone (419 pg/ml vs. 149 pg/ml; P < 0.01) and alkaline phosphatase levels (746 U/l vs. 277 U/l; P < 0.01) were significantly higher in the SA than MGD group.ConclusionsIn MIBI-negative patients with indications for surgery, MIP should not be carried out without a clear localization of SA, or in MGD.

Multiple endocrine neoplasia type 1 with anterior mediastinal parathyroid adenoma: successful localization using Tc-99m sestamibi SPECT/CT

The most common manifestation of multiple endocrine neoplasia type 1 (MEN1) is hyperparathyroidism. Treatment of hyperparathyroidism in MEN patients is surgical removal of the parathyroid glands, however ectopic parathyroid gland is challenging for treatment. A 51-year-old female, the eldest of 3 MEN1 sisters, had hyperparathyroidism with ectopic parathyroid adenoma in the mediastinal para-aortic region, which was detected by technetium-99m (Tc-99m) sestamibi scintigraphy and single-photon emission computed tomography/computed tomography (SPECT/CT). She underwent total parathyroidectomy with video-assisted thoracoscopic surgery on an anterior mediastinal mass. Anterior mediastinal parathyroid adenoma in MEN1 patients is rare. Precise localization of an ectopic parathyroid gland with Tc-99m sestamibi SPECT/CT can lead to successful treatment of hyperparathyroidism. This is the first reported case in the literature of mediastinal parathyroid adenoma in MEN1 patient visualized by Tc-99m sestamibi SPECT/CT.

Improvement of minimally invasive parathyroidectomy outcomes by real time ultrasonography performed by a surgeon and radiologist team.

Minimally invasive parathyroidectomy (MIP) has become the first line of treatment for primary hyperparathyroidism caused by solitary parathyroid adenoma. In order to increase the sensitivity of high-resolution ultrasonography (hUS), surgeon performed ultrasonography (SUS) has been increasingly used preoperatively. However, a radiologist and surgeon performing ultrasonography (RSUS) has not been a usual practice. In this study, we aimed to evaluate the clinical contribution of RSUS on MIP. From 2012 to 2014, a total of 30 consecutive patients (4 male, 26 female, mean age 48.87+/-14.52 years) with solitary parathyroid adenoma, were included in the study. All patients underwent preoperative hUS and Technetium-99m sestamibi scintigraphy. In patients, demographic characteristics, diagnostic tools used, levels of biochemical parameters, duration of operation, and length of hospital stay were recorded. Adenomas were successfully localized by US in all patients and the surgical approach was determined according to this localization. Parathyroidectomy with MIP was successfully performed under local anesthesia in all patients. Mean operation time was 19.87+/-3.35 min. Postoperative PTH and calcium values were significantly decreased. All patients were discharged from the hospital in the same day. None of the patients had complications such as recurrent laryngeal nerve injury, hematoma, or injury to nearby organs. None of the patients had drains placed. Adenoma is well localized by US and thus, MIP can be completed under local anesthesia. US provides a very important clinical contribution to the success of MIP. In addition to these, RSUS helps in determining the location of the incision and the shortest way to achieve the lesion; therefore, it provides a small incision and shortens duration of the operation with a minimal dissection.

Abstract #1065: Technetium 99M Sestamibi Scintigraphy Steal: “Parathyroid Steal” by Papillary Thyroid Cancer

Abstract #1065: Technetium 99M Sestamibi Scintigraphy Steal: “Parathyroid Steal” by Papillary Thyroid Cancer

A 20-year study on 190 patients with primary hyperparathyroidism in a developing country: Turkey experience.

The aim of this study was to present our 20-year experience regarding primary hyperparathyroidism (PHPT). PHPT patients who underwent parathyroidectomy in our clinic were reviewed retrospectively. There were 190 PHPT patients, of whom 137 were asymptomatic (72%). The mean serum calcium at the time of diagnosis was 11.9 ± 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 ± 78 pg/mL. Ultrasonography (USG) identified all abnormal glands accurately (82.6%) and Technetium-99m sestamibi scintigraphy (MIBI) was used in 89.4% of the patients and magnetic resonance imaging (MRI) in 61%. The common use of USG and MIBI detected 92% of the lesions. Bilateral neck exploration (BNE) was performed in 12.2% of the patients and focused unilateral neck exploration (FUNE) in the remaining 87.8%. Surgical intervention was unsuccessful in 1 patient (0.5%). The conversion ratio from FUNE to BNE was 5.2%. The mean operation time and mean hospital stay decreased significantly in patients with FUNE. Pathologic examination revealed single adenoma in 93% of the patients. New imaging techniques result in the conversion of surgical treatments of PHPT. FUNE in parathyroidectomy performed by an experienced surgeon may provide successful treatment rates.

Role of ultrasonography in the management of patients with primary hyperparathyroidism: retrospective comparison with technetium-99m sestamibi scintigraphy

Primary hyperparathyroidism (PHPT) is a common endocrine disorder that can be cured only by parathyroidectomy. Cervical ultrasonography and scintigraphy are the imaging studies most widely used for preoperative localization of the affected glands. The aim of this retrospective comparative study was to define the respective roles of ultrasonography and parathyroid scintigraphy in these cases. We analyzed 108 patients who had undergone parathyroidectomies for PHPT following cervical ultrasonographic and scintigraphic examinations. The ultrasound examinations were carried out by an expert physician sonographer in 61 cases and by various physician sonographers with different levels of experience in 47 cases. Sonographic and scintigraphic findings were compared with surgical findings and the diagnostic performance of the two imaging methods was evaluated by means of statistical analysis. The operator dependency of ultrasonography was confirmed by marked variations in sensitivity related to the experience of the sonographer. When sonography was performed by an expert, the sensitivity of combined use of the two methods was not significantly higher than that of sonography alone. In expert hands, the diagnostic yield of ultrasound is appreciably superior. It can therefore be used as the main and possibly sole method for preoperative localization of pathological parathyroid tissues. Combined use of ultrasound and scintigraphy is not cost-effective in these cases. Scintigraphy is indicated only when the ultrasound examination produces negative results.

Peri-procedural tight glycemic control during early percutaneous coronary intervention up-regulates endothelial progenitor cell level and differentiation during acute ST-elevation myocardial infarction: Effects on myocardial salvage

We examined the effects of peri-procedural intensive glycemic control during early percutaneous coronary intervention (PCI) on the number and differentiation of endothelial progenitor cells (EPCs) and myocardial salvage (MS) in hyperglycemic patients with first ST-elevation myocardial infarction (STEMI). We conducted a randomized, prospective, open label study on 194 patients with STEMI undergoing PCI: 88 normoglycemic patients (glucose < 140 mg/dl) served as the control group. Hyperglycemic patients (glucose ≥140 mg/dl) were randomized to intensive glycemic control (IGC) for almost 24 h after PCI (n = 54; 80-140 mg/dl) or conventional glycemic control (CGC, n = 52; 180-200 mg/dl). EPC number, differentiation, and SIRT1expression were assessed immediately before, 24 h, 7, 30 and 180 days after PCI. The primary end point of the study was salvage index, measured as the proportion of initial perfusion defect (acute technetium-99m sestamibi scintigraphy, performed 5 to 7 days after STEMI) and myocardium salvaged by therapy (6 months after STEMI). Hyperglycemic patients had lower EPC number and differentiation and lower SIRT1 levels than normoglycemic patients (P < 0.01). After the insulin infusion, mean plasma glucose during peri-procedural period was greater in CGC group than in IGC group (P < 0.001). The EPC number, their capability to differentiate, and SIRT1 levels were significantly higher in IGC group than in CGC, peaking after 24 h (P < 0.01). In the IGC group, the salvage index was greater than in patients treated with CGC (P < 0.001). Optimal peri-procedural glycemic control, by increasing EPC number and their capability to differentiate, may improve the myocardial salvage.

Can the use of intraoperative intact parathyroid hormone monitoring be abandoned in patients with hyperparathyroidism?

BackgroundUltrasound (US) and technetium-99m sestamibi scintigraphy (MIBI) are used to determine the localization of abnormal glands in cases of primary hyperparathyroidism (PHPT). Intraoperative intact parathyroid hormone (iPTH) monitoring is a reliable examination used to cure PHPT. The aim was to assess the necessity of intraoperative iPTH monitoring. MethodsSixty patients were examined using preoperative MIBI and US. iPTH was measured at 3 time points: (1) at the start of surgery; (2) 10 minutes after gland resection; and (3) more than 60 minutes after surgery. We defined a decreased iPTH level as an iPTH measured 10 minutes after resection that was less than 50% of the preoperative level. ResultsThe iPTH of 55 patients with concordant lesions decreased to within the normal range more than 60 minutes after surgery. ConclusionsIt is not necessary to monitor intraoperative iPTH when single concordant lesions are preoperatively identified on both MIBI and US.

Early-phase technetium-99m sestamibi scintigraphy can improve preoperative localization in primary hyperparathyroidism

BackgroundIn hyperparathyroidism, dual-phase technetium-99m sestamibi scintigraphy is important for parathyroid adenoma localization. We hypothesized that reviewing early-phase scans can increase localization in patients with primary hyperparathyroidism (PHPT). MethodsWe reviewed our prospectively maintained database for patients with sestamibi scans before parathyroidectomy for PHPT from 2001 to 2011. Early-phase scans were read and compared with the location of the gland(s) removed at operation. ResultsOf 902 patients identified, radiologists read 693 scans as positive. Of 209 negative scans, 141 (67%) were positive in the early phase; 135 (96%) correctly identified the side of the adenoma. Using radiologist reads, 35% of patients with negative scans and 41% of patients with falsely localized glands required bilateral exploration compared with 5% of patients with correctly localized glands. ConclusionsA review of early scans in patients with negative imaging increases accurate adenoma localization and allows for minimally invasive operations in more patients.