American Association of Endocrine SurgeonDetection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy
Section snippets
Methods
Patients (N = 358) undergoing parathyroidectomy at one institution (Froedtert Memorial Lutheran Hospital/Medical College of Wisconsin)4 starting from December 1999 through January 2004 were prospectively entered into a database. Of these, 233 met the criteria of having (1) primary hyperparathyroidism, (2) no prior parathyroid operation, and (3) preoperative sestamibi imaging (MIBI), ultrasound, and IOPTH. Fourteen patients were excluded because of secondary and tertiary hyperparathyroidism; 28
Results
Of the 233 patients studied, 173 (74%) were female, and 60 (26%) were male. Their mean age was 56 years (range, 16-91 years). The mean preoperative calcium concentration was 11.2 mg/dL (range, 9.6-14 mg/dL; reference range, 8.4-10.5 mg/dL), and PTH level was 132 pg/mL (range, 41-571 pg/mL; reference range, 10-65 pg/mL). None had multiple endocrine neoplasia, and 7 had prior thyroid operations. There were 23 (10%) patients with MGD, 204 (88%) with SGD, and 6 (2.6%) had persistent
Discussion
A focused approach to parathyroid surgery has been increasingly utilized since the introduction of IOPTH and the gamma probe. Although this approach is ideal for SGD, its ability to produce long-term cure rates equivalent to 4-gland exploration has been questioned by some, citing the possibility of missed MGD with a lesser exploration.16 The success of a focused or minimally invasive approach is dependent on the detection of MGD with the various modalities including preoperative imaging with
Conclusion
The detection of MGD with preoperative imaging is poor with either ultrasound or MIBI alone. The combination of ultrasound and MIBI provided information (MGD, discordant, nonlocalizing) warranting a bilateral approach in most patients with MGD. IOPTH was the most sensitive test but still failed to detect some cases of MGD. The combination of preoperative imaging and IOPTH is the best predictor of MGD. Further refinement and experience with these methods will hopefully lead to improvement in
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Cited by (83)
Analysis of Preoperative Predictors of Single and Multigland Primary Hyperparathyroidism
2023, Journal of Surgical ResearchFocused parathyroidectomy without intraoperative parathyroid hormone measurement in primary hyperparathyroidism: Still a valid approach?
2021, Surgery (United States)Citation Excerpt :Importantly, FPTx is associated with decreased rates of recurrent laryngeal nerve injuries, postoperative pain, and transient or permanent hypocalcemia as well as shorter operative time, length of stay, improved cosmesis, and cost-effectiveness.19,30–33,41,42 The potential shortcoming of the FPTx is the failure in patients with unrecognized MGD of 16% with and 22%43 without ioPTH and the low sensitivity of preoperative imaging to detect MGD.25,44,45 FPTx should be avoided in patients with discordant or negative localization studies and used very selectively in those with known propensity to multiple gland disease, that is, known or suspected multiple endocrine neoplasia types 1 and 2a, familial PHPT, or lithium-induced disease due21,22,46,47 or those with other aspects that may contribute to missed lesions on imaging (eg, thyroid nodularity, thyroiditis).
Parathyroid Imaging: Four-dimensional Computed Tomography, Sestamibi, and Ultrasonography
2021, Neuroimaging Clinics of North AmericaEvaluation of switch from satellite laboratory to central laboratory for testing of intraoperative parathyroid hormone
2020, Practical Laboratory Medicine
Presented at the 25th Annual Meeting of the American Association of Endocrine Surgeons, Charlottesville, Virginia, April 4-6, 2004.
Supported in part by the Geiger Foundation.