Initial failure of surgical exploration in patients with primary hyperparathyroidism

Auguste, Louis‐Joseph; Attie, Joseph N.; Schnaap, David

doi:10.1016/s0002-9610(05)80536-7

Cited by 61 publications

(21 citation statements)

References 11 publications

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“…811/0 compares well with the rates of between 3% and 8% seen in other studies. 12 It may be possible to achieve a definitive diagnosis of FBH without resorting to family studies by employing a plot of CaE against fasting serum PTH concentration (Fig. 4).…”

Section: Discussionmentioning

confidence: 99%

Urine Calcium and Serum Ionized Calcium, Total Calcium and Parathyroid Hormone Concentrations in the Diagnosis of Primary Hyperparathyroidism and Familial Benign Hypercalcaemia

Gunn¹,

Wallace²

1992

Ann Clin Biochem

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SUMMARY.A relationship between serum concentrations of ionized calcium and parathyroid hormone (PTH) in persons without parathyroid over activity was defined by performing an oral calcium load test. As a result, a serum PTH concentration greater than 2· 6 pmol/L in a hypercalcaemic patient was regarded as suggestive of hyperparathyroidism. Fasting serum PTH concentrations in 58 patients with surgically and histologically proven primary hyperparathyroidism (PHPD were all above 2· 7 pmol/L (range 3' 2-84' 5). Thirteen of 20 patients with familial benign hypercalcaemia (FBH) had fasting serum PTH concentrations greater than 2· 6 pmollL (range 1'6-6'1). There was a significant correlation between serum PTH and age in the FBH patients only. Fasting urine calcium excretion (CaE) ranged from 14 to 222 p.mol/L of glomerular filtrate in PHPT and 3-34 p.mol/L of glomerular filtrate in FBH. The best biochemical discriminant between patients with PHPT and FBH was a plot of fasting serum PTH against CaE' A plot of post-calcium load PTH against post-load CaE showed no further significant advantage in discriminating between the two conditions. Additional key phrases: hypercalcaemia; calcium excretion; differential diagnosisMost patients with biochemical evidence of primary hyperparathyroidism (PHPT) are referred to a parathyroid surgeon, even if symptoms are mild or absent.t-' The advent of technology enabling measurement of the intact PTH molecule in serum has improved our ability to diagnose PHPT biochemically.v' but the lower limit of serum PTH concentration in patients with proven PHPT has not been established. The inherited condition familial benign hypercalcaemia (FBH) is recognized as one which can be difficult to distinguish from PHPT biochemically. 5 FBH is characterized by asymptomatic hypercalcaemia beginning early in life. It is inherited in an autosomal dominant pattern with high penetrance. Patients with FBH should not be advised to undergo parathyroid surgery. The condition probably accounts for around 10070 of cases of unsuccessful parathyroid explorations.' We have studied a number of blood and urine measurements to try to achieve Correspondence: Dr Ian R Gunn. 52clear distinction among patients without parathyroid pathology, patients with PHPT and those with FBH. SUBJECTS AND METHODSHealthy volunteers comprised 38 laboratory workers (19 women, 19 men, age range 18-60).Fifty-eight patients (43 females, 15 males, age range 24-90) had histologically proven PH PT. Fifty had a single adenoma, and the remaining eight had two or three enlarged overactive glands. None had diffuse hyperplasia of all four glands. Three of the eight with more than one enlarged gland developed post-operative hypocalcaemia which required treatment with vitamin D. In two cases, the diagnosis of PHPT had been confirmed at post-mortem examination, but in the other 53 cases stable normocalcaemia was achieved postoperatively without calcium or vitamin D therapy.Twenty patients (12 females, 8 males, age range 9-69) from four different families ...

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Section: Discussionmentioning

confidence: 99%

Urine Calcium and Serum Ionized Calcium, Total Calcium and Parathyroid Hormone Concentrations in the Diagnosis of Primary Hyperparathyroidism and Familial Benign Hypercalcaemia

Gunn¹,

Wallace²

1992

Ann Clin Biochem

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“…It appears difficult to propose an alternative surgical approach able to further improve the efficacy of BNE. However, some considerations can be made: (i) without preoperative imaging, the parathyroid glands localized in orthotopic sites are easily detected intraoperatively -conversely, the ectopic glands can be missed; (ii) some morbidity (hypoparathyroidism and laryngeal nerve injury) is associated with BNE, especially when biopsy of normal-sized glands is applied or when re-operation is required for persistent/recurrent HPT (2,4); and (iii) cosmetic results are less than optimal. Furthermore, since primary HPT is caused by a solitary adenoma in about 85% of all cases, BNE is felt by many surgeons to be overtreatment in the majority of these patients.…”

Section: Introductionmentioning

confidence: 99%

Role of gamma probes in performing minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: optimization of preoperative and intraoperative procedures

Rubello

Piotto²,

Casara³

et al. 2003

European Journal of Endocrinology

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Objective: In the last decade, surgery of primary hyperparathyroidism (HPT) due to a solitary adenoma has moved on from the traditional wide bilateral neck exploration (BNE) to more limited approaches such as unilateral neck exploration and minimally invasive parathyroidectomy. Design: To define the role of intraoperative gamma probe and injection of a low 99m Tc-MIBI dose in performing minimally invasive radio-guided surgery (MIRS) in HPT patients with a solitary parathyroid adenoma. Methods: From September 1999 to July 2002, 214 patients with primary HPT entered the study. All patients were preoperatively investigated by a 99m Tc-pertechnetate/MIBI subtraction scan and high-resolution neck ultrasound. The intraoperative technique we developed differs from other previously described techniques being based on the injection of a low (37 MBq) MIBI dose in the operating theatre a few minutes before the beginning of intervention. Results: On the basis of scan/ultrasound findings 147 patients were selected for a MIRS and 144 of them (98%) were successfully treated by this approach: a solitary parathyroid adenoma was removed through a small 2-2.5 cm skin incision with a mean operative time of 35 min, and a mean hospital stay of 1.2 days. In the other 67 patients with scan/ultrasound evidence of concomitant nodular goiter (n ¼ 45) or multi-gland disease (n ¼ 13) or with a negative scan (n ¼ 9), the gamma probe was utilized during a traditional BNE. A low 37 MBq MIBI dose proved to be sufficient to perform a MIRS; moreover it delivered to the patient and surgeon a low, negligible, radiation exposure dose. Conclusions: The combination of a 99m Tc-pertechnetate/MIBI subtraction scan and neck ultrasound appears to be an accurate imaging protocol in selecting primary HPT patients as candidates for a MIRS. A MIBI dose as low as 37 MBq injected in the operating theatre just before the start of surgery appears to be adequate to perform radio-guided surgery.

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“…Indeed, Doppman suggested that the only localisation procedure required in these patients is to locate an experienced surgeon (1). The majority of patients are cured by means of this strategy, but a small percentage remain with persistent or recurrent hyperparathyroidism and some of them have ectopic glands (2). It is this group that require imaging before further, more technically difficult, surgical exploration.…”

Section: Introductionmentioning

confidence: 99%

[11C]Methionine positron emission tomography for patients with persistent or recurrent hyperparathyroidism after surgery

Cook

Wong

Smellie³

et al. 1998

European Journal of Endocrinology

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Objective: Reoperation in patients with recurrent hyperparathyroidism usually requires localisation of abnormal glands. Current imaging techniques are not always successful in this group of patients. An evaluation of [ 11 C]methionine positron emission tomography (PET) has been made to assess the ability of the technique to localise abnormal glands in patients with hyperparathyroidism after previous surgery. Subjects and Methods: Eight patients (five with primary, and three with tertiary hyperparathyroidism) who had undergone one to three previous surgical explorations were studied. [11 C]methionine PET scans of the neck and mediastinum were performed in all patients. All had recent technetium-99mTc subtraction (n ¼ 1) parathyroid scans available for comparison. Subsequent surgical correlation was available in all cases. Results: [11 C]methionine PET correctly located an abnormal site of uptake in all five patients with primary hyperparathyroidism compared with only one when conventional nuclear medicine methods were used. In the patients with tertiary hyperparathyroidism, [ 11 C]methionine PET correctly located one, confirmed the absence of cervical or mediastinal abnormality in a patient with an autotransplanted forearm autonomous gland, and failed to demonstrate an abnormality in a third. Tc-labelled sestamibi scans were negative in all three patients. Conclusion: [11 C]methionine PET correctly locates abnormal parathyroid glands in the majority of patients with persistent or recurrent hyperparathyroidism after surgery in whom conventional non-invasive nuclear medicine imaging has failed.

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Initial failure of surgical exploration in patients with primary hyperparathyroidism

Cited by 61 publications

References 11 publications

Urine Calcium and Serum Ionized Calcium, Total Calcium and Parathyroid Hormone Concentrations in the Diagnosis of Primary Hyperparathyroidism and Familial Benign Hypercalcaemia

Urine Calcium and Serum Ionized Calcium, Total Calcium and Parathyroid Hormone Concentrations in the Diagnosis of Primary Hyperparathyroidism and Familial Benign Hypercalcaemia

Role of gamma probes in performing minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: optimization of preoperative and intraoperative procedures

[11C]Methionine positron emission tomography for patients with persistent or recurrent hyperparathyroidism after surgery

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