Randomized clinical trial comparing scan-directed unilateral <i>versus</i> bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma

Russell, C. F. J.; Dolan, S. J.; Laird, J. D.

doi:10.1002/bjs.5250

Cited by 100 publications

(71 citation statements)

References 14 publications

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“…However, 24-27% of preoperative imaging results are discordant (6,16) and 12-18% are negative (17,18,19); for these cases, the gold standard for surgery remains bilateral exploration (5). The choice between the treatment strategies of focused parathyroidectomy and bilateral exploration remains a matter of debate (20,21,22,23). However, recent data in the literature suggested that focused parathyroidectomy was less expensive and induced fewer side effects with at least identical remission rates, resulting in a shorter hospital stay (5,24).…”

Section: Introductionmentioning

confidence: 99%

Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

Philippon

Guérin

Taïeb

et al. 2014

European Journal of Endocrinology

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Introduction: Focused parathyroidectomy is the treatment of choice for patients with concordant positive imaging. Bilateral cervical exploration is performed for cases with discordant imaging, yet more than 70% of those cases are the result of a single-gland disease. As focused parathyroidectomy is generally costless and harmless, for cases with discordant imaging, we tried to determine whether preoperative characteristics can lead to a diagnosis of single-gland disease. Methods: This study included 182 patients treated for primary hyperparathyroidism by bilateral exploration from 2009 to 2012 at La Timone Hospital, Marseille, France. We classified patients based on preoperative images and pathological results (single-gland or multiglandular disease). We then compared the demographical, laboratory and imaging results. We also asked a senior nuclear medicine practitioner who was blind to the ultrasound and pathological results to perform a second reading. Results: Of the total number of patients, 15.4% had negative, 54.4% discordant and 30.2% concordant imaging. After reviewing the scintigraphy results, 8% of the cases with discordant imaging would have been classified as concordant with ultrasound. Subtraction scintigraphy obtained better results than dual-phase scintigraphy (concordance with ultrasound in 50 vs 31% with classical scintigraphy). For the cases of discordant imaging, no predictive factors of single-gland disease could be identified. Ultrasound and scintigraphy were similarly effective in determining the correct location of the abnormal gland. Conclusion: Discordant results of preoperative imaging modalities do not discriminate between uniglandular and multiglandular diseases in hyperparathyroidism. Diagnostic differentiation between the different causes of hyperparathyroidism requires improvements in imaging techniques and might benefit from subtraction scintigraphy.

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Section: Introductionmentioning

confidence: 99%

Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

Philippon

Guérin

Taïeb

et al. 2014

European Journal of Endocrinology

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“…6,10,11,13,15,16 Focused unilateral parathyroid exploration leads to reduced postoperative pain and lower incidence of hypocalcaemia from ischemia of other glands with smaller incision and less dissection, less operation time, hospital stay, and patient cost. [30][31][32][33][34][35] In this study, focused unilateral parathyroid exploration was performed with small cervical incision under general anesthesia. One recurrence and 2 transient unilateral recurrent nerve paralyses were found, achieving a success rate of 99.52%.…”

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confidence: 99%

A 20-Year Study on 190 Patients With Primary Hyperparathyroidism in a Developing Country: Turkey Experience

Usta

Alhan

Çinel

et al. 2015

International Surgery

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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 6 2.2 mg/dL. The mean parathyroid hormone (PTH) level was 467 6 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.

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“…Recently, preoperative localization imaging studies including by sestamibi scintigraphy and ultrasonography, have enabled accurate localization of enlarged parathyroid glands [5][6][7], and the surgical approach to the treatment of pHPT has changed to image-guided, focused, targeted parathyroidectomy through smaller incisions, with fewer complications and a shorter operating time [8][9][10][11]. However, the success of this minimally invasive surgery depends not only on the accuracy of localization studies, but on the methods of ruling out multiglandular disease and determining that a cure has been achieved.…”

Section: Discussionmentioning

confidence: 99%

Minimally invasive surgery for primary hyperparathyroidism with or without intraoperative parathyroid hormone monitoring

et al. 2010

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Bilateral neck exploration, the identification of all parathyroid glands and removal of all abnormal glands, has traditionally been regarded as the standard surgical strategy for the treatment of primary hyperparathyroidism (pHPT) [1][2][3][4]. However, in recent years, several investigators have questioned the routine performance of bilateral neck exploration because the cause of pHPT in most patients is a single parathyroid adenoma and preoperative imaging tests, such as Technetium-99m sestamibi scans and ultrasound examination have enabled precise localization of the affected parathyroid gland with high sensitivity [5][6][7]. Use of intraoperative PTH (IOPTH) measurement or the gamma probe with perioperative sestamibi injection has also contributed to improving results A group who underwent surgery without IOPTH monitoring (Group 1; n=87), and a group who underwent surgery with IOPTH monitoring (Group 2; n=80), in which IOPTH was measured at 5, 10, 15 minutes after excision of the abnormal parathyroid gland. Criterion for evaluation as a cure was a drop in intact PTH level of 50% or more from the preoperative baseline value. The overall cure rate in Group 1 was 93.1%. An enlarged parathyroid gland that was consistent with the results of a preoperative imaging study was found in 84 patients (96.6%). The overall cure rate in Group 2 was 97.5%. In 7 of the patients, there was no drop of 50% or more at any of the 3 points in time measured. Two of these patients were found to have had double adenomas, one on each side, during the initial surgery. Three others were eucalcemic and had normal intact PTH values after surgery, and the remaining 2 patients had persistent disease. Although preoperative localization studies are accurate and essential, IOPTH monitoring improves the cure rate of minimally invasive parathyroidectomy. IOPTH monitoring is a valuable adjunct to achieve adequate intraoperative decision-making, recognizing and resecting additional image-negative hyperfunctioning lesions.

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Randomized clinical trial comparing scan-directed unilateral versus bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma

Abstract: Scan-directed unilateral cervical exploration for HPT does not significantly increase the incidence of persistent hypercalcaemia compared with standard bilateral operation.

Cited by 100 publications

References 14 publications

Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

A 20-Year Study on 190 Patients With Primary Hyperparathyroidism in a Developing Country: Turkey Experience

Minimally invasive surgery for primary hyperparathyroidism with or without intraoperative parathyroid hormone monitoring

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