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PubMed2002

Comparison of quick parathyroid assay for uniglandular and multiglandular parathyroid disease.

BACKGROUND: The quick intraoperative parathyroid assay (qPTH) has been proposed as an effective tool in the surgical management of hyperparathyroidism. This assay may facilitate directed, unilateral exploration for uniglandular disease; however, its role in the management of multiglandular disease remains unclear. The purpose of this study is to evaluate the use of qPTH in parathyroid surgery, and to compare the results for uniglandular and multiglandular disease. METHODS: A prospective analysis of 63 consecutive patients explored for hyperparathyroidism using the qPTH assay was performed. Preoperative localization studies including ultrasonography and sestamibi scan were routinely obtained. Blood samples for qPTH were routinely drawn prior to the surgical incision, prior to gland excision, as well as 5 and 10 minutes after gland excision. Patients with primary or secondary hyperplasia had blood samples drawn relative to a 3-1/2 gland resection. Additional samples were drawn as needed for patients with a double adenoma. A qPTH decline of greater than or equal to 50% of the highest preincision or gland preexcision level was considered successful. Unilateral neck exploration was routinely performed unless multiglandular disease was identified. Patients were followed up postoperatively with serum calcium levels and an 8-month median follow-up was recorded. RESULTS: Forty-nine of 63 (78%) patients were found to have a solitary parathyroid adenoma. The qPTH assay was successful in 48 (97%) patients with uniglandular disease. Forty-four of these 48 patients showed an appropriate assay decline 5 minutes after adenoma excision. One patient with a single adenoma showed a delayed 50% decline in qPTH at 20 minutes. Fourteen (22%) patients were found to have multiglandular disease: 6 patients with primary hyperplasia, 4 patients with hyperplasia secondary to renal failure, and 4 patients with double adenomas. All patients with multiglandular disease demonstrated a successful decrease in qPTH levels. All patients with hyperplasia secondary to renal failure showed a successful assay decline 5 minutes after 3-1/2 gland resection. Eight of 14 (57%) patients with multiglandular disease (4 double adenomas, and 4 hyperplasia) were suspected to have solitary adenomas preoperatively. Overall, 62 of 63 (98%) patients showed an appropriate assay decline within 10 minutes after gland excision. Postoperatively, all patients were normocalcemic with a median follow-up of 8 months. CONCLUSIONS: These data suggest that qPTH can accurately facilitate unilateral, directed neck exploration for uniglandular parathyroid disease, as well as guide the extent of gland resection for multiglandular disease. This assay reliably eliminates the most common cause of parathyroidectomy failure, which is unrecognized multiglandular disease. The qPTH assay can reliably be used with similar accuracy for patients with multiglandular disease as has been shown for uniglandular parathyroid disease.

Adenoma↗
PubMed1997

Percutaneous ethanol injection therapy in the treatment of thyroid and parathyroid diseases.

Relevant English language articles published from 1966 to 1995 regarding ethanol therapy in the treatment of thyroid and parathyroid diseases were identified through a MEDLINE search and manual searches of identified articles. The sclerosing properties of ethanol have been recognized for many years and have offered interventional possibilities in the management of various benign as well as malignant lesions. The mechanism of action of ethanol appears to be related to a direct coagulative necrosis and local partial or complete small vessel thrombosis. Ultrasound-guided percutaneous ethanol injection therapy (PEIT) is rapid and performed on an out-patient basis and has now gained wide acceptance due to the accumulating evidence of the efficacy and safety of this therapeutic tool. Yet, there is a lack of prospective, randomized clinical trials comparing PEIT with 131I therapy or surgery with regard to its effects, especially long-term ones and it should therefore still be considered an experimental procedure. In benign endocrine diseases, PEIT has shown promising results in the treatment of autonomous thyroid nodules, benign solitary cold solid as well as cystic thyroid nodules and parathyroid tumours. Its use in pretoxic and toxic thyroid nodules has been evaluated in several uncontrolled studies, all demonstrating a high success rate in spite of the large number of treatments needed. So far efficacy and cost-effectiveness seem inferior to 131I and surgery. Short-term results of PEIT in benign cystic thyroid nodules are convincing with a high cure rate, but no controlled studies with long-term results are available. Preliminary results suggest that PEIT could become an alternative to surgical excision or levothyroxine therapy in the symptomatic solid cold benign thyroid nodule. Ultrasound-guided PEIT of parathyroid tumours has proven to be a useful method in highly selected patients in whom surgery has been found non-attractive and medical treatment ineffective. However, no prospective randomized trials have been published comparing the results of PEIT in parathyroid tumours with conventional surgical and medical treatments. PEIT has never been tested against standard therapy, but seems inferior to 131I and surgery. Side-effects caused by ethanol injection are generally few and transient and are related to the injection into solid nodules rather than cysts. Ethanol injection into solid profund nodules may seriously jeopardize subsequent surgery because of perinodular fibrosis. As an experimental procedure, not yet evaluated sufficiently, it should be reserved for patients who cannot or will not undergo standard therapy. Caution in routine use is advisable.

Administration, Cutaneous↗
PubMed1977

Technetium-99m-Sn-pyrophosphate pharmaco-kinetics and bone image changes in parathyroid disease.

Skeletal abnormalities in 12 patients with primary hyperparathyroidism, five patients with pseudohypoparathyroidism, and three patients with hypoparathyroidism were studied to compare the diagnostic sensitivity of bone radiologic examination to that of radionuclide studies using 99mTc-Sn-pyrophosphate (99mTc-PPi) a skeletal-seeking radiopharmaceutical. The results were compared with bone mineral content as measrued by the Norland--Cameron densitometer. Kinetic data of the blood disappearance and plasma clearance of 99mTc-PPi were obtained and compared with data of control subjects without evidence of parathyroid disease. Bone imaging with 99mTc-PPi may be more sensitive than routine skeletal radiographs and bone mineral analysis for the evaluation of skeletal abnormalities in patients with parathyroid disfunction. The enhanced plasma clearance of the tracer observed in patients with primary hyperparathyroidism may reflect the direct effect of excessive parathyroid hormone on the renal handling of 99mTc-Sn-pyrophosphate.

Adolescent↗
PubMed1987

Autotransplantation of diseased parathyroid glands into subcutaneous abdominal adipose tissue.

From October 1981 to the end of 1984, 13 patients with primary hyperparathyroidism (PHPT) and 17 with secondary hyperparathyroidism (SHPT) received fresh autografts of diseased parathyroid tissue into their subcutaneous abdominal adipose tissue. Because of previous surgery to treat hyperparathyroidism (HPT) (23%), concomitant thyroid surgery (26%), and a high proportion of multiglandular disease (73%), the patients were at high risk for HPT. During the follow-up period, hypercalcemia was diagnosed in five patients and successfully treated in four: by graft excision in two patients, by excision of a fourth gland from the neck in one patient, and with prednisolone in a patient with sarcoidosis. At follow-up (an average of 30 months after grafting), one patient had HPT and 29 others were euparathyroid. Parathyroid tissue can survive and function in adipose tissue, as was demonstrated by normocalcemia in 14 patients (whose only probable remaining parathyroid tissue had been transplanted into fat), by the demonstration that graft-dependent hypercalcemia could be eliminated by excision of the transplant, and by the demonstration of viable parathyroid tissue by microscopic examination of excised grafts. Autotransplantation of diseased parathyroid tissue into fat is simple and reliable. In cases of recurrent HPT, all or a portion of the graft can be removed while the patient is under local anaesthesia. If infiltrating growth occurs, broad excisions can be performed without sacrificing vital structures.

Abdomen↗
PubMed2004

The coming of age of radiation-induced hyperparathyroidism: evolving patterns of thyroid and parathyroid disease after head and neck irradiation.

BACKGROUND: This study investigates the association of thyroid and parathyroid disease in radiation-exposed patients and tests the hypothesis that hyperparathyroidism (HPT) occurs after a longer latency period. METHODS: Routine questioning identified 40 patients in the endocrine surgery clinic with a history of radiation exposure. Patients with thyroid disease were screened for HPT and vice versa. RESULTS: The known diagnosis at initial referral was thyroid disease alone in 26 of 40 patients, HPT alone in 9 of 40 patients, and both in 5 of 40 patients. After screening was completed, a total of 18 of 40 patients were found to have both thyroid disease and HPT. HPT manifested an average of 17 years later than thyroid disease (52.6 +/- 10.0 years vs 35.5 +/- 13.8 years after radiation therapy [ P < .05]). One third of the patients with HPT had normal serum calcium levels despite elevated parathyroid hormone levels and abnormal parathyroid glands. CONCLUSION: As the widespread use of x-ray therapy for benign childhood conditions becomes more remote, practitioners should expect a decreasing number of patients with radiation-associated thyroid disease, with an increase in HPT. Patients with radiation exposure and thyroid disease should be evaluated carefully and followed for HPT. Those patients who undergo surgical procedures should have close inspection of the parathyroid glands, with biopsy and excision when appropriate.

Adult↗
PubMed1983

Nuclear diameter in parathyroid disease.

The nuclear diameter of chief cells was measured in 17 cases of parathyroid adenomas, four cases of secondary hyperplasia, five cases of primary hyperplasia and six cases of tertiary hyperparathyroidism. All the cases with secondary hyperplasia and tertiary hyperparathyroidism were associated with chronic renal failure. The nuclear diameter in both the adenomatous and hyperplastic areas of tertiary hyperparathyroidism were measured. The adenomatous areas of tertiary hyperparathyroidism contained nuclei of a larger diameter than those in the hyperplastic foci of the same gland. The nuclear diameter in adenomatous foci of tertiary hyperparathyroidism was similar to that in adenomas from primary hyperparathyroidism. These findings lend support to the concept of formation of autonomous adenomas against a background of reactive parathyroid hyperplasia in cases of tertiary hyperparathyroidism. Using statistical methods there were differences between the nuclear diameter in cases of primary adenomata, and cases of primary and secondary hyperplasia. Primary parathyroid hyperplasia stood out as a distinct group. The significance of these findings is discussed.

Adenoma↗
PubMed2006

Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model.

HYPOTHESIS: Preoperative clinical, biochemical, and imaging studies could be used to reliably select patients with single-gland primary hyperparathyroidism who could undergo minimally invasive parathyroidectomy and to determine whether additional perioperative testing is necessary. DESIGN: Retrospective analysis. SETTING: Tertiary referral center. PATIENTS: A total of 238 patients who underwent neck surgical exploration and parathyroidectomy for primary hyperparathyroidism from January 7, 2002, to December 23, 2004. MAIN OUTCOME MEASURES: Demographic, clinical, biochemical, and imaging factors that predict single-gland vs multigland parathyroid disease, and biochemical cure. RESULTS: Of the 238 patients, 75.2% had a single adenoma, 21.4% had asymmetric 4-gland hyperplasia, and 3.4% had double adenomas. A biochemical cure was achieved in 99.2% of the patients. Preoperative calcium and intact parathyroid hormone levels were significantly higher (P = .03 and .04, respectively) and ultrasound and sestamibi scan results were more likely to be positive (both P<.001) in single-gland primary hyperparathyroidism. A dichotomous scoring model based on preoperative total calcium level (>/=3 mmol/L [>/=12 mg/dL]), intact parathyroid hormone level (>/=2 times the upper limit of normal levels), positive ultrasound and sestamibi scan results for 1 enlarged gland, and concordant ultrasound and sestamibi scan findings reliably distinguished single-gland vs multigland cases (P<.001). The positive predictive value of this scoring model to correctly predict single-gland disease was 100% for a total score of 3 or higher. CONCLUSIONS: Preoperative biochemical and imaging study results reliably distinguished single-gland vs multigland parathyroid disease in primary hyperparathyroidism. Our findings suggest that patients with a score of 3 or higher can undergo a minimally invasive parathyroidectomy without the routine use of intraoperative parathyroid hormone or additional imaging studies, and those with a score of less than 3 should have additional testing to ensure that multigland disease is not overlooked.

Adolescent↗
PubMed1984

Value of high-resolution computerized tomography in localizing diseased parathyroid glands.

Eighteen patients with hyperparathyroidism underwent high-resolution computerized tomography of the neck and superior mediastinum to assess the accuracy of the method in localizing diseased parathyroid glands preoperatively. The tomograms were correlated with surgical and pathological findings. Four scans were technically unsatisfactory. Of the remaining 14 scans, 8 showed an enlarged parathyroid gland; in 7 cases, the scan correctly identified the location of the diseased gland while in 1 case, the side of the lesion was incorrect. The other six scans did not show an abnormal parathyroid. These glands varied in size from 0.05 to 5.0 cm3 at the time of pathological examination. Three patients were undergoing re-exploration for persistent disease; technically acceptable scans were obtained in two and, in both, the location of the adenoma was correctly identified. Excluding patients with technically unsatisfactory scans, this technique has a sensitivity of 50% (7/14) and a false-negative rate of 43% (6/14) independent of gland size. However, in the eight scans interpreted as positive, the correct side of the lesion was localized in 7 (88%). This technique is not recommended for routine preoperative localization but may be of value in re-exploration for persistent disease.

Adenoma↗
PubMed2004

Historical perspective of parathyroid disease.

This article highlights key historical developments in the understanding of parathyroid function and disease, a story that involves many clinical investigators and classic scientific debate. The current medical community is certainly indebted to the innate curiosity and perseverance of these historical figures.

Endocrinology↗