Radioguided Parathyroidectomy via VATS Combined With Intraoperative Parathyroid Hormone Testing: The Surgical Approach of Choice for Patients With Mediastinal Parathyroid Adenomas?
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Abstract:
Despite the excellent results with bilateral exploration, minimally invasive parathyroidectomy has become the procedure of choice for patients with hyperparathyroidism in which a single parathyroid lesion can be localized preoperatively. In this article, we discuss a patient who presented with primary hyperparathyroidism for the first time and had a Tc-99m sestamibi scan to localize a single parathyroid lesion in the left, anterior mid-mediastinum. We subsequently performed a radioguided parathyroidectomy via video-assisted thoracoscopic surgery (VATS) to resect this parathyroid adenoma and used intraoperative parathyroid hormone (PTH) testing to confirm cure and avoid neck exploration. We concluded that radioguided parathyroidectomy via VATS combined with intraoperative PTH testing is an effective approach for patients with primary hyperparathyroidism and mediastinal parathyroid lesions, and perhaps should be the technique of choice.Keywords:
Parathyroid neoplasm
Gamma probe
During the last years for surgical treatment of primary hyperparathyroidism minimally invasive operations were applied. The results of the introduction of video-assisted parathyroidectomy in the clinic in 8 (32%) of 25 patients with primary hyperparathyroidism, who were operated during the 2010-2012 were analysed. Video-assisted parathyroidectomy compared to conventional operation allowed to reduce significantly the duration of the operation, to reduce the incidence of postoperative complications, to achieve a better cosmetic effect.
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Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)
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Parathyroid neoplasm
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症例は64歳，男性．近医で以前から高カルシウム血症を指摘されていたが，intact-PTHの高値を認め当院内分泌外科へ紹介となった．頸部超音波検査では甲状腺両葉の上極あるいは下極の背側に腫瘤はなく，甲状腺右葉内に，上極より1.7cm，下極より1.2cmの内部均一で低エコーな腫瘤を認めた．MIBIシンチグラム検査では甲状腺右葉にのみ結節状の集積がわずかに認められた．甲状腺腫瘤が副甲状腺腺腫の可能性があると考え甲状腺右葉切除のみを行った．甲状腺右葉上極よりの結節は濾胞上皮の密な増生よりなるものであり，下極よりの結節は境界明瞭で，好酸性上皮よりなる濾胞の密な増生を示した．ともに濾胞状構造を示し，甲状腺組織との鑑別が困難であったのでPTH・TTF-1・Tgの免疫染色を行ったが，上極よりの結節はPTH陽性，TTF-1・Tg陰性，下極よりの結節はPTH陰性，TTF-1・Tg陽性で，それぞれ甲状腺内副甲状腺腺腫，甲状腺好酸性細胞型濾胞腺腫と最終診断した．
Parathyroid neoplasm
Parathyroid carcinoma
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Introduction: Preoperative and intraoperative localization strategies have allowed the development of minimally invasive surgical techniques for the treatment of primary hyperparathyroidism while maintaining high rates of biochemical cure. Radio-guided parathyroidectomy has been described and corroborated in the literature as a technique that allows the surgeon to be confident of biochemical cure without the need for parathyroid biopsy or parathyroid hormone assays. Materials and Methods: Informed consent was obtained from two patients with confirmed diagnoses of primary hyperparathyroidism to obtain optimal footage of the procedure. Preoperative four-dimensional computed tomography localized right superior parathyroid adenomas in both patients. A dose of 25–30 mCi of technetium 99 m sestamibi was administered intravenously in the preoperative holding area ~3 hours before surgery. Background and ex vivo radiation counts of the excised tissues were measured using the handheld gamma probe. The Norman rule of radiation counts >20% of the background was used to confirm resection of parathyroid adenoma. Results: The enlarged right superior parathyroid gland was resected using a minimally invasive approach. Ex vivo counts using the gamma probe satisfied the Norman rule for an offending adenoma. Biochemical cure of primary hyperparathyroidism was confirmed with normal serum calcium and parathyroid hormone levels at the first postoperative clinic visit. Conclusions: Minimally invasive radio-guided parathyroidectomy affords a high rate of biochemical cure of primary hyperparathyroidism. Principal benefits include the immediate confirmation of adenoma resection, avoidance of parathyroid biopsy, and prevention of longer operating room time while waiting for parathyroid hormone levels to drop. No competing financial interests exist. Runtime of video: 7 mins 49 secs
Gamma probe
Parathyroid neoplasm
Ex vivo
Parathyroid carcinoma
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Endocrine surgery
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Objective: The aim of the present study was to determine the success rate of parathyroidectomy in primary hyperparathyroidism (pHPT) and the related causes for the persistence or recurrence of the disease after surgery. Materials and Methods: A single center retrospective study of patients with primary hyperparathyroidism who underwent parathyroidectomy at the Department of Surgery, Faculty of Medicine Siriraj Hospital, during the period January 2007 to December 2015 was conducted. Results: In total, 79 patients with a median follow-up period of 29 months (ranging from 6 to 110 months) were enrolled on the study. The success rate of parathyroidectomy was reported to be 90%, while 7% of the patients had persistent pHPT and 3% developed recurrent pHPT after surgery. The most common postoperative complications were transient symptomatic hypocalcemia (8%). There were no statistically significant related factors to the persistence or recurrence of the disease. Conclusion: The high positive outcome of parathyroidectomy for pHPT patients in Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, shows it is safe and effective, with a success rate in 9-year experience of 90%. The authors believe that an improvement of pre-operative imaging for localization and the use of surgical adjuncts may help improve the outcome of the surgery in the future. Keywords: Primary hyperparathyroidism, Persistent hyperparathyroidism, Recurrent hyperparathyroidism, Parathyroidectomy
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