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Pre-operative localization of parathyroid adenoma

Pre-operative localization of parathyroid adenoma. Dr Chan Man-yi Tuen Mun Hospital. Primary hyperparathyroidism. Gold standard = bilateral neck exploration 95 – 98% at first exploration Imaging used only after failed initial surgery. Etiology of primary hyperparathyroidism

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Pre-operative localization of parathyroid adenoma

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  1. Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital

  2. Primary hyperparathyroidism • Gold standard = bilateral neck exploration • 95 – 98% at first exploration • Imaging used only after failed initial surgery

  3. Etiology of primary hyperparathyroidism • Solitary parathyroid adenoma 80-85% • Unilateral neck exploration • Minimally invasive surgery • Foscused parathyroidectomy • Video-assisted parathyroidectomy • Videoscopic parathyroidectomy

  4. Minimally Invasive parathyroidectomy Pre-operative Intra-operative PTH assay Ultrasound Gamma probe • Ultrasound • Sestamibi scan • CT • MRI • Angiography / selective venous sampling

  5. Ultrasound • Sensitivity (55-83%) • Ruda et al, Otolaryngol Head Neck Surg 2005; 132:359–372 • High frequency linear transducer • Carotid arteries – hyoid bone – sternal notch • Parathyroid adenoma • Gray-scale image • Oval / bean-shaped • Homogenously hypoechoic • Doppler • Characteristic arc / rim of vascularity • Present in 83% Lane MJ, Am J Roentgenol. Sept 1998; 171(3:819-23)

  6. USG by surgeon • Sensitivity of USG • Specific side – 84% • Specific quadrant – 79% • Sensitivity of USG + MIBI – 98%

  7. Sestamibi scan • Istopic scan with technetium Tc 99m sestamibi • Single isotope dual phase scan • IV injection  early and delayed image • Correlate with larger size / predominance of oxyphil cells / presence of P-glycoprotein Bhatnagar et al, J Nucl Med 1998;39:1617-1620 Carpentier et al, J Nucl Med 1998;39:1441-1444

  8. Advantage • Good at identifying ectopic glands in mediastinum or deep cervical location • Sensitivity (68-95%) Ruda et al, Otolaryngol Head Neck Surg 2005; 132:359–372

  9. Planar imaging SPECT/CT SPECT

  10. Planar, SPECT or SPECT/CT • Dual phase SPECT/CT > dual phase SPECT / planar • Early phase SPECT/CT + any form of delayed imaging > dual phase SPECT / planar

  11. USG vs MIBI • Sensitivity of USG – 65% • Sensitivity of MIBI-SPECT – 68% • Detected only by one modality – 16% •  USG and MIBI complementary

  12. USG + MIBI

  13. USG + MIBI • Surgical failure • w/o PTH – 2% • With PTH – 1% P=0.5

  14. Reoperation?

  15. 163 patients with ?missed adenoma Pre-op localization  surgery 140 unilateral exploration 18 mediastinal procedure 92% long term resolution of hypercalcemia

  16. Sensitivity = 70%

  17. Proposed strategy

  18. ? False positive Assumed false +ve as surgeon failed to identified adenoma All repeated scan showed same foci of radioactivity  Errors in interpertation rather than in scan itself

  19. John Doppman 1986 “The best localization study prior to primary exploration in a patient with primary hyperparathyroidism is to locate an experienced parathyroid surgeon”

  20. Initial surgery: MIBI + USG if MIP • Both +ve • Concordant result MIP (? IOPTH) • Discordant result  IOPTH mandatory if MIP • One +ve  IOPTH mandatory if MIP • Both -ve  bilateral exploration • Re-operation • MIBI as first line • USG / CT / MRI • FNA / arteriogram / SVS • An experienced surgeon is the key to success

  21. END

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