Table of Contents
1
UI - 11774396
AU - Ulanovski D; Feinmesser R; Cohen M; Sulkes J; Dudkiewicz M; Shpitzer T
TI -
Preoperative evaluation of patients with parathyroid adenoma: role of
high-resolution ultrasonography.
SO - Head Neck 2002 Jan;24(1):1-5
AD - Department of Otolaryngology-Head and Neck Surgery, Rabin Medical
Center, Beilinson Campus, Petah Tikva 49100, Israel. Ulanovski@yahoo.com
BACKGROUND: Unilateral parathyroid exploration with adenoma removal and
identification of a normal parathyroid gland is a controversial surgical
approach to the treatment of primary hyperparathyroidism. The aim of
this study was to evaluate the ability of high-resolution
ultrasonography to localize adenomas preoperatively and to assess the
effect of such localization on operative time. METHODS: One hundred
twenty consecutive previously non-operated patients with primary
hyperparathyroidism underwent ultrasonography before surgery, which
consisted of unilateral neck exploration. The procedure was changed to
bilateral exploration when justified by the surgical findings. RESULTS:
The sensitivity and positive predictive value of the ultrasonographic
examinations were 89% and 98%, respectively. These results were obtained
regardless of the size of the adenoma. No significant difference was
found in the presence of thyroid multinodular disease (p =.2). A
positive sonographic examination decreased the operative time to an
average of 59 minutes. The average size of the adenomas was 19 mm
(range, 4-55 mm). A positive and highly statistically significant
correlation was found between adenoma size and both preoperative calcium
level (p =.01) and parathyroid hormone level (p =.0001). CONCLUSIONS: In
experienced hands, high-resolution ultrasonography can be a
cost-effective means of localizing parathyroid adenomas when unilateral
neck exploration is considered the acceptable surgical approach.
Copyright 2002 John Wiley & Sons, Inc.
2
UI - 11796876
AU - Alfaro JJ; Lamas C; Estrada J; Lucas T
TI -
MEN-2A syndrome and pulmonary metastasis.
SO - Postgrad Med J 2002 Jan;78(915):51-2
AD - Division of Endocrinology and Nutrition, Clinica Puerta de Hierro,
Madrid, Spain. jalfaro@arrakis.es
A case of multiple endocrine neoplasia syndrome type-2A (MEN-2A) with
primary hyperparathyroidism and medullary carcinoma of thyroid initially
treated by surgery is reported. The presence of pulmonary nodules six
years after the initial treatment was thought to be related to
metastasis of medullary carcinoma, and the increase in serum calcium
concentrations was assumed to be caused by persistence of parathyroid
adenomatous or hyperplastic tissue. The patient underwent surgery again
and the pulmonary nodules were confirmed to be metastases of a
parathyroid carcinoma, a very rare entity in MEN-2A syndrome.
3
UI - 11603567
AU - Yamashita K; Suzuki S; Yumita W; Ikeo Y; Uehara Y; Minemura K; Sakurai
TI -
A; Hashizume K
A case of familial isolated hyperparathyroidism with ectopic parathyroid
cancer.
SO - Endocr J 2001 Aug;48(4):453-8
AD - Department of Aging Medicine and Geriatrics, Shinshu University School
of Medicine, Matsumoto, Japan.
We report the kindred with familial isolated hyperparathyroidism with
parathyroid cancer. The proband was diagnosed as having primary
hyperparathyroidism at age 43. The same disorder was also found in his
daughter who had low bone mass. His son was found to have primary
hyperparathyroidism by family screening. The pathological diagnosis of
the resected parathyroid in both father and daughter was parathyroid
cancer, and that in son was parathyroid adenoma. The right lower gland
of the proband and the left lower gland of the son were present in
thymus. No mutations were found in the sequences of MEN1 gene, hence
gene(s) other than MEN1 gene may have contributed to the malignant
potency in our cases.
4
UI - 11711312
AU - Sun SS; Shiau YC; Lin CC; Kao A; Lee CC
TI -
Correlation between P-glycoprotein (P-gp) expression in parathyroid and
Tc-99m MIBI parathyroid image findings.
SO - Nucl Med Biol 2001 Nov;28(8):929-33
AD - Department of Nuclear Medicine, China Medicine College Hospital,
Taichung, Taiwan.
The major factor to influence localization of parathyroid adenomas is
tumor size. P-glycoprotein (P-gp) expression in parathyroid adenomas has
been considered to be an another possible factor to influence
localization of parathyroid adenomas because false-negative studies have
been reported with large tumors and true-positives reported with very
small tumors in previous studies. The aim of this study was to
characterize Tc-99m MIBI uptake and retention by parathyroid adenomas
and to correlate this with cell surface expression of P-gp. Sixteen
patients with parathyroid adenoma (larger than 1.5 gm) underwent
dual-phase (10min and 2hr) Tc-99m MIBI parathyroid image immediately
before parathyroid exploration. Tissues were obtained from normal and
abnormal parathyroid glands and from the thyroid gland.
Immunohistochemistry (IHC) was obtained with monoclonal antibodies to
identify P-gp expression in all tissues. All of the 16 parathyroid
adenomas and 32 normal control specimens (16 normal parathyroid and 16
normal thyroid specimens) were submitted for P-gp detection by IHC. The
dual-phase Tc-99m MIBI parathyroid image accurately localized 14
parathyroid adenomas, but not the remaining 2 adenomas. The 14
parathyroid adenomas with significant Tc-99m MIBI uptake in delayed 2hr
images revealed negative P-gp expression, but the 2 adenomas without
significant Tc-99m MIBI uptake, as well as normal parathyroid and normal
thyroid specimens, revealed positive P-gp expression when evaluated by
IHC. Not only the size of parathyroid adenomas, but also significant
P-gp expression limited the sensitivity of dual-phase Tc-99m MIBI
parathyroid image to localize parathyroid adenomas before operation.
5
UI - 11795928
AU - Scheiner JD; Dupuy DE; Monchik JM; Noto RB; Cronan JJ
TI -
Pre-operative localization of parathyroid adenomas: a comparison of
power and colour Doppler ultrasonography with nuclear medicine
scintigraphy.
SO - Clin Radiol 2001 Dec;56(12):984-8
AD - Department of Diagnostic Imaging, Brown University School of Medicine,
Rhode Island Hospital, Providence, Rhode Island 02903, USA.
jscheiner@lifespan.org
AIM: To compare power and colour Doppler ultrasonography (US) with
nuclear medicine scintigraphy (NM) in the preoperative localization of
parathyroid adenomas in patients with primary hyperparathyroidism
(PHPT). MATERIALS AND METHODS: Thirty-one patients with biochemical
evidence of PHPT underwent pre-operative US and NM for parathyroid
adenoma localization. Both studies were interpreted independently
without prior knowledge of the other study's findings. All patients had
surgical removal of the parathyroid adenoma utilizing standard neck
exploration or minimally invasive unilateral surgical techniques with
rapid serum assay of circulating parathyroid hormone levels. RESULTS:
All patients had single parathyroid adenomas at surgery. Prospective
sensitivities for US, NM and both studies combined were 65%, 68%, and
74%, respectively, with a positive predictive value of 100% each. The
adenoma was localized by only one imaging modality in 16% of cases.
CONCLUSIONS: US and NM provide complementary roles in the pre-operative
localization of parathyroid adenomas in patients with PHPT.
6
UI - 11842966
AU - Lucas DG Jr; Lockett MA; Cole DJ
TI -
Spontaneous infarction of a parathyroid adenoma: two case reports and
review of the literature.
SO - Am Surg 2002 Feb;68(2):173-6
AD - Department of Surgery, Medical University of South Carolina, Charleston
29425, USA.
The spontaneous infarction of a parathyroid adenoma is an uncommon
event, although it has been previously described. Patients may present
symptomatically or experience resolution of their hyperparathyroidism.
As such the appropriate clinical management of these patients remains
unclear. We present two cases of spontaneous infarction of parathyroid
adenomas. The first presented with neck pain and dysphagia and
experienced at least temporary resolution of her hyperparathyroidism.
The second patient experienced a fall in his parathyroid hormone and
calcium levels before neck exploration. Infarcted parathyroid adenoma
was diagnosed on pathologic evaluation of the surgical specimen.
Inflammation surrounding the infarcted adenoma provided for a
technically difficult operation. Although resolution of
hyperparathyroidism has been described postinfarction, a regeneration of
the parathyroid adenoma may occur. Therefore neck exploration and
parathyroidectomy should still be considered. We propose a period of
observation after diagnosis of spontaneous parathyroid adenoma
infarction to avoid these acute inflammatory changes that have been
described.
7
UI - 11216806
AU - Tovar EA
TI -
Minimally invasive resection of mediastinal parathyroid adenomas.
SO - Ann Thorac Surg 2001 Jan;71(1):402-3
8
UI - 11585294
AU - Casara D; Rubello D; Pelizzo MR; Shapiro B
TI -
Clinical role of 99mTcO4/MIBI scan, ultrasound and intra-operative gamma
probe in the performance of unilateral and minimally invasive surgery in
primary hyperparathyroidism.
SO - Eur J Nucl Med 2001 Sep;28(9):1351-9
AD - Department of Radiotherapy, Regional Hospital of Padova, Italy.
dario.casara@unipd.it
The main purposes of this study were: (a) to investigate the efficacy of
an imaging protocol based on the combination of 99mTcO4/MIBI
scintigraphy and neck ultrasound (US) in selecting patients with primary
hyperparathyroidism (HPT) for unilateral neck exploration, and (b) to
help define the role of the intraoperative MIBI gamma probe (IMGP)
technique in the performance of minimally invasive radio-guided surgery
(MIRS). One hundred and forty-three consecutive patients with primary
HPT were enrolled in the study. We used a modified 99mTcO4/MIBI
scintigraphic procedure which included the oral administration of
potassium perchlorate to cause rapid 99mTcO4 washout from the thyroid
tissue, thereby permitting the acquisition of high-quality early MIBI
images. A single-photon emission tomography (SPET) acquisition was also
obtained in 21 patients, of whom seven had an enlarged parathyroid gland
(EPG) in the mediastinum at planar scintigraphy and 14 had discordant
scan/US findings for the presence of a cervical EPG. Neck US was
performed in the same session as scintigraphy using a small-parts,
high-resolution 10-MHz transducer. All patients were then operated on by
the same surgical team. Quick PTH assay (QPTH) was used to measure PTH
intraoperatively to confirm successful parathyroidectomy. In patients
with scan/US evidence of a solitary EPG and with a normal thyroid gland,
limited, unilateral neck surgery or, more recently, MIRS was planned
(n=91). In patients with scan/US evidence of multiglandular disease
(MGD) (n=21) or concomitant nodular goitre (n=24) or in patients with a
negative scan/US evaluation (n=7), extensive bilateral neck exploration
was planned (n=52). In 87 of the 91 patients (95.6%) in whom
preoperative imaging indicated the presence of a solitary EPG and a
normal thyroid gland, a single parathyroid adenoma was found at surgery,
and these patients were treated by unilateral neck exploration or MIRS.
In the remaining four patients of this group, conversion to bilateral
neck exploration was required because parathyroid carcinoma (n=3) or MGD
(n=1) was diagnosed at operation. In some cases SPET was helpful in
better localising the EPG. In particular, in 5 of the 21 patients
evaluated, SPET localised an EPG deep in the neck or mediastinum and at
surgery a parathyroid adenoma was found in the paratracheal or
para-oesophageal space. In 43 of the 46 patients (93.5%) who were
candidates for MIRS, the IMGP technique allowed parathyroidectomy to be
performed through a small, 2- to 2.5-cm skin incision with a short
duration of intervention (mean 34 min). We conclude that: (a) The
integrated scan/US imaging protocol that we used appears to be accurate
in selecting patients with primary HPT for unilateral neck exploration.
(b) In our series the most prevalent cause of bilateral neck exploration
was the co-existence of a nodular goitre; thus accurate preoperative
evaluation of the thyroid gland by dual-tracer scintigraphy and US
imaging is strongly recommended in all patients with HPT. (c) SPET can
provide the surgeon with useful information when an EPG is located deep
in the neck or mediastinum. (d) IMGP appears to be a useful
intraoperative device in HPT patients with solitary parathyroid adenomas
and a normal thyroid gland, since it permits minimally invasive and
time-saving surgery.
9
UI - 11759885
AU - Ito Y; Iwase H; Tanaka H; Yuasa H; Kureyama Y; Yamashita H; Toyama T;
TI -
Kimura M; Kobayashi S
Metachronous primary hyperparathyroidism due to a parathyroid adenoma
and a subsequent carcinoma: report of a case.
SO - Surg Today 2001;31(10):895-8
AD - Department of Surgery, Toyokawa City Hospital, Toyokawa, Japan.
An extremely rare case of metachronous primary hyperparathyroidism (PHP)
due to a parathyroid adenoma and subsequent carcinoma with local
lymphatic spread is presented herein. A 55-year-old woman was operated
on for a parathyroid adenoma in the right inferior gland. Thirteen years
after the first operation, she was again hospitalized for hypercalcemia
and the presence of a hard mass in the right anterior neck region.
Exploratory surgery and a histological examination of the resected tumor
provided evidence of a parathyroid neoplasm in the right superior gland
but the malignancy was equivocal. Postoperatively, her serum parathyroid
hormone (PTH) level remained at 1.5-fold the upper limit of the normal
range, and hypercalcemia again gradually developed. The results of
higher positive rates by Ki-67 immunohistochemical staining and an
aneuploid pattern by a flow cytometric analysis of the second neoplasm
were consistent with a histological diagnosis of carcinoma, and she
therefore underwent further surgery. A radical neck dissection revealed
two lymph node metastases which were both successfully removed. The
postoperative serum PTH and calcium levels then returned to within the
normal ranges. These findings indicate the usefulness of Ki-67
immunohistochemical staining and a flow cytometric analysis for
differentiating malignant lesions from benign parathyroid lesions, and
the importance of surgically treating cases limited to local regions
without distant metastasis.
10
UI - 11766088
AU - Marchesi M; Biffoni M; Benedetti RN; Campana FP
TI -
Incidental parathyroid adenomas with normocalcemia discovered during
thyroid operations: report of three cases.
SO - Surg Today 2001;31(11):996-8
AD - Third Department of Surgery, University La Sapienza, Rome, Italy.
We report three cases of parathyroid adenoma incidentally discovered
during a total thyroidectomy. No patients showed any clinical or
chemical features that led us to suspect a hyperparathyroidism condition
before operation, but a macroscopically enlarged parathyroid was
discovered during the dissection and it was removed in all three cases.
All patients had a single adenoma confirmed by a histological analysis.
Calcemia decreased after operation in every case but only one patient
needed temporary adjunctive therapy. No permanent hypoparathyroidism or
recurrent hyperparathyroidism was observed. We recommend that any
enlarged parathyroid discovered during neck surgery should thus be
removed in order to avoid the risks of future surgical procedures due to
successive bouts of clinical hyperparathyroidism.
11
UI - 11846729
AU - Gulkesen KH; Kilicarslan B; Altunbas HA; Karpuzoglu G
TI -
EGFR and p53 expression and proliferative activity in parathyroid
adenomas; an immunohistochemical study.
SO - APMIS 2001 Dec;109(12):870-4
AD - Akdeniz University, Pathology Department, Antalya, Turkey.
gulkesen@med.akdeniz.edu.tr
EGFR (epidermal growth factor receptor), p53, and proliferative markers
provide some clues as to the formation of several tumours. In this study
the mechanism of the genesis of parathyroid adenomas was investigated
using immunohistochemistry. Sections of parathyroid adenomas from 12
cases were stained using PCNA (proliferating cell nuclear antigen),
EGFR, and p53 immunohistochemistry. Correlations between PCNA LI
(labelling index), EGFR expression, p53 expression, age, serum
parathormone, Ca and P levels, and tumour diameter were investigated.
PCNA LI was 45.8+/-33.1 (mean+/-standard deviation) and all the cases
were somewhat positive. Five cases (41.67 %) were EGFR positive. Maximum
10 % of the cells were positive in these cases. All the cases were p53
negative. There was a correlation between PCNA LI and serum parathormone
level (r=0.607, p=0.036). According to these results, parathormone
synthesis is high when the proliferative activity of parathyroid adenoma
is high. Four of the five EGFR-positive patients were below 35 years of
age. These data may indicate that formation of parathyroid adenoma in
young patients is related to a mechanism involving EGFR. Absence of p53
expression suggests that p53 mutation is not a common component of
parathyroid adenomas.
12
UI - 11848628
AU - Mozes G; Curlee KJ; Rowland CM; van H; Thompson GB; Grant CS; Farley DR
TI -
The predictive value of laboratory findings in patients with primary
hyperparathyroidism.
SO - J Am Coll Surg 2002 Feb;194(2):126-30
AD - Department of Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN
55905, USA.
BACKGROUND: Despite extensive preoperative imaging and intraoperative
"gadgetry" to facilitate localization of abnormal parathyroid glands,
the onus of identification and resection remains with the surgeon in the
operating room. We pondered the relative usefulness of routine
laboratory studies to the surgeon as predictive guides to the
intraoperative findings in patients with primary hyperparathyroidism
(HPT). STUDY DESIGN: Pre- and postoperative laboratory data were
analyzed in 166 consecutive patients (1998 to 1999) undergoing
successful cervical exploration for sporadic primary HPT and were
correlated with the pathologic findings. Patients with secondary HPT,
multiple endocrine neoplasia, familial HPT, and parathyroid carcinoma
were not included in this study. RESULTS: One hundred eighteen women and
48 men (mean age = 63 years) with parathyroid adenoma (n = 155) and
sporadic hyperplasia (n = 11) were evaluated. Mean parathormone (PTH)
levels varied little with the pathology: adenoma = 9.6 pmol/L and
hyperplasia = 10.2 pmol/L (p > 0.05). In patients with parathyroid
adenoma, analysis of preoperative measures showed a positive correlation
(r = 0.48, p < 0.0001) with PTH and gland weight. The correlation
appeared to be the strongest in the tails of the distribution; in 22 of
23 (96%) cases with PTH levels lower than 6 pmol/L, the offending lesion
or lesions were less than 400 mg; in all six cases with PTH levels
higher than 18.0 pmol/L, the abnormal gland or glands weighed more than
800 mg. PTH levels between 6 and 18 pmol/L revealed mean adenoma weight
of 757 mg (median = 420 mg; range = 50 to 5,500 mg). CONCLUSIONS:
Extreme values of PTH in patients with single-gland parathyroid disease
alert the surgeon to the likelihood of small or large parathyroid
adenomas. Laboratory studies do not differentiate adenoma from
hyperplasia, nor do they pinpoint the size of abnormal glands with
moderate-range PTH values.
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