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  • A study of 645 adult parathyroid glands in 160 cadavers
    Wang,c. Ann Surg Mar 1976
    Frozen section examination for stromal and intracellular fatty content is an added assurance of normalcy. That parathyroid glands sink in saline solution, and fat globules float, may aid in differentiating the two types of tissue. That parathyroid glands sink in saline solution, and fat globules float, may aid in differentiating the two types of tissue
    The parathyroid gland, located within the surgical capsule of the thyroid (subcapsular),
    A gland outside of the capsule (extracapsular) is often displaced into the posterior or anterior mediastinum.
    Supernumerary, fused, and intrathyroidal parathyroids, albeit rare, are of surgical importance
    SubcapsularParathyroid gland, located within the surgical capsule of the thyroid (subcapsular),
    A gland outside of the capsule (extracapsular) is often displaced into the posterior or anterior mediastinum.
  • The anatomy of primary hyperparathyroidism.SourceSurgery. 92(5):814-21, 1982 Nov.Drawings were made of the exact locations of each of the normal and enlarged parathyroid glands identified, immediately following neck explorations in all patients with primary hyperparathyroidism during a 4-year period (1977 to 1981). The enlarged glands were also measured and weighed after excision. The records of 273 patients were reviewed
    The records of 273 patients were reviewed. Single gland enlargement (adenoma) was found in 218 patients (80%). Hyperplasia of all identified parathyroid glands was found in 42 patients (15%). Two adenomas (at least two other glands grossly and microscopically normal) were found in seven patients (2.6%). Seven patients (2.6%) with biochemical evidence of the disease had only normal glands at neck exploration. Adenomas in ectopic locations were frequent. However, their locations, with few exceptions, were predictable. The larger an adenoma, the more likely it was to be ectopic. Right superior gland adenomas (mean size 2.6 cm) were ectopic in 39%. Left superior glands (mean size 2.62 cm) were ectopic in 36%. No superior parathyroid adenomas were intrathyroidal. five of 223 (2%) adenomas were entirely surrounded by thyroid parenchyma in the lower pole. Nearly all inferior gland adenomas within the thymus could be readily excised through the cervical incision. In the seven cases in which only normal parathyroids were identified, no fewer than three glands wer proven in each. Three patients have had subsequent mediastinal exploration and excision of an adenoma. This failure rate of cervical exploration (4%) is attributed to mediastinal adenomas, and a second adenoma, and incorrect diagnosis
  • Objective
    To evaluate a method of limited parathyroid exploration for primary hyperparathyroidism.
    Summary Background Data
    Although preoperative localization of parathyroid adenomas has become sensitive enough for clinical practice, it has not achieved success as the basis for limited parathyroid exploration, because multiglandular disease is routinely underdiagnosed. The rapid intraoperative parathyroid hormone assay is sensitive for multiglandular disease, because hormone levels will not fall within 10 minutes of adenoma removal if additional abnormal tissue is present. A combination technique in which the exploration is limited according to the localization studies and the success is confirmed with the parathyroid hormone assay has promise for producing a high rate of curative limited parathyroid explorations.
    Methods
    Forty-eight consecutive patients with primary hyperparathyroidism and indications for surgery underwent preoperative localization. After tests, 45 patients underwent unilateral parathyroid exploration and confirmation of the success of unilateral exploration during surgery using the rapid parathyroid hormone assay. The intraoperative management of these patients and their follow-up to 3 months was recorded.
    Results
    Thirty-two of the 48 patients (67%) had successful unilateral exploration as gauged by a marked drop in parathyroid hormone levels during the procedure and by 3-month clinical follow-up. Of the 16 patients who ultimately underwent bilateral exploration, 7 had parathyroid hormone levels that did not fall after adenoma removal. Of these seven, five were found to have a second adenoma and two had slow metabolism of hormone with no additional abnormal tissue found. In 5 of the 16 patients, bilateral exploration was performed for erroneous localization. Four additional patients underwent bilateral exploration for improved exposure or negative results on localization tests.
    Conclusions
    These results show that unilateral parathyroid exploration is limited by the intrinsic 15% rate of multiglandular primary hyperparathyroidism, combined with the imperfections of preoperative localizing techniques. Although an 85% rate of unilateral exploration can theoretically be obtained for unselected cases, the other vagaries of the technique make a 70% rate a more reasonable expectation.
  • Orloff, Lisa A. MDInstitutionFrom the Division of Otolaryngology-Head and Neck Surgery, University of California, San Diego Medical Center, San Diego, California, U.S.A.TitleMethylene Blue and Sestamibi: Complementary Tools for Localizing Parathyroids.[Article]SourceLaryngoscope. 111(11):1901-1904, November 2001.AbstractObjective : To determine the value and correlation between sestamibi scan and methylene blue staining for localization of parathyroid glands in patients with primary hyperparathyroidism.Study Design : Nonrandomized convenience sample, followed prospectively.Methods : Twenty-three consecutive patients underwent 24 operations for primary hyperparathyroidism. All patients underwent preoperative technetium 99m-sestamibi planar scintigraphy, preoperative administration of 7.5 mg/kg methylene blue initiated within 60 minutes of surgical incision, and surgical neck exploration supervised by a single surgeon.Results : All patients were cured of hypercalcemia. Sensitivity for sestamibi and for methylene blue staining was 76% and 79%, respectively. Specificity for sestamibi and for methylene blue was 98% and 93%, respectively. Agreement between sestamibi and methylene blue was 96%.Conclusions : Sestamibi scanning and methylene blue staining are useful, complementary localizing tools for patients undergoing surgery for primary hyperparathyroidism. When used together, these studies decrease operative time, justify unilateral exploration in patients with parathyroid adenoma, and increase the ease of identification of hyperplastic parathyroid glands.
  • Retrospective review of 352 patients undergoing parathyroidectomy for primary hyperparathyroidism from January 1, 1999, to December 31, 2004. We evaluated 6-month postoperative IOPTH values and serum calcium levels.Setting: Tertiary referral center.Main Outcome Measures: The IOPTH values at baseline (preincision and preexcision) and at 5 and 10 minutes after parathyroidectomy were reviewed according to the Miami criterion (>50% drop from highest baseline IOPTH level at 10 minutes after excision), criterion 1 (>50% drop from preincision IOPTH level at 10 minutes), criterion 2 (>50% drop from highest baseline IOPTH level at 10 minutes and final IOPTH level within the reference range), criterion 3 (>50% drop from highest baseline IOPTH level at 10 minutes and final IOPTH level less than the preincision value), criterion 4 (>50% drop from highest baseline IOPTH level at 5 minutes), and criterion 5 (>50% drop from preexcision IOPTH level at 10 minutes).Results: Criterion 2 had sensitivity of 88%, specificity of 22%, positive predictive value of 97%, and negative predictive value of 6%. Criterion 2 had good agreement with criteria 1 and 3. Of patients whose IOPTH level drop satisfied criterion 2 but not criterion 1, 14% had postoperative hypercalcemia at 6 months. When criterion 2 was not satisfied but criteria 1, 3, 4, and 5 and the Miami criterion were, failure rates were 0%, 4%, 7%, 6%, and 9%, respectively.Conclusions: Satisfying criterion 2 had a high operative success but resulted in additional unnecessary surgical exploration. Criterion 1 was better at predicting postoperative normocalcemia than criterion 2.
  • M

    1. 1. ParathyroidectomyParathyroidectomy preoperative and intraoperativepreoperative and intraoperative localization of abnormal parathyroid glandslocalization of abnormal parathyroid glands Rummana Aslam,Rummana Aslam, MDMD
    2. 2. Anatomic distribution ofAnatomic distribution of the parathyroidsthe parathyroids  Upper glandUpper gland in order of frequency,in order of frequency, – the cricothyroid junction; the dorsum of the upper pole ofthe cricothyroid junction; the dorsum of the upper pole of the thyroid; and the retropharyngeal spacethe thyroid; and the retropharyngeal space  Lower glandLower gland – at the lower pole of the thyroid and the thymic tongue;at the lower pole of the thyroid and the thymic tongue; rarely in the upper, the lateral neck, or the mediastinumrarely in the upper, the lateral neck, or the mediastinum  SubcapsularSubcapsular located within the surgical capsule of the thyroidlocated within the surgical capsule of the thyroid  Extracapsular in posteriorior or anterior mediastinumExtracapsular in posteriorior or anterior mediastinum  Supernumerary, fused, and intrathyroidal parathyroidsSupernumerary, fused, and intrathyroidal parathyroids Wang,. Ann Surg Mar 1976Wang,. Ann Surg Mar 1976
    3. 3. ““The anatomy of primaryThe anatomy of primary hyperthyroidism”hyperthyroidism”  Single gland enlargement (adenoma) 218/273 patientsSingle gland enlargement (adenoma) 218/273 patients (80%); Hyperplasia of all identified parathyroid glands 42/273(80%); Hyperplasia of all identified parathyroid glands 42/273 patients (15%)patients (15%)  Two adenomas :7 patients (2.6%).Two adenomas :7 patients (2.6%).  Biochemical evidence of the disease with normal glands atBiochemical evidence of the disease with normal glands at neck exploration: 7 patients (2.6%)neck exploration: 7 patients (2.6%)  Ectopic right superior gland adenomas (mean size 2.6 cm) 39%Ectopic right superior gland adenomas (mean size 2.6 cm) 39%  Ectopic left superior gland adenomas (mean size 2.62 cm) 36%.Ectopic left superior gland adenomas (mean size 2.62 cm) 36%.  Intrathyroid superior adenomas: none.Intrathyroid superior adenomas: none.  Intrathyroid inferior adenomas: five of 223 (2%)Intrathyroid inferior adenomas: five of 223 (2%)  Inferior gland adenomas within the thymusInferior gland adenomas within the thymus  Failure rate of cervical exploration (4%): attributed toFailure rate of cervical exploration (4%): attributed to mediastinal adenomas, and a second adenoma, and incorrectmediastinal adenomas, and a second adenoma, and incorrect diagnosisdiagnosis Thompson NW. Surgery. 1982 Nov.
    4. 4.  48 patients with neck exploration for parathyroid adenomas48 patients with neck exploration for parathyroid adenomas  Thirty-two of the 48 patients (67%) had successful unilateralThirty-two of the 48 patients (67%) had successful unilateral explorationexploration  16 patients underwent bilateral exploration, and 7/16 had no16 patients underwent bilateral exploration, and 7/16 had no reduction in PTH levelreduction in PTH level  Of these seven, five were found to have a second adenoma and twoOf these seven, five were found to have a second adenoma and two had slow metabolism of hormone with no additional abnormal tissuehad slow metabolism of hormone with no additional abnormal tissue found.found.  In 5 of the 16 patients, bilateral exploration was performed forIn 5 of the 16 patients, bilateral exploration was performed for erroneous localization.erroneous localization.  Four additional patients underwent bilateral exploration for improvedFour additional patients underwent bilateral exploration for improved exposure or negative results on localization tests.exposure or negative results on localization tests.  Conclusions: 70% rate of unilateral neck explorationConclusions: 70% rate of unilateral neck exploration  Intrinsic 15% rate of multinodular primary hyperparathyroidismIntrinsic 15% rate of multinodular primary hyperparathyroidism combined with limited results of preoperative localizing techniquescombined with limited results of preoperative localizing techniques Moore, Francis D. Jr. Annals of surgery 1999
    5. 5. Preoperative localizationPreoperative localization Hajioff d., (2004)Hajioff d., (2004) Clin. otolarygolClin. otolarygol ““accuracy of ultrasonography, sestamibi scintigraphy and theiraccuracy of ultrasonography, sestamibi scintigraphy and their combination in 48 cases of primary hyperparathyroidism”combination in 48 cases of primary hyperparathyroidism” Ultrasound had a sensitivity of 64.3%Ultrasound had a sensitivity of 64.3% and positive predictive value (PPV) of 100% (81.5–100) for correctand positive predictive value (PPV) of 100% (81.5–100) for correct lateralization.lateralization. Sestamibi had a sensitivity of 83.3% (69.8–92.5) and PPV of 87.1%Sestamibi had a sensitivity of 83.3% (69.8–92.5) and PPV of 87.1% (73.7–95.1).(73.7–95.1). The simple combination of ultrasound with sestamibi had a sensitivity ofThe simple combination of ultrasound with sestamibi had a sensitivity of 82.1% (63.1–93.9) and a PPV of 92.0% (74.0–99.0): little different82.1% (63.1–93.9) and a PPV of 92.0% (74.0–99.0): little different from sestamibi alone.from sestamibi alone. Hajioff d., (2004) Clin. otolarygol
    6. 6. Preoperative localizationPreoperative localization  Twenty-three consecutive patients underwent 24 operationsTwenty-three consecutive patients underwent 24 operations for primary hyperparathyroidism.for primary hyperparathyroidism. – preoperative technetium 99m-sestamibi planar scintigraphy,preoperative technetium 99m-sestamibi planar scintigraphy, – preoperative administration of 7.5 mg/kg methylene blue initiatedpreoperative administration of 7.5 mg/kg methylene blue initiated within 60 minutes of surgical incision, and surgical neckwithin 60 minutes of surgical incision, and surgical neck exploration supervised by a single surgeon.exploration supervised by a single surgeon.  RESULTS: All patients were cured of hypercalcemia.RESULTS: All patients were cured of hypercalcemia. – Sensitivity for sestamibi and for methylene blue stainingSensitivity for sestamibi and for methylene blue staining was 76% and 79%, respectively.was 76% and 79%, respectively. – Specificity for sestamibi and for methylene blue was 98%Specificity for sestamibi and for methylene blue was 98% and 93%, respectively.and 93%, respectively. – Agreement between sestamibi and methylene blue wasAgreement between sestamibi and methylene blue was 96%.96%. Orloff, Lisa A. MD., Larygoscope 2001
    7. 7. Intraoperative PTH assayIntraoperative PTH assay • Miami criterion (>50% drop from highest baseline IOPTH level at 10 minutes after excision) • criterion 1 (>50% drop from preincision IOPTH level at 10 minutes) • criterion 2 (>50% drop from highest baseline IOPTH level at 10 minutes and final IOPTH level within the reference range) • criterion 3 (>50% drop from highest baseline IOPTH level at 10 minutes and final IOPTH level less than the preincision value) • criterion 4 (>50% drop from highest baseline IOPTH level at 5 minutes), and criterion 5 (>50% drop from preexcision IOPTH level at 10 minutes). • Conclusions: Satisfying criterion 2 had a high operative success but resulted in additional unnecessary surgical exploration. Criterion 1 was better at predicting postoperative normocalcemia than criterion 2. • Chiu, Bill MD, Arch of Surgery, May 2006
    8. 8.  ““The adenoma is confined by the thyroid capsule and mimics theThe adenoma is confined by the thyroid capsule and mimics the shape of the thyroid pole.shape of the thyroid pole.  This conformation can often be confirmed on anterior and lateralThis conformation can often be confirmed on anterior and lateral pinhole views using a dual-isotope technique. In these cases,pinhole views using a dual-isotope technique. In these cases,  109 patients identified, 10 were diagnosed with parathyroid109 patients identified, 10 were diagnosed with parathyroid hyperplasia and 99 with parathyroid adenomashyperplasia and 99 with parathyroid adenomas  Of the 99 adenomas, 16 (16%) were in subcapsular locations.ThreeOf the 99 adenomas, 16 (16%) were in subcapsular locations.Three patterns as related to thyroidpatterns as related to thyroid – (1) focal convex distortion of the posterior aspect of the thyroid, 11/16(1) focal convex distortion of the posterior aspect of the thyroid, 11/16 – (2) polar lentiform configuration, and 3/16(2) polar lentiform configuration, and 3/16 – (3) compression of the posterior thyroid parenchyma.2/16(3) compression of the posterior thyroid parenchyma.2/16 Kraas J.Kraas J. Clinical Nuclear Medicine. April 2005.Clinical Nuclear Medicine. April 2005. Kraas J. Clinical Nuclear Medicine. April 2005
    9. 9. ReferencesReferences  1. Sackett WR, Barraclough B, Reeve TS, et al. Worldwide trends in the1. Sackett WR, Barraclough B, Reeve TS, et al. Worldwide trends in the surgical treatment of primary hyperparathyroidism in the era of minimallysurgical treatment of primary hyperparathyroidism in the era of minimally invasive parathyroidectomy.invasive parathyroidectomy. Arch SurgArch Surg. 2002;137:1055.. 2002;137:1055.  2. Thompson NBahar, Gideon MD a; Feinmesser, Raphael MD a; Joshua,2. Thompson NBahar, Gideon MD a; Feinmesser, Raphael MD a; Joshua, Ben-Zion MD a; Shpitzer, Thomas MD a; Morgenstein, Sara MD b; Popovtzer,Ben-Zion MD a; Shpitzer, Thomas MD a; Morgenstein, Sara MD b; Popovtzer, Aharon MD a; Shvero, Jacob MD a Hyperfunctioning intrathyroid parathyroidAharon MD a; Shvero, Jacob MD a Hyperfunctioning intrathyroid parathyroid gland: A potential cause of failure in parathyroidectomy.gland: A potential cause of failure in parathyroidectomy. Surgery. 139(6):821-Surgery. 139(6):821- 826, June 2006826, June 2006  3. Lee NJ, Blakey JD, Bhuta S, et al. Unintentional parathyroidectomy during3. Lee NJ, Blakey JD, Bhuta S, et al. Unintentional parathyroidectomy during thyroidectomy.thyroidectomy. LaryngoscopeLaryngoscope. 1999;109:1238.. 1999;109:1238.  4. McIntyre RC Jr, Eisenach JH, Pearlman NW, et al. Intrathyroidal4. McIntyre RC Jr, Eisenach JH, Pearlman NW, et al. Intrathyroidal parathyroid glands can be a cause of failed cervical exploration forparathyroid glands can be a cause of failed cervical exploration for hyperparathyroidism.hyperparathyroidism. Am J SurgAm J Surg. 1997;174:750.. 1997;174:750.  5. Clark PB, Case D, Watson NE Jr, et al. Enhanced scintigraphic protocol5. Clark PB, Case D, Watson NE Jr, et al. Enhanced scintigraphic protocol required for optimal preoperative localization before targeted minimallyrequired for optimal preoperative localization before targeted minimally invasive parathyroidectomy.invasive parathyroidectomy. Clin Nucl MedClin Nucl Med 2003;28:955.2003;28:955.  6. Kumar A, Cozens NJA, Nash JR. Sestamibi scan-directed unilateral neck6. Kumar A, Cozens NJA, Nash JR. Sestamibi scan-directed unilateral neck exploration for primary hyperparathyroidism due to a solitary adenoma.exploration for primary hyperparathyroidism due to a solitary adenoma. Eur JEur J Surg OncolSurg Oncol 2000;26:785.2000;26:785.]]
    10. 10.  7. Chapuis Y, Fulla Y, Bonnichon P, et al. Values of ultrasonography,7. Chapuis Y, Fulla Y, Bonnichon P, et al. Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH forsestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism. World J Surgunilateral neck exploration of primary hyperparathyroidism. World J Surg 1996; 20: 835–840.1996; 20: 835–840.  8. Casas A7. Mariani G, Gulec SA, Rubello D, et al. Preoperative localization8. Casas A7. Mariani G, Gulec SA, Rubello D, et al. Preoperative localization and radioguided parathyroid surgery.and radioguided parathyroid surgery. J Nucl MedJ Nucl Med. 2003;44:1443.. 2003;44:1443.  9. Feliciano DV. Parathyroid pathology in an intrathyroidal position.9. Feliciano DV. Parathyroid pathology in an intrathyroidal position. Am JAm J SurgSurg. 1992;164:496.. 1992;164:496.  10. Lorberboym M, Minski I, Macadziob S, et al. Incremental diagnostic value10. Lorberboym M, Minski I, Macadziob S, et al. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma.of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma. JJ Nucl MedNucl Med. 2003;44:904.. 2003;44:904.  11.T, Burke GJ, Mansberger AR, Wei JP. Impact of technetium-99m-11.T, Burke GJ, Mansberger AR, Wei JP. Impact of technetium-99m- sestamibi localization on operative time and success of operations for primarysestamibi localization on operative time and success of operations for primary hyperparathyroidism. Am Surg 1994; 60: 12–17.hyperparathyroidism. Am Surg 1994; 60: 12–17.  12. Takei H, Iino Y, Endo K, et al. The efficacy of technetium-99m-MIBI scan12. Takei H, Iino Y, Endo K, et al. The efficacy of technetium-99m-MIBI scan and intraoperative methylene blue staining for the localization of abnormaland intraoperative methylene blue staining for the localization of abnormal parathyroid glands. Surgery Today 1999; 29: 307–312.parathyroid glands. Surgery Today 1999; 29: 307–312.  13. Flynn MB, Bumpous JM, Schill K, McMasters KM. Minimally invasive13. Flynn MB, Bumpous JM, Schill K, McMasters KM. Minimally invasive radioguided parathyroidectomy. J Am Coll Surg 2000; 191: 24–31.radioguided parathyroidectomy. J Am Coll Surg 2000; 191: 24–31.
    11. 11.  14. Westerdahl, Johan PhD; Bergenfelz, Anders PhD Parathyroid Surgical14. Westerdahl, Johan PhD; Bergenfelz, Anders PhD Parathyroid Surgical Failures With Sufficient Decline of Intraoperative Parathyroid Hormone Levels:Failures With Sufficient Decline of Intraoperative Parathyroid Hormone Levels: Unobserved Multiple Endocrine Neoplasia as an ExplanationUnobserved Multiple Endocrine Neoplasia as an Explanation.. Archives ofArchives of Surgery. 141(6):589-594, June 2006.Surgery. 141(6):589-594, June 2006.  15. W, Eckhauser FE, Harness JK. The anatomy of primary15. W, Eckhauser FE, Harness JK. The anatomy of primary hyperparathyroidism.hyperparathyroidism. SurgerySurgery. 1982;92:814.. 1982;92:814.

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