10.1245/s10434-006-9254-y
Annals of Surgical Oncology 14:739-743 (2007)
© 2007 Society of Surgical Oncology
Radioguided Parathyroidectomy in Patients with Familial Hyperparathyroidism
Alysandra Lal, MD1,
Jesus Bianco, MD2 and
Herbert Chen, MD, FACS1
1 Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, H4/750 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA
2 Department of Radiology, University of Wisconsin, Madison, WI, USA
Correspondence: Address correspondence and reprint requests to: Herbert Chen, MD FACS. Department of Surgery, Section of Endocrine Surgery, University of Wisconsin, H4/750 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA; E-mail: chen{at}surgery.wisc.edu
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ABSTRACT
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Background: In patients with sporadic hyperparathyroidism (HPT), radioguided parathyroidectomy (RGP) has been shown to facilitate intraoperative localization of parathyroid glands, reduced operative time, and improve patient outcomes. No studies have focused on the role of RGP in patients with familial HPT.
Methods: Between 3/01 and 6/05, 419 patients underwent RGP. Nineteen had familial HPT, including 12 with Multiple Endocrine Neoplasia (MEN), and 94 had sporadic HPT with parathyroid hyperplasia. All patients were injected with sestamibi pre-operatively and a gamma probe was used intraoperatively. Radiotracer counts were recorded prospectively.
Results: In patients with familial HPT, the gamma probe detected all abnormal parathyroid glands with a mean in vivo radiotracer count of 157 ± 9% above background. Importantly, 5 patients (25%) had ectopic parathyroid glands localized by the probe in the thymus, thyroid and retroesophageal region. All resected hyperplastic parathyroid glands had ex vivo counts > 20%. All patients were cured after surgery with mean calcium and parathyroid hormone levels of 9.4 ± 0.1 mg/dl and 31 ± 7 pg/ml, respectively, and a mean hospital stay of 0.7 ± 0.1 days. In comparing the 2 groups, while patients with familial HPT had lower pre-operative parathyroid hormone levels, the ex vivo radiotracer counts were significantly higher.
Conclusion: RGP in patients with familial HPT is technically feasible and perhaps more sensitive than in patients with sporadic hyperplastic disease. The gamma probe efficiently localized all parathyroid glands including those in ectopic locations, and resulted in high cure rates and short hospital stays. RGP is a viable and useful technique in patients with familial HPT.
Key Words: Parathyroidectomy • Minimally invasive parathyroidectomy • Radioguided parathyroidectomy • MIRP • Multiple endocrine neoplasia
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INTRODUCTION
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The only curative treatment for hyperparathyroidism (HPT) is parathyroidectomy. Originally described by Felix Mandl in 19251, there have been many novel techniques applied to this procedure. In patients with sporadic hyperparathyroidism, radio-guided parathyroidectomy (RGP) has been shown to facilitate intraoperative localization of parathyroid glands, reduced operative time, and potentially improve patient outcomes. This has been proven to be efficacious in patients in patients with primary2–4 secondary and tertiary hyperparathyroidism.5 However, no studies have focused on the feasibility and efficacy of RGP in patients with familial HPT, including multiple endocrine neoplasia (MEN).
Hyperparathyroidism is the most common endocrine manifestation of MEN type 1 (MEN1). Almost all patients with MEN1 develop hyperparathyroidism, often with multiple affected glands and with an increased risk of recurrence.6 For this reason, it is essential to locate and remove all glands performing a total parathyroidectomy with reimplantation, or a sub-total parathyroidectomy.7 Multiple studies have shown the high propensity of patients with MEN to have persistent or recurrent disease after parathyroidectomy, with significantly increased rates of recurrence with anything less than a subtotal parathyroidectomy. Therefore it is paramount to locate all parathyroid glands in these patients. RGP may facilitate location of these glands, particularly when they are ectopic.
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METHODS
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Between March 2001 and June 2005, 419 consecutive patients underwent RGP by a single surgeon at our institution. Of these patients, 19 had familial HPT including 12 (63%) with MEN and seven with one or more relatives who had endocrine tumors. Of the patients with a familial history, three had siblings with HPT, one patient had a nephew with HPT, one patient had a cousin with HPT and two patients had extensive family histories of HPT without the diagnosis of MEN. Ninety-four patients had sporadic parathyroid hyperplasia. All patients were injected with 10 mCi of technetium99m sestamibi 1–2 h prior to surgery. Patients with MEN did not have sestamibi studies but patients with other types of familial hyperparathyroidism did undergo sestamibi scans and were then eligible for minimally invasive parathyroidectomy. Pre-operative ultrasound was not routinely used and screening of these patients consisted of physical exam surveillance for thyroid nodules. If a thyroid nodule was palpated or suspected, ultrasound-guided fine needle aspiration was performed. Intraoperatively, a 11 mm collimated gamma probe (Neoprobe 2000, Ethicon Endo-Surgery Breast-Care, Cincinnati, OH, USA) was used to obtain background counts on the thyroid isthmus through the skin. After an incision was made, the probe was again used to localized the gland by looking for counts exceeding the background. Once the parathyroid gland was identified, the gamma probe was placed on the gland and these counts were recorded as "in vivo" counts and expressed as a percent of the background counts. After the gland was excised, the gamma probe was again used to obtain counts (with the probe pointing away from the patient) and these counts were recorded as the "ex vivo" value. Again, ex vivo counts were expressed as a percentage of the background.
Intraoperative parathyroid hormone levels were checked prior to parathyroid resection and at both five and ten minutes after resection.8 A fall in PTH confirmed that all affected parathyroids were removed. Radioguided techniques assisted with localization of the parathyroids but did not replace the use of intraoperative PTH testing to confirm adequacy of resection.
All data were recorded prospectively. Surgical cure was defined as a serum calcium level less than 10.5 mg/dL at 6 months after surgery. Recurrence was defined as a serum calcium greater than 10.5 mg/dl in consecutive samples anytime beyond six months postoperatively. If a serum calcium remained above 10.5 mg/dl within 6 months, we defined this as persistent disease. Median follow-up was 32 months. Data were recorded as the mean ± SEM. Statistical analysis was performed using the SPSS program (SPSS Inc.). Statistical significance was defined as P < 0.05.
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RESULTS
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We compared 19 patients with familial HPT with 94 patients who had sporadic parathyroid hyperplasia. Eleven of the 19 patients had MEN1, one had MEN2 and the rest had family histories of HPT. Of the seven patients with a familial history, three had siblings with HPT, one patient had a nephew with HPT, one patient had a cousin with HPT and two patients had extensive family histories of HPT without the diagnosis of MEN. Etiology of hyperparathyroidism in the familial group was divided between patients with single adenoma (n = 9), double adenoma (n = 1) and hyperplasia (n = 9). The groups were comparable in age and pre-operative laboratory values except for PTH (Table 1
). Patients with familial disease had a significantly lower pre-operative PTH (131 ± 25 vs. 345 ± 44 pg/ml, P = 0.035) likely due to the increased number of patients with adenomas in the familial group. Post-operatively, the PTH was comparable (30 ± 7 vs. 38 ± 4 pg/ml). The mean hospital stay (LOS) was shorter in patients with familial disease. All patients were cured after surgery with a mean calcium and parathyroid hormone level of 9.4 ± 0.1 mg/dl and 31 ± 7 pg/ml, respectively.
Received for publication May 10, 2006.
Accepted for publication October 4, 2006.
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ABSTRACT
INTRODUCTION
. Therefore, we found that radioguided detection of the abnormal parathyroid glands apply equally to these conditions. 
