Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital.
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Transcript of Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital.
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Pre-operative localization of parathyroid adenoma
Dr Chan Man-yi
Tuen Mun Hospital
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Primary hyperparathyroidism
Gold standard = bilateral neck exploration 95 – 98% at first exploration
Imaging used only after failed initial surgery
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Etiology of primary hyperparathyroidism Solitary parathyroid adenoma 80-85%
Unilateral neck explorationMinimally invasive surgery
Foscused parathyroidectomyVideo-assisted parathyroidectomyVideoscopic parathyroidectomy
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Minimally Invasive parathyroidectomy
Pre-operative Ultrasound Sestamibi scan CT MRI Angiography / selective
venous sampling
Intra-operative PTH assay Ultrasound Gamma probe
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Ultrasound 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)
Sensitivity (55-83%)Ruda et al, Otolaryngol Head Neck Surg 2005;
132:359–372
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USG by surgeon
Sensitivity of USG Specific side – 84% Specific quadrant – 79%
Sensitivity of USG + MIBI – 98%
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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-glycoproteinBhatnagar et al, J Nucl Med 1998;39:1617-1620
Carpentier et al, J Nucl Med 1998;39:1441-1444
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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
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Planar imagingSPECT/CT
SPECT
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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
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USG vs MIBI
Sensitivity of USG – 65% Sensitivity of MIBI-SPECT – 68% Detected only by one modality – 16% USG and MIBI complementary
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USG + MIBI
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USG + MIBI
Surgical failure w/o PTH – 2% With PTH – 1%
P=0.5
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Reoperation?
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163 patients with ?missed adenoma Pre-op localization surgery
140 unilateral exploration 18 mediastinal procedure
92% long term resolution of hypercalcemia
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Sensitivity = 70%
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Proposed strategy
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? 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
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John Doppman 1986
“The best localization study prior to primary exploration in a patient with primary hyperparathyroidism is to locate an experienced parathyroid surgeon”
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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
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