Parathyroid scintigraphy in preoperative detection of parathyroid adenomas and use of gama probe in minimal invasive surgery

Abstract

Clinical or subclinical hyperparathyroidism is one of the most common endocrine disorders. Excessive secretion of parathyroid hormone is most frequently caused by an adenoma of a parathyroid gland or glands. The conventional surgical approach is bilateral neck exploration, whereas minimally invasive parathyroidectomy has been made possible by the introduction of 99mTc-sestamibi scintigraphy for preoperative localization of parathyroid adenomas. Especially in ectopic localizations of parathyroid gland and its lesions preoperative localization have undeniable value. In minimally invasive technique the incision is small, dissection is minimal, postoperative pain is less, and hospital stay is shorter. Minimally invasive technique is easy, safe, with a low morbidity rate and has better cosmetic results lower overall cost than conventional bilateral neck exploration. In this technique greatly aided by intraoperative guidence with a gamma probe, based on in vivo radioactivity counting after administrating 99mTc-MIBI. In pres¬ent article, we reviewed actual literature on the preoperative localization of parathyroid adenomas and radioguided minimal invasive surgery.

Keywords

• Paratyhroid adenoma, minimal invasive, surgery, parathyroid scintigraphy, gamma probe

Parathyroid scintigraphy in preoperative detection of parathyroid adenomas and use of gama probe in minimal invasive surgery

Öz

Aşikar ya da subklinik hiperparatiroidi klinikte en sık karşılaşılan endokrin bozukluklardan biridir. Paratiroid hormonun bir ya da daha fazla paratiroid bezindeki adenomdan aşırı salgılanması en sık görülen hiperparatiroidi nedenidir. Geleneksel yöntemle yapılan paratiroid cerrahisinde iki taraflı boyun eksplorasyonu yaklaşımı kullanılmakta iken minimal invaziv paratiroidektomide 99mTc-sestamibi paratiroid sintigrafisi ile preoperatif olarak lezyonun yeri tespit edilmektedir. Özellikle ektopik paratiroid glandından kaynaklanan lezyonlarda adenomun yerinin tespit edilmesinin önemi büyüktür. Minimal invaziv teknikte ameliyat kesisi küçük olmakta, diseksiyon minimal ölçülerde kalmakta, ameliyat sonrası ağrı daha az olmakta ve hastane yatışları daha kısa sürmektedir. Bu teknik ile yapılan operasyonlar konvansiyonel iki taraflı boyun eksplorasyonuna göre daha kolay, güvenli, düşük morbiditeye neden olan, kozmetik olarak daha iyi sonuçlar veren ve genel maliyeti düşüren sonuçlara sahiptir. Bu teknik, intraoperatif olarak kullanılan ve IV yoldan enjekte edilen 99mTc-MIBI gama prob ile sayılmasını baz alan nükleer tıp metodu ile başarılı bir biçimde desteklenmektedir. Bu makalede Güncel literatüre ait paratiroid adenomlarının preoperatif lokalizasyonun tanınması ve minimal invaziv paratiroid cerrahisinde paratiroid sintigrafisi ve gama prob kullanımına ait bilgilerin gözden geçirilmesi amaçlanmıştır. Anahtar kelimeler: Paratiroid adenom, minimal invaziv, cerrahi, paratiroid sintigrafisi, gama prob

Anahtar Kelimeler

• Paratiroid adenom, minimal invaziv, cerrahi, paratiroid sintigrafisi, gama prob

References

1. Bilezikian JP, Silverberg SJ. Clinical spectrum of pri- mary hyperparathyroidism. Rev Endocr Metab Disord 2000;1(4):237-45.
2. Sywak MS, Robinson BG, Clifton-Bligh P, et al. Increase in presentations and procedure rates for hyperparathyroid- ism in Northern Sydney and New SouthWales. Med J Aust 2002;177(5):246-249.
3. Heath H 3rd, Hodgson SF, Kennedy MA. Primary hyperpara- thyroidism: incidence, morbidity, and potential economic impact in a community. N Engl J Med 1980;302(4):189- 93.
4. Clark OH, Siperstein AE. The hypercalcemic syndrome. In: Friesen SR, Thompson NW, eds. Surgical Endocrinol- ogy Clinical Syndromes. Philadelphia, PA:Lippincott; 1990:311-339.
5. Melton LJ 3rd. The epidemiology of primary hyperparathy- roidism in North America. J Bone Miner Res 2002;17(suppl 2):N12-N17.
6. Adami S, Marcocci C, Gatti D. Epidemiology of prima- ry hyperparathyroidism in Europe. J Bone Miner Res 2002;17(suppl 2):N18-N23.
7. Bilezikian JP, Meng X, Shi Y, Silverberg SJ. Primary hyper- parathyroidism in women: a tale of two cities—New York and Beijing. Int J Fertil Womens Med 2000;45(2):158-165.
8. Mariani G, Gülec SA, Rubello D. Preoperative localiza- tion and radioguided parathyroid surgery. J Nucl Med 2003;44(9):1443-1458

9. Appleton JL. The hypertrophy of the submaxillary gland in the albino rat, following parathyroidectomy. Am J Pathol 1925;1(2):217-23.
10. Kaplan EL, Yashiro T, Salti G. Primary hyperparathyroid- ism in the 1990s: choice of surgical procedures for this dis- ease. Ann Surg 1992;215(4):301-7.
11. Auguste LJ, Attie JN, Schnaap D. Initial failure of surgical exploration in patients with primary hyperparathyroidism. Am J Surg 1990;160(4):333-6.
12. van Heerden JA, Grant CS. Surgical treatment of primary hyperparathyroidism: an institutional perspective. World J Surg. 1991;15(6):688-92.
13. Chen H, Zeiger MA, Gordon TA, Udelsman R. Parathyroi- dectomy in Maryland: effects of an endocrine center. Sur- gery 1996;120(6):948-52.
14. Chen H, Mack E, Starling JR. Radioguided parathyroidec- tomy is equally effective for both adenomatous and hyper- plastic glands. Ann Surg 2003;238(3):332-7.
15. Udelsman R. Six hundred fifty-six consecutive explo- rations for primary hyperparathyroidism. Ann Surg 2002;235(5):665-70.
16. Akerstrom G, Malmaeus J, Bergstrom R. Surgical anatomy of human parathyroid glands. Surgery 1984;95(1):14-21.
17. Numano M, Tominaga Y, Uchida K, Orihara A, Tanaka Y, Takagi H. Surgical significance of supernumerary para- thyroid glands in renal hyperparathyroidism. World J Surg 1998;22(10):1098-102.
18. Bringhurst FR, Stern AM, Yotts M, Mizrahi N, Segre GV, Potts JT Jr. Peripheral metabolism of parathyroid hormone in vivo: influence of alterations in calcium availability and parathyroid status. J Endocrinol 1989;122(1):237-45.
19. Russell CF, Edis AJ. Surgery for primary hyperparathyroid- ism: experience with 500 consecutive cases and evaluation of the role of surgery in the asymptomatic patient. Br J Surg 1982;69(5):244-7.
20. Ammori BJ, Madan M, Gopichandran TD, et al. Ultrasound guided unilateral neck exploration for sporadic primary hy- perparathyroidism: is it worthwhile? Ann R Coll Surg Engl. 1998;80(6):433-7.
21. Geatti O, Shapiro B, Orsolon PG, Proto G, Guerra UP, An- tonucci F, et al. Localization of parathyroid enlargement: experience with technetium 99m methoxyisobutylisonitrile and thallium-201 scintigraphy, ultrasound and computed tomography. Eur J Nucl Med 1994;21(1):17-23.
22. Casara D, Rubello D, Pelizzo MR, Shapiro B. Clinical role of 99mTcO4/MIBI scan, ultrasound and intra-operative gamma probe in the performance of unilateral and mini- mally invasive surgery in primary hyperparathyroidism. Eur J Nucl Med 2001;28(9):1351-9.
23. Koong HN, Choong LH, Soo KC. The role of preoperative localisation techniques in surgery for hyperparathyroidism. Ann Acad Med Singapore 1998;27(2):192-5.
24. Levin KE, Clark OH. Localization of parathyroid glands. Annu Rev Med 1988;39(1):29-40.
25. Billotey C, Sarfati E, Aurengo A, et al. Advantages of SPECT in technetium-99 m-sestamibi parathyroid scintig- raphy. J Nucl Med 1996;37(11):1773-8.
26. Carty SE, Worsey MJ, Virji MA, Brown ML, Watson CG. Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay. Surgery 1997;122(8):1107-16.
27. Gallowitsch HJ, Mikosch P, Kresnik E, Gomez I, Lind P. Technetium-99m-tetrofosmin parathyroid imaging: results with double-phase study and SPECT in primary and sec- ondary hyperparathyroidism. Invest Radiol 1997;32(8):459- 65.
28. Neumann DR, Esselstyn CB Jr, Go RT, Wong CO, Rice TW, Obuchowsky NA. Comparison of double-phase 99mTc- sestamibi with 123I-99mTc-sestamibi subtraction SPECT in hyperparathyroidism. AJR 1997;169(6):1671-4.
29. Francis IS, Loney EL, Buscombe JR, Thakrar DS, Berger L, Hilson AJW. Technetium-99m-sestamibi dual-phase SPECT imaging: concordance with ultrasound. Nucl Med Commun 1999;20(4):487-8.
30. Irvin GL 3rd. American Association of Endocrine Sur- geons presidential address: Chasin’ hormones. Surgery 1999;126(6):993-7.
31. Irvin GL 3rd, Carneiro DM. Rapid parathyroid hormone as- say guided exploration. Oper Tech Gen Surg 1999;1(1):18- 27.
32. Irvin GL 3rd, Dembrow VD, Prudhomme DL. Operative monitoring of parathyroid gland hyperfunction. Am J Surg 1991;162(4):299-302.
33. Piwnica-Worms D, Kronauge JF, Chiu ML. Uptake and retention of hexakis (2-methoxyisobutyl isonitrile) techne- tium (I) in cultured chick myocardial cells. Mitochondrial and plasma membrane potential dependence. Circulation 1990;82(5):1826-38.
34. Harioka T, Odori T, Kohno S, et al. CT evaluation of para- thyroid tumor. Nippon Igaku Hoshasen Gakkai Zasshi 1984;44(7):948-55.
35. Melloul M, Paz A, Koren R, Cytron S, Feinmesser R, Gal R. 99mTc-MIBI scintigraphy of parathyroid adenomas and its relation to tumour size and oxyphil cell abundance. Eur J Nucl Med 2001;28(10):209-13.
36. Taillefer R, Boucher Y, Potvin C, Lambert R. Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med 1992;33(10):1801-7.
37. Varoglu E et al. Turkish Society of Nuclear Medicine En- dokrinology and Radyonuelide Treatment Task Group Guideline for Parathyroid Scintigraphy Turk J Nucl Med 2001;3(Supp 10):23-9.
38. Martinez DA, King DR, Romshe C, Lozano RA, Morris JD, O’Dorisio MS, et al. Intraoperative identification of para- thyroid gland pathology: a new approach. J Pediatr Surg 1995;30(9):1306-9.
39. Norman J, Chheda H. Minimally invasive parathyroidecto- my facilitated by intraoperative nuclear mapping. Surgery 1997;122(6):998-1003.
40. Murphy C, Norman J. The 20% rule: a simple, instanta- neous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery 1999;126(6):1023-8.
41. McGreal G, Winter DC, Sookhai S, et al. Minimally inva- sive, radioguided surgery for primary hyperparathyroidism. Ann Surg Oncol 2001;8(10):856-60.
42. You CJ, Zapas JL. Diminished dose minimally invasive radioguided parathyroidectomy: a case for radioguidance. Am Surg 2007;73(7):669-72.
43. Chen H, Sippel SR, Schaefer S, The Effectiveness of radioguided parathyroidectomy in patients with nega- tive Technetium Tc 99m-Sestamibi scans. Arch Surg 2009;144(7):643-8.
44. Pitt SC, Panneerselvan R, Sippel RS, Chen H. Radioguided parathyroidectomy for hyperparathyroidism in the reopera- tive neck. Surgery 2009;146(4):592-8.
45. Norman J, Denham D. Minimally invasive radioguid- ed parathyroidectomy in the reoperative neck. Surgery 1998;124(6):1088-93.
46. Burkey SH, Snyder WH III, Nwariaku F, Watumull L, Mathews D. Directed parathyroidectomy:feasibility and performance in 100 consecutive patients with primary hy- perparathyroidism. Arch Surg 2003;138(6):604-9.
47. Chen H, Pruhs Z, Starling JR, Mack E. Intraoperative para- thyroid hormone testing improves cure rates in patients un- dergoing minimally invasive parathyroidectomy. Surgery 2005;138(4):583-90.
48. Beierwaltes WH. Endocrine imaging: parathyroid, adrenal cortex and medulla, and other endocrine tumors—Part 2. J Nucl Med 1991;32(8):1627-39.
49. Rubella D,Mariani G, Pelizzo MR; Italian Study Group of Radioguided Surgery and ImmunoScintigraphy. Minimally invasive radio-guided parathyroidectomy on a group of primary hyperparathyroid patients: refinement of preopera- tive imaging and intraoperative procedure. Nuklearmedizin 2007;46(3):85-92.
50. Chen H. Radioguided Parathyroid surgery. Adv Surg 2004;38(4):377-92.
51. Weigel TL, Murphy J, Kabbani L, Ibele A, Chen H. Ra- dioguided thoracoscopic mediastinal parathyroidectomy with intraoperative parathyroid hormone testing. Ann Tho- rac Surg 2005;80(4):1262-5.