Recurrent hyperparathyroidism due to parathyroid autografts: incidence, presentation, and management

Recurrent hyperparathyroidism (HPT) occurs in a small percentage of patients undergoing parathyroidectomy for primary HPT and is usually due to inadequate excision of hyperfunctioning parathyroid tissue in the neck, a missed ectopic and hyperplastic parathyroid, or, less commonly, parathyroid carcinoma and parathyroid autografts. In order to determine the incidence, clinical characteristics, and outcome of patients with recurrent HPT due to parathyroid autografts, we reviewed our experience with 604 consecutive patients operated on for primary HPT between 1965 and 1989. One hundred of these patients received parathyroid autografts consisting of portions of one or more parathyroid glands. Three patients with autografts, placed in the sternocleidomastoid muscle, developed recurrent HPT due to their autografts for an incidence of 3 per cent. Recurrent disease was diagnosed between 62 and 113 months with an average of 89 months. The autotransplants in all three of these patients were from hyperplastic or adenomatous parathyroid tissue. Two patients had a history of neck irradiation. Preoperative thallium scans accurately localized the hyperfunctioning parathyroid tissue in all three patients. At operation, the hyperfunctioning autografts had grown into a discrete mass with a single vascular pedicle and were resected. Histologic examination disclosed either hyperplastic or adenomatous tissue, and corresponded to the histology and location of the original tissue transplanted in each case. Follow-up ranges from 12 to 67 months, with an average of 48 months. All patients remain cured and none require oral calcium supplementation. We conclude that graft-dependent recurrent HPT is due to the autotransplantation of hyperplastic or adenomatous parathyroid tissue and that thallium scanning is instrumental for diagnosis and localization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary diffuse microscopical hyperplasia of the parathyroid glands: surgical importance

In two of 182 patients with verified primary hyperparathyroidism, microscopical hyperplasia was present in all parathyroid glands that were normal in size or only slightly enlarged. All parathyroid glands in another two patients showed microscopical hyperplasia and varied from a normal size of 190 mg. In seven additional patients, microscopical hyperplasia was present in one, several, or all parathyroid glands, which varied in weight from normal to 350 mg. Familial hyperparathyroidism or multiple endocrine neoplasia was evident in five of 11 patients. Contributing to difficulties was the experience in five patients in whom removal of mildly enlarged parathyroid glands corrected hypercalcemia, but definite microscopical abnormalities were not evident by routine histologic study of the glands. Thus, there appears to be a spectrum of abnormalities relative to size and microscopical changes in parathyroid glands of patients with primary hyperparathyroidism. The surgeon should be aware of these patterns of parathyroid hyperplasia that require a search for a fifth parathyroid gland and a subtotal parathyroidectomy.     

D-penicillamine-induced myasthenia gravis in a case of eosinophilic fasciitis

During the period 1983-1995, 200 chronic renal failure patients (115 males and 85 females) were parathyroidectomized for hyperparathyroidism in our Department. In all of them, the presenting clinical symptoms, physical signs, biochemical and radiological tests were typically those of hyperparathyroidism. One hundred ninety patients were operated for the first time whereas 10 were re-operated due to relapse of the disease; 3 of these cases were primary hyperparathyroidism, 182 secondary and 5 tertiary. All three primary hyperparathyroidism cases underwent removal of the adenoma; in the group of secondary hyperparathyroidism, 50 underwent removal of all the parathyroid glands found, 25 underwent total parathyroidectomy with forearm or deltoid autograft and 60 subtotal parathyroidectomy whereas in 39 and 8 patients only 3 and 2 parathyroid glands were found respectively. In the group of tertiary hyperparathyroidism, we removed only the hyperplastic gland detected as the operative detection of the rest was not possible. Ten cases were re-operated for removal of the remaining glands. No complications were noted postoperatively, apart from severe hypocalcemia in 20 cases, treated successfully by Calcium and Vitamin D administration. The highest relapse rate was noted among the 8 patients with only the 2 parathyroid glands removed. It seems that total or subtotal parathyroidectomy represents the most successful methods for surgical treatment of hyperparathyroidism complicating chronic renal failure.     

Value of ultrasonography, CT and MR imaging in the diagnosis of primary hyperparathyroidism

PURPOSE: To evaluate the significance of preoperative localization of abnormal parathyroid glands to the surgical outcome in patients with primary hyperparathyroidism. MATERIAL AND METHODS: Thirty-nine patients with primary hyperparathyroidism were studied preoperatively with US (39 patients), CT (30 patients) and MR imaging (18 patients). The overall diagnostic accuracy for US was 87%, CT 66% and MR 94%. In patients with a single parathyroid adenoma US was the most cost-effective localization technique with a detection rate of 96%. CT had a lower detection rate (78%) but was of particular value for fairly large ectopic adenomas in the root of the neck. MR imaging was a good confirmatory test (93%). In patients with multiple gland disease (primary hyperplasia and multiple adenomas), no single localization study alone was sufficient. Combination of all 3 studies, however, alerted the physician to the presence of disease in more than one gland in 87% of these patients. CONCLUSION: US, CT and MR imaging followed by surgery performed by an experienced surgeon provided good clinical results in 39 patients with primary hyperparathyroidism. Preoperative localization was especially useful in patients with primary parathyroid hyperplasia or multiple adenomas and in patients with ectopic parathyroid adenomas in the root of the neck. We recommend identification of all abnormal parathyroid glands prior to surgery.     

Preoperative parathyroid gland localization with technetium-99m sestamibi in secondary hyperparathyroidism

Technetium-99m sestamibi scintigraphy has become a valuable tool in locating parathyroid glands in patients with primary hyperparathyroidism. The aim of this study was to evaluate its usefulness in secondary hyperparathyroidism. Twenty patients were injected intravenously with 740 MBq of 99mTc-sestamibi and images were obtained at 15 min and 2 h post injection. All patients underwent parathyroid ultrasonography (US) as well as bilateral surgical neck exploration and 64 parathyroid glands were removed. US revealed at least one enlarged gland in 15/20 patients (75%), while 99mTc-sestamibi scintigraphy showed focal areas of increased uptake in at least one gland in 17/20 patients (85%). When imaging results for all glands were evaluated according to surgical results, sensitivity was 54% for parathyroid scintigraphy and 41% for US, and specificity was 89% for both imaging techniques. There was a discrepancy between the two imaging modalities in 28 glands (35%). The mean surgical weight of US-positive glands (1492+/-1436 mg) was significantly higher than that of US-negative glands (775+/-703 mg) (P<0.05). However, there were no significant differences in weight between sestamibi-positive and sestamibi-negative glands. When only sestamibi-positive glands were considered, a positive correlation between uptake and weight was found (r=0.4, P<0.05). In conclusion, parathyroid US and 99mTc-sestamibi scintigraphy are complementary imaging techniques in the preoperative localization of abnormal parathyroid glands in patients with secondary hyperparathyroidism. The limited sensitivity of the techniques means that patients will still require bilateral neck exploration; therefore routine preoperative parathyroid scanning in renal patients is not justified.     

Hyperparathyroidism due to a cystic parathyroid adenoma after irradiation of the neck

A 48-year-old female with hypercalcaemia diagnosed 3 years prior to admission is described. The patient underwent x-ray therapy of the neck for keloid scars 35 years prior to the diagnosis of hypercalcaemia. The hypercalcaemia was found to be the result of primary hyperparathyroidism. A cystic parathyroid adenoma was identified during surgery and was, on microscopic examination, composed of oxyphil cells rich in mitochondria. The cystic fluid contained 360 times higher C-terminal PTH than peripheral serum and almost 4000 times higher PTH as intact 1-84 amino acid residue species. We concluded that previous X-ray irradiation was related to the pathogenesis of the patient's parathyroid adenoma. The mild nature of the patient's hyperparathyroidism was possibly related to the composition of the tumour of oxyphil cells, known to be a poorly functioning variant of the parathyroid cell. Since parathyroid 'cysts' are obviously necrotic parathyroid adenomas, aspiration of the cysts alone cannot be expected to be curative and, therefore, it is recommended to treat cystic parathyroid adenomas by surgical extirpation.     

Analysis of proliferative activity of the parathyroid glands using proliferating cell nuclear antigen in patients with hyperparathyroidism

To elucidate the cellular proliferative kinetics of the parathyroidal gland in patients with hyperparathyroidism, we investigated the expression of proliferating cell nuclear antigen (PCNA) in parathyroidal tissues using an immunohistochemical procedure. The PCNA labeling index (LI; maximum LI, maximal stained area; average LI, evenly distributed stained area) indicating cellular proliferative activity was defined as the number of PCNA-positive cells per 1000 parathyroid cells in the region of interest. We used these indexes to compare and investigate the proliferative activity of parathyroid cells under various conditions. The specimens used for the study were 42 parathyroid glands from 21 patients with primary hyperparathyroidism (19 cases of adenoma and 2 cases of primary hyperplasia due to multiple endocrine neoplasia type 1) and 129 parathyroid glands from 32 patients with secondary hyperparathyroidism. An additional 40 parathyroid glands resected during thyroid surgery of 30 normocalcemic patients were used as normal controls. In normally functioning parathyroids, a small number of cells in the growth phase were found. In primary hyperparathyroidism, proliferative activity was highest in the adenoma followed by primary hyperplasia. In contrast, the PCNA LIs showed a low value in the normal rim of the adenoma and normal glands resected as biopsy specimens from adenoma patients. We, therefore, assumed that proliferative activity was suppressed in these cells compared with that in normally functioning glands. In secondary hyperparathyroidism, when the cell component of the parathyroid tissues was divided into five types, PCNA immunoreactivity was lowest in the dark chief cells. Proliferative activity in cells of the oxyphil series was the same or higher than that in the clear chief cells or vacuolated chief cells. When classified according to the structure of the parathyroid glands, cell proliferation was significantly higher in the nodular type than in the diffuse type (maximum LI, 176 +/- 231 vs. 38.3 +/- 55.7; average LI, 120 +/- 188 vs. 24.8 +/- 43.5; mean +/- SD; P < 0.001). More PCNA-immunoreactive cells were found in autotransplanted glands with recurrence than in glands resected during the initial surgery. To summarize the PCNA expression classified according to the pathological types of hyperparathyroidism, the PCNA LIs were highest in secondary hyperplasia (maximum LI, 144 +/- 212; average LI, 96.0 +/- 169) and adenoma (maximum LI, 102 +/- 81.7; average LI, 67.5 +/- 67.7), followed by primary hyperplasia (maximum LI, 25.0 +/- 25.4; average LI, 19.2 +/- 22.2) and normal glands (maximum LI, 13.6 +/- 23.9; average LI, 4.40 +/- 8.90). These findings suggest that the cellular proliferative kinetics of the parathyroid gland differ depending on the type of hyperparathyroidism, glandular structure, and cell components. As the detection method of intranuclear expression of PCNA in cells is too sensitive, we should be careful not to overestimate the number of cells in the proliferative cycle. However, these results could not have been obtained using a conventional method such as DNA analysis by flow cytometry.     

Sestamibi scanning is inadequate for directing unilateral neck exploration for first-time parathyroidectomy

OBJECTIVE: To determine whether technetium Tc 99m sestamibi scanning is accurate enough to allow surgeons to perform unilateral neck exploration for first-time parathyroidectomy in patients with primary hyperparathyroidism. DESIGN: Retrospective review. SETTING: University tertiary care center. PATIENTS: Forty patients with primary hyperparathyroidism who underwent sestamibi scanning before first-time parathyroidectomy, of whom 28 had single adenomas, 9 had multiple adenomas, and 3 had hyperplasia. INTERVENTIONS: All 40 patients underwent bilateral neck exploration with identification of 4 parathyroid glands. MAIN OUTCOME MEASURES: We compared the results of preoperative sestamibi scanning with operative and histologic findings. We then used these data to calculate the projected success rates of parathyroidectomy if unilateral neck explorations had been performed based on the results of sestamibi scanning, instead of bilateral explorations. RESULTS: Sestamibi scanning was correct in 20 (71%) of 28 patients with single adenomas, 4 (44%) of 9 patients with multiple adenomas, and 0 (0%) of 3 patients with hyperplasia. If unilateral neck explorations had been performed on the basis of localization by sestamibi scanning, parathyroidectomy would have failed in 4 (10%) of 40 patients. CONCLUSIONS: Sestamibi scanning, although helpful, is inadequate for directing unilateral neck exploration for first-time parathyroidectomy. Surgeons who perform unilateral neck exploration based on the results of sestamibi scanning will record a higher failure rate and incur higher costs than those who perform bilateral neck exploration for first-time parathyroidectomy.     

Use of a press as support of the temporal bone in experimental otologic surgery]

Sixty-seven cases of neck exploration for suspected hyperparathyroidism were reviewed. Thirty-nine patients underwent removal of an adenoma with biopsy of one or more other parathyroid glands. In another group, nine patients underwent removal of the adenoma only. Both groups have had no recurrences of hyperparathyroidism in follow-up periods of two months to twelve years. The data presented indicate that removal of a parathyroid adenoma alone, without biopsy of other tissue, represents satisfactory treatment. Experience with hyperplastic glands is also reviewed. Subtotal parathyroidectomy was effective treatment in all patients, but a 30 per cent incidence of hypocalcemia was noted after this operation.     

Nonadenomatous thymic unencapsulated parathyroid tissue as a cause of persistent primary hyperparathyroidism

Primary hyperparathyroidism may be caused by ectopic intrathymic parathyroid adenomas or hyperplastic parathyroid glands. The association of the ectopic inferior parathyroid glands and the thymus is due to their common embryologic origin from the third pharyngeal pouch. We report a case of primary hyperparathyroidism due to an unusual pathologic parathyroid gland formation: nonadenomatous thymic unencapsulated parathyroid tissue. Two unsuccessful neck exploration revealed only two normal parathyroid glands within the cervical area. Radiologic imaging studies failed to localize an ectopic parathyroid adenoma. Mediastinal exploration and thymectomy showed one small focus of unencapsulated hypercellular parathyroid tissue expanding peripherally along the septa of thymic adipose tissue. The hyperparathyroidism resolved with the surgical procedure.     

Parathyroid scintigraphy with Tc99m Sestamibi

BACKGROUND: Parathyroid scintigraphy with Tc99m Sestamibi, a tracer that is taken up by hyperfunctioning parathyroid tissue, has a high yield in the diagnosis of abnormal parathyroid growths. AIM: To assess the usefulness of parathyroid scintigraphy with Tc99m Sestamibi in patients with suspected hyperparathyroidism. PATIENTS AND METHODS: We analyzed retrospectively 29 patients with suspected hyperparathyroidism, in whom a scintigraphy with Tc99m Sestamibi was performed. RESULTS: Twenty four of 25 patients in whom hyperfunctioning parathyroid tissue was evidenced with scintigraphy, were operated. Histological diagnosis of the excised parathyroid gland, showed 23 adenomas and 1 hyperplasia. Anatomical location disclosed by scintigraphy was concordant with surgical findings in all cases, including a mediastinic adenoma. Of the four patients with negative scintigraphic findings, two had transitory PTH elevations and in two the presence of adenoma or hyperplasia could not be demonstrated with other diagnostic procedures. CONCLUSIONS: Parathyroid scintigraphy with Tc99m Sestamibi had an 86% sensitivity for the detection of hyperfunctioning parathyroid tissue in patients with elevated PTH.     

Management of hyperparathyroidism in an endemic goiter area

In an endemic goiter area patients with hyperparathyroidism (HPTH) frequently also have thyroid abnormalities. In a retrospective study of 95 patients with HPTH we assessed the diagnostic accuracy of imaging techniques (ultrasonography or radionuclide scanning) for preoperative localization of parathyroid adenomas. Altogether 86% of our patients had goiter, requiring thyroid resections in 37%. For 19 patients the parathyroid exploration was the second or third cervical operation, most of them due to goiter. We found that the overall rate of transient and permanent recurrent nerve paralysis is considerably increased in patients with previous neck surgery (26% vs. 7%). The combination of ultrasonography and radionuclide scanning can lead surgeons to the site of parathyroid lesions responsible for HPTH in 85% of cases, although frequent nodular goiters can produce pitfalls for correct imaging in iodine-deficient countries. In endemic goiter areas preoperative localization studies can be recommended in patients with primary HPTH--for evaluation of thyroid pathology possibly leading to resection or its accuracy in localizing parathyroid adenomas. These studies also seem justified in patients with previously unsuccessful neck explorations for HPTH.     

Cost utility of routine imaging with Tc-99m-sestamibi in primary hyperparathyroidism before initial surgery

Tc-99m-sestamibi has been shown to localize parathyroid adenomas effectively, but controversy continues as to the use of this scan before initial surgery for primary hyperparathyroidism. We analyzed the cost utility of obtaining this study before initial surgery for primary hyperparathyroidism. Twenty-two consecutive patients with primary hyperparathyroidism underwent dual-phase Tc-99m-sestamibi scan before initial bilateral neck exploration. Surgical findings were correlated with the results of sestamibi scan. There were 15 women and 7 men, with a mean age of 50.5 years (range, 22-76). Preoperative mean total calcium was 11.74 mg/dL (range, 10-15), ionized calcium was 6.19 mg/dL (range, 5.2-7.7), and intact parathyroid hormone was 153.5 pg/mL (range, 83.1-551). Postoperative mean ionized calcium was 4.56 mg/dL (range, 4.1-5.57). Twenty sestamibi scans had a positive localization, and 2 scans had no localization. At surgery, 18 solitary adenomas, 3 diffuse hyperplasias, and 1 patient with four normal parathyroid glands were found. Sixteen sestamibi scans were true positive (solitary adenoma), 4 scans were false positive (2 diffuse hyperplasia, 1 wrong side, and 1 lymph node), 1 negative scan was true negative (diffuse hyperplasia), and 1 negative scan was false negative (adenoma). One patient (four normal glands) at the second operation had a supernumerary fifth gland adenoma excised from the mediastinum. Preoperative Tc-99m-sestamibi scan did not offer any advantage when a complete bilateral neck exploration is performed. Sixteen of (84%) adenomas were correctly localized, but 18 of 19 adenomas were in the neck and were easily found. The 1 ectopic adenoma was not found by scanning or with initial surgery. The 4 of 22 (18%) false-positive localizations and the 2 of 22 (9%) negative scans contributed nothing to the surgery. Of the 22 localizing sestamibi scans, surgery was not altered to affect the outcome. At a cost of $550 per sestamibi scan and with the error inherent in the scan, it is not cost effective to obtain Tc-99m-sestamibi scan before initial surgery for primary hyperparathyroidism.     

Surgical management of parathyroid disease

One hundred fifty patients who had operation for hyperparathyroidism at the National Institutes of Health are reviewed. The series is composed of several groups of patients, including 18 with normocalcemic hyperparathyroidism, 13 with hyperparathyroidism associated with MEA II, and 24 patients with a history of previous parathyroid operation. Selective venous catherization and radioimmunoassay of parathormone was carried out in 81 patients and was interpreted as being localizing in 65 cases. Following operation, six patients remained hypercalcemic. There were nine instances of permanent hypocalcemia and four cases in which permanent recurrent nerve injuries were experienced. The operative management of these patients is outlined in detail, stressing an approach which includes the surgeon, the internist and the pathologist. Based upon pathological evidence, the importance of identifying by frozen section four glands is emphasized.     

Phytohemagglutinin-induced gut hyperplasia and the growth of a mouse lymphosarcoma tumor

OBJECTIVE: To identify possible causes for the increased cardiovascular morbidity and mortality seen in patients with primary hyperparathyroidism. DESIGN: Prospective, blind study. SETTING: University hospital, Sweden. SUBJECTS: 44 Patients with primary hyperparathyroidism and 23 (sex and age matched) control patients with atoxic nodular goitres. INTERVENTIONS: Exploration of the neck with removal of pathological parathyroid glands or thyroid resection. Echocardiography before, and one year after, the operation. MAIN OUTCOME MEASURES: Blood pressure and echocardiographic findings. RESULTS: Hyperparathyroid patients had higher blood pressure and greater left atrial diameter than control patients preoperatively. They also had a significantly lower E:A ratio (mitral flow velocity pattern) than the controls (p = 0.02) indicating a disturbance in early diastolic filling of the left ventricle. The E:A ratio correlated negatively with the systolic blood pressure. 19 of the hyperparathyroid patients (43%) had cardiac calcifications as did 14 (61%) of the controls. Most of calcifications were located in the aortic and mitral valves; only a few patients had calcifications in the myocardium. No significant changes had occurred one year after parathyroidectomy, except for a reduction in systolic blood pressure, in the hyperparathyroid patients. CONCLUSION: Echocardiographic investigation of patients with primary hyperparathyroidism shows early signs of left ventricular dysfunction that may be of clinical importance.     

Stapedial reflex: a biological index found to be abnormal in clinical and subclinical hypothyroidism

INTRODUCTION: Parathyroidectomy via cervical exploration is an effective primary-modality treatment for hyperparathyroidism, with cure rates of greater than 95%. We retrospectively reviewed 866 consecutive parathyroidectomies performed by a single surgeon between 1960 and 1997. We attempted to describe the polymorphic variation in multiglandular disease, the anatomic locations of pathologic glands, and the operative strategy and techniques which we believed were important to minimizing morbidity and maximizing curative success. METHODS: The cases of 329 males and 537 females (age, 1-88 years) were reviewed. There were 766 operations performed: primary hyperparathyroidism (713), tertiary hyperparathyroidism (100), reoperations (53). The strategy for primary exploration includes a bilateral neck exploration, early recurrent laryngeal nerve skeletonization, and identification of at least four glands. RESULTS: Normocalcemia was achieved in 98.2% of cases after initial cervical exploration. Persistent hypercalcemia occurred in 7 patients (<1%). Nine patients (1%) suffered persistent postoperative hypocalcemia. Unilateral recurrent laryngeal nerve injury occurred in two patients (<1%). Other perioperative complications included: reoperation for hematoma, repaired carotid artery injury, unexplained dysphagia, pneumothorax, deep venous thrombosis, and aspiration pneumonia. There were two mortalities (<1%) attributable to severe, comorbid disease. Ectopic glands were found in 120 cases. The frequency of glands at these sites were as follows: mediastinal (4.9%), intrathymic (8.4%), intrathyroid (6.7%), and retroesophageal/retrotracheal (3.5%). Thyroid resections provided diagnosis of concomitant thyroid carcinoma in 8.0% of resected patients. The pathology of patients with primary hyperparathyroidism (PHPT) consisted of single adenomas (77.2%), hyperplasia (21.0%), normal glands (1%), double adenomas (<1%), and parathyroid carcinoma (<1%). The distribution of adenomas was as follows: left upper, 25.3%; left lower, 27.3%; right upper, 26.8%; right lower, 20.6%. Hyperplastic glands were found in ectopic positions as follows: intrathymic (7.5%), intrathyroid (11.3%), mediastinal (2.5%), and retroesophageal/retrotracheal (0%). The average volume difference between the largest and smallest hyperplastic gland of each case was 1.80 + 4.40 cm3. Reoperations were performed upon 53 referred patients and 7 patients after failed exploration. Normocalcemia was attained in 98.3% of cases. Glandular pathology was identified in the previous operative field in 52 patients (86.7%). Adenomas were identified in 56.0% (n = 23) and hyperplasia in 39.0% (n = 16). CONCLUSIONS: In our series, we were able to attain normocalcemia in 98.2% of cases after initial cervical exploration. We believe that identification of four glands, an exhaustive search of ectopic sites, bilateral exploration, and liberal use of biopsy and intraoperative frozen section were essential to curative success. The pathologist should identify parathyroid tissue in the specimen and differentiate the "abnormal" from "normal" gland. Morphologic criteria alone cannot be used because of polymorphic variation in hyperplasia in which pathologic glands may appear normal. Early identification of the recurrent laryngeal nerve allows for a safer neck exploration by alerting the surgeon to the location and course of the nerve. A bilateral approach does not contribute increased morbidity from recurrent laryngeal nerve injury.     

Asymptomatic hyperparathyroidism. Influence of PTH values on the therapeutic decision

The majority of patients affected by primary hyperparathyroidism present now in surgical series are little or totally asymptomatic. This is due to widespread use of multiphasic screening for hypercalcemia as far as to more liberal indications for parathyroid exploration. The debate about the need for parathyroidectomy is open in these patients, having few or no signs at all of primary hyperparathyroidism, because conservative treatment has yielded confused results. The authors analyzed preoperative biochemical values and surgical outcome from 26 patients affected by primary hyperparathyroidism. Thirteen cases had overt primary hyperparathyroidism (group A) and 13 had asymptomatic disease (group B). Patients in group A had higher preoperative PTH values than patients in group (p < 0.05). After surgery, the patients in group A showed parathyroid glands which weighted significatively more than ones in group B (p +/- 0.01). Further, a significant correlation between preoperative PTH value and glandular weight was demonstrated in all cases. The authors conclude surgery for patients having mild primary hyperparathyroidism may give some problems related to the very small size of abnormal glands found during operation. We advise a close follow-up for these patients initially without treatment: surgery should be recommended for those showing PTH values higher than 150 pg/ml.     

Parathyroid detection in secondary hyperparathyroidism with 123I/99mTc-sestamibi subtraction single photon emission computed tomography

123I/99mTc-sestamibi subtraction single photon emission computed tomography (SPECT) has been proposed to detect hyperplastic parathyroid tissue, but the clinical usefulness of this technique in secondary hyperparathyroidism is uncertain. The purpose of this study was to evaluate preoperative parathyroid localization using 123I/99mTc-sestamibi subtraction SPECT in patients with renal failure and secondary hyperparathyroidism. Nineteen patients with chronic renal failure and secondary hyperparathyroidism underwent 123I/99mTc-sestamibi subtraction SPECT imaging preoperatively. None of these patients had undergone previous neck surgery. The location, weight, and histopathological results of all identified parathyroid glands were recorded. Surgery was considered successful in all patients, with resection of a total of 74 hyperplastic parathyroid glands. 123I/99mTc-sestamibi subtraction SPECT correctly identified 57 of these parathyroid glands (77% sensitivity). The mean weight among the true positive glands (n = 57) was 1031 mg (range, 45-7900 mg), and that among the false negative glands (n = 17) was 465 mg (range, 20-1800 mg). This difference between the mean weights was statistically significant (P = 0.018). There was a positive correlation between parathyroid weight and detectability with 123I/99mTc-sestamibi subtraction SPECT (Spearman correlation = 0.28; P = 0.0167). 123I/99mTc-sestamibi subtraction SPECT is able to correctly localize hyperplastic parathyroid glands in patients with renal failure and secondary hyperparathyroidism, but there is a fairly weak relationship between preoperative detection rate and anatomical parathyroid gland size.     

Surgical significance of supernumerary parathyroid glands in renal hyperparathyroidism

In secondary hyperparathyroidism (2HPT) fundamentally all parathyroid glands, including supernumerary glands, become hyperplastic, and stimulation of parathyroid glands continues after parathyroidectomy (PTx). Therefore supernumerary glands have special significance during surgery for 2HPT, whether persistent or recurrent HPT. In the present study 570 patients underwent initial total PTx with a forearm autograft. The frequency, type, location, histopathology, and clinical significance of the supernumerary glands were evaluated. At the initial operation 90 supernumerary glands were removed from 82 to 570 patients (14.4%); 12 patients (2.1%) required extirpation of supernumerary glands for persistent/recurrent HPT. Altogether 104 supernumerary glands were identified at operation in 94 of the 570 patients (16.5%). Among these 104 glands, 25 (24.0%) were of the rudimentary, or split, type and 79 (76.0%) of the proper type. Supernumerary glands were most frequently identified in the thymic tongue (53/104, 51.0%); 32 (60.4%) of these 53 glands were identified only microscopically. In 6 of the 570 cases (1.1%), reoperation was required for persistent HPT due to supernumerary glands located in the mediastinum, and 6 patients underwent neck reexploration for recurrence. Histopathologically, 61 of 104 (58.7%) supernumerary glands, including 36 glands recognized only microscopically, showed diffuse hyperplasia, and 43 (41.3%) displayed nodular hyperplasia. Residual small supernumerary glands with diffuse hyperplasia have the potential to be transformed to nodular hyperplasia during long-term hemodialysis. Therefore all parathyroid glands including supernumerary glands should, if possible, be removed at the initial operation. Routine removal of the thymic tongue and careful examination of the regions surrounding the lower poles of the thyroid, especially on the left side, are important steps in the surgical treatment.     

Effect of surgeon expertise on the outcome in primary hyperparathyroidism

BACKGROUND: Success in surgery for primary hyperparathyroidism (PHPT) is thought to be closely linked to surgical expertise. We investigated the effect of the surgeon's experience on the postoperative outcome in patients with PHPT. DESIGN: Cohort study with retrospective analysis. SETTING: University tertiary care center. PATIENTS: Two hundred thirty consecutive patients with PHPT. We excluded patients with prior cervical surgery, parathyroid carcinoma, multiple endocrine neoplasia types 1 and 2, and renal hyperparathyroidism. INTERVENTIONS: All 230 patients underwent bilateral neck exploration for PHPT. MAIN OUTCOME MEASURES: We registered complication rates, fulfillment of predefined operative concepts, and operative time in 230 cervical revisions for PHPT and compared the results of experienced surgeons (40 or more cervical revisions for PHPT performed before 1988) with those of surgeons still in training. RESULTS: Two surgeons classified as experienced operated on 75 patients. Under supervision of these surgeons, most operative procedures (n=155) were performed by 12 different surgeons classified as less experienced. Complications were observed in 31 patients (13.5%) with no statistical difference between the specialists and the less-experienced surgeons (P=.85). The ability to demonstrate 4 or more parathyroid glands was significantly increased for the specialists (74.7% vs 51.6%; P<.001), who also terminated the operation earlier (average, 15 minutes; P<.001). CONCLUSION: In an analysis of 230 operations for PHPT in patients without prior neck surgery, no effect of the surgeon's experience on postoperative outcome was demonstrated. Under the supervision of experienced endocrine surgeons, less-experienced surgeons perform cervical revisions for PHPT with comparable results, although with longer operating time.