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Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital.

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Presentation on theme: "Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital."— Presentation transcript:

1 Pre-operative localization of parathyroid adenoma Dr Chan Man-yi Tuen Mun Hospital

2 Primary hyperparathyroidism  Gold standard = bilateral neck exploration  95 – 98% at first exploration  Imaging used only after failed initial surgery

3  Etiology of primary hyperparathyroidism  Solitary parathyroid adenoma 80-85% Unilateral neck exploration Minimally invasive surgery Foscused parathyroidectomy Video-assisted parathyroidectomy Videoscopic parathyroidectomy

4 Minimally Invasive parathyroidectomy Pre-operative  Ultrasound  Sestamibi scan  CT  MRI  Angiography / selective venous sampling Intra-operative  PTH assay  Ultrasound  Gamma probe

5 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

6 USG by surgeon  Sensitivity of USG  Specific side – 84%  Specific quadrant – 79%  Sensitivity of USG + MIBI – 98%

7 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-glycoprotein Bhatnagar et al, J Nucl Med 1998;39: Carpentier et al, J Nucl Med 1998;39:

8  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

9 Planar imaging SPECT/CT SPECT

10 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

11 USG vs MIBI  Sensitivity of USG – 65%  Sensitivity of MIBI-SPECT – 68%  Detected only by one modality – 16%   USG and MIBI complementary

12 USG + MIBI

13  Surgical failure  w/o PTH – 2%  With PTH – 1% P=0.5

14 Reoperation?

15  163 patients with ?missed adenoma  Pre-op localization  surgery  140 unilateral exploration  18 mediastinal procedure  92% long term resolution of hypercalcemia

16 Sensitivity = 70%

17 Proposed strategy

18 ? 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

19 John Doppman 1986 “The best localization study prior to primary exploration in a patient with primary hyperparathyroidism is to locate an experienced parathyroid surgeon”

20  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

21 END


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