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      99mTc-MIBI SPECT/CT imaging had high sensitivity in accurate localization of parathyroids before parathyroidectomy for patients with secondary hyperparathyroidism

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          Abstract

          Purpose: Accurate preoperative parathyroid localization is important for successful parathyroidectomy (PTX). The aim of our study was to investigate whether SPECT/CT has enhanced effect in preoperative localization of parathyroids.

          Methods: In our retrospective cohort study, we evaluated the effects of technetium-99m methoxyisobutylisonitrile-single-photon emission computed tomography/computed tomography ( 99mTc-MIBI SPECT/CT) on preoperative parathyroid localization for 645 secondary hyperparathyroidism (SHPT) patients. Among them, 569 successful PTX patients were divided into group A (received 99mTc-MIBI scintigraphy, n = 175) and group B (received 99mTc-MIBI scintigraphy and SPECT/CT imaging, n = 394). Sensitivity, specificity, and consistency of two imaging methods in preoperative localization of parathyroids were compared.

          Results: Overall sensitivity and consistency were higher in group B, while there was no difference in specificity between the two groups. In group A, the sensitivity of 99mTc-MIBI was 50.00%, 77.11%, 61.76%, and 76.54% in the right upper gland (RU), right lower gland (RL), left upper gland (LU), and left lower gland (LL) subgroups, while the consistency was 52.00%, 76.57%, 61.71%, and 75.43%, respectively. In group B, the sensitivity of 99mTc-MIBI with SPECT/CT was 69.39%, 90.03%, 78.07%, and 84.27%, and the consistency was 69.54%, 88.32%, 78.43%, and 84.26%, respectively. The sensitivity and consistency in lower glands were higher than in upper glands in both groups. Sensitivity for eutopic parathyroid was higher in group B, while there was no difference for ectopic parathyroid.

          Conclusions: 99mTc-MIBI SPECT/CT can increase the sensitivity and consistency of preoperative localization of eutopic parathyroid glands, and it can accurately locate ectopic parathyroid without sensitivity improvement.

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          Most cited references 21

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          Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease–Mineral and Bone Disorder: Synopsis of the Kidney Disease: Improving Global Outcomes 2017 Clinical Practice Guideline Update

          The Kidney Disease: Improving Global Outcomes (KDIGO) 2017 Clinical Practice Guideline Update for the Diagnosis, Evaluation, Prevention, and Treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD) is a selective update of the prior CKD-MBD guideline published in 2009. The guideline update and the original publication are intended to assist practitioners caring for adults with CKD and those receiving long-term dialysis.
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            The anatomic basis of parathyroid surgery.

             C. Wang (1976)
            A study of 645 normal adult parathyroid glands in 160 cadavers revealed that there is a definite pattern of anatomic distribution on the basis of the embryologic development of the parathyroid, thyroid, and thymic glands. The sites of predilection of the upper gland (Parathyroid IV) are, in order of frequency, the cricothyroid junction; the dorsum of the upper pole of the thyroid; and the retropharyngeal space. Those of the lower gland (Parathyroid III) are at the lower pole of the thyroid and the thymic tongue; rarely in the upper, the lateral neck, or the mediastinum. An understanding of the developmental relationship of the parathyroid glands to the thyroid and the thymus is fundamental in the delineation of the embryologic origin of the parathyroid glands. The parathyroid gland, located within the surgical capsule of the thyroid (subcapsular), when diseased, remains in place locally. A gland outside of the capsule (extracapsular) is often displaced into the posterior or anterior mediastinum. A collective assessment of the size, weight, color, shape, and consistency of the parathyroid gland is mandatory in the determination of its normalcy. Frozen section examination for stromal and intracellular fatty content is an added assurance of normalcy. That parathyroid glands sink in saline solution, and fat globules float, may aid in differentiating the two types of tissue. Supernumerary, fused, and intrathyroidal parathyroids, albeit rare, are of surgical importance.
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              Long-Term Outcome after Total Parathyroidectomy for the Management of Secondary Hyperparathyroidism

              In patients with chronic renal failure, secondary hyperparathyroidism (sHPT) is a common problem requiring surgical parathyroidectomy (PTX) if medical treatment with active vitamin D and calcimimetics fails. To minimize the risk for recurrence, we perform total PTX (tPTX) without autotransplantation. From October 1997 to January 2004, 46 patients (31 men and 15 women) underwent tPTX without autotransplantation (median age 51 years; range 19–80 years; median dialysis time before PTX 5 years; range 0–25 years). Indications for PTX were hyperparathyroid bone disease in 41 cases and calciphylaxis in 5 cases. Postoperatively, all patients were supplemented with vitamin D analogues, both calcitriol and cholecalciferol. Patients were followed up for 4–107 months (median 63 months). Although tPTX was intended in all cases, we saw recurrent or persistent hyperparathyroidism in 26% and supernumerary glands in 15% of cases. In 7 patients (15%), five or more glands were documented and in another four suspected confirming the clinical relevance of intraoperative parathyroid hormone (PTH) measurement. In our study, the positive predictive value of a low intraoperative PTH (<20 pg/ml) for a successful tPTX was 92%. 15 patients received a renal transplant after tPTX without autotransplantation. Here, an uncomplicated hypocalcaemia was noted in 3 patients. Last available calcium levels were between 1.72 and 2.66 mmol/l (median 2.35 mmol/l). After follow-up, active vitamin D was given in a median daily dose of 0.5 μg calcitriol (range 0–2.5 μg/day). There was no evidence of clinical bone disease and no pathological fractures after tPTX after a median observation period of 63 months. tPTX still offers the highest percentage of cure for sHPT, it is safe and postoperatively easily manageable. It allows for adequate supplementation with active vitamin D, and it is the most cost-effective procedure. It should be reconsidered an option for the treatment of sHPT.
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                Author and article information

                Journal
                Ren Fail
                Ren Fail
                IRNF
                irnf20
                Renal Failure
                Taylor & Francis
                0886-022X
                1525-6049
                2019
                20 September 2019
                : 41
                : 1
                : 885-892
                Affiliations
                [a ]Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , Nanjing, China;
                [b ]Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , Nanjing, China;
                [c ]Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , Nanjing, China;
                [d ]Department of Epidemiology and Biostatistics, School of Public Health , Nanjing Medical University , Nanjing, China;
                [e ]Clinical Medicine Research Institution, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , Nanjing, China;
                [f ]Department of Nephrology, Henan Provincial Key Laboratory of Kidney Disease and Immunology, Henan Provincial People’s Hospital, People's Hospital of Zhengzhou University , Zhengzhou, China
                Author notes
                [*]

                These authors contributed equally to this work.

                CONTACT Ningning Wang wangnn@ 123456njmu.edu.cn Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , 300 Guangzhou Road, Nanjing, Jiangsu 210029, China;
                Changying Xing cyxing62@ 123456126.com Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital , 300 Guangzhou Road, Nanjing, Jiangsu 210029, China
                Article
                1662804
                10.1080/0886022X.2019.1662804
                6758704
                31537128
                © 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Page count
                Figures: 3, Tables: 3, Pages: 8, Words: 4552
                Product
                Funding
                Funded by: National Natural Science Foundation of China 10.13039/501100001809
                Award ID: 81270408
                Award ID: 81570666
                Funded by: International Society of Nephrology (ISN)
                Award ID: 18–01-0247
                Funded by: Jiangsu Provincial Special Program of Medical Science
                Award ID: BL2014080
                Funded by: Construction Program of Jiangsu Provincial Clinical Research Center Support System
                Award ID: BL2014084
                Funded by: Chinese Society of Nephrology
                Award ID: 13030300415
                Funded by: Jiangsu Province Key Medical Personnel Project 10.13039/501100005066
                Award ID: RC201162
                Award ID: ZDRCA2016002
                Funded by: Six Major Talents Summit of Jiangsu Province
                Award ID: 2010-WS-026
                This work was funded by the National Natural Science Foundation of China [81270408, 81570666], International Society of Nephrology (ISN) Clinical Research Program [18–01-0247], Jiangsu Provincial Special Program of Medical Science [BL2014080], Construction Program of Jiangsu Provincial Clinical Research Center Support System [BL2014084], Chinese Society of Nephrology [13030300415], Jiangsu Province Key Medical Personnel Project [RC201162, ZDRCA2016002], Six Major Talents Summit of Jiangsu Province [2010-WS-026].
                Categories
                Clinical Study

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