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      Gamma probe-assisted excision of an ectopic parathyroid adenoma located within the thymus: case report and review of the literature

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          Primary hyperparathyroidism due to parathyroid adenomas may be associated with ectopic parathyroid gland localization in 20-25% of the patients. We report herein the excision of an ectopic parathyroid adenoma which was detected in the thymus gland by gamma probe intraoperatively. A 38-year-old patient presented to our clinic with a history of bilateral nephrolithiasis, chronic hypercalcaemia, and PTH elevation. A combination of Technetium-99 m sestamibi scintigraphy and Computed Tomography scan of the chest and neck revealed an ectopic parathyroid adenoma of 8.5 mm in its greatest dimension. The patient underwent sternotomy and the adenoma was found within the right lobe of the thymus gland with the intraoperative use of gamma probe. PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively. We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery. The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

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          Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: which criterion is the most accurate?

          The quick parathyroid hormone assay (QPTH) reliably measures intact parathyroid hormone (iPTH) levels intraoperatively. The accuracy in predicting postoperative calcemia is related to blood sample timing and the criteria applied. To improve specificity or to decrease the cost of QPTH, several criteria have been used to predict complete excision. This study compares the Miami criterion with other published QPTH criteria in predicting operative outcome. QPTH and the Miami criterion (iPTH drop > or =50% from the highest of either preincision or pre-excision level at 10 minutes after gland excision), were used to predict postoperative calcium levels of 341 consecutive patients with sporadic primary hyperparathyroidism who were followed > or =6 months after the operation or recognized as operative failures. Intraoperative iPTH values of these patients were reanalyzed with the use of 5 published criteria to predict complete resection. Postoperative calcium levels were correlated with criteria predictions. Miami criterion correctly predicted postoperative calcium levels in 329 of 341 patients and was incorrect in 12 (3 false positives, 9 false negatives). With the use of other criteria, 2 of the 3 false-positive results would be prevented, but the 3% rate of false-negative predictions would increase to between 6% and 24%, causing unnecessary neck explorations to search for multiglandular disease. Surgeons trying to increase QPTH specificity significantly decrease the accuracy and intraoperative usefulness of the assay. The Miami criterion has the highest accuracy when compared with other criteria.
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            Epidemiology of primary hyperparathyroidism in Europe.

            Primary hyperparathyroidism (PHPT) is one of the most common endocrine diseases. Its clinical presentation has dramatically changed in the last 40 years, and now the disease typically affects elderly women and is characterized by mild hypercalcemia and few traditional classic (bone and kidney) manifestations. The change in clinical presentation was largely caused by development of automated serum calcium measurement in the early 1970s that made possible the introduction of serum calcium determination in the routine biochemical screening and the identification of a large number of "asymptomatic" patients. This led also to a 5-fold increase in the apparent incidence of PHPT for the identification of patients who were never diagnosed before (catch-up effect). From the most recent and accurate study, a 21/1000 PHPT prevalence was found in women aged 55-75 years, which is equivalent to 3/1000 prevalence in the general population. Epidemiological studies performed in Rochester, Minnesota, have shown an apparent decline in the annual incidence from 75 to approximately 20/100,000 in the last decade. Most of this apparent decline in the incidence of PHPT is explained by the decline of the "catch-up effect," although a number of factors that might result in changes in PHPT incidence have been identified. Vitamin D deficiency is particularly common in people living in Southern European countries, and this may contribute to underestimating the prevalence of PHPT, because total serum calcium may be normal in these patients. On the other hand vitamin D deficiency may be associated with more severe clinical expression of the disease, which may make clinically manifest otherwise mild asymptomatic cases. Irradiation of the neck and upper chest for benign diseases is a well-known risk factor for the development of PHPT, and a history of irradiation can be obtained in as many as 15-25% of PHPT patients. Because this therapeutic procedure is no longer used, the number of radiation-associated cases of PHPT is expected to progressively decline in the future. Restriction of healthcare financing may also contribute to the apparent decrease in the incidence of PHPT because calcium measurement is now performed only in patients who have a suspected abnormality in calcium homeostasis is. On the other hand, the screening for osteoporosis, which often includes serum calcium determination, is increasingly carried out in women around the sixth decade of life, when the incidence of PHPT is by far more frequent. In conclusion, the introduction of serum calcium screening in the early 1970s exerted an impressive effect on the epidemiology of PHPT, with an apparent incidence initially rising and then falling by the 1990s secondary to the diminution of the "catch-up effect." Other environmental, nutritional, or iatrogenic factors might influence the incidence of the disease, but the overall effect is unlikely to be relevant.
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              Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy.

              Intraoperative parathyroid hormone assay (IOPTH) has been used during minimally invasive parathyroidectomy (MIP) to predict operative success. However, the applied criteria are not equivalent in detection of multiglandular disease (MGD) and predicting cure. The purpose of this study was to evaluate the most commonly applied criteria of IOPTH in patients undergoing MIP in a tertiary referral center. A retrospective review of 260 patients with sporadic primary hyperparathyroidism and concordant results of sestamibi scanning and ultrasound of the neck undergoing MIP (135 video-assisted and 125 open) between Dec 2002 and May 2008, with a 6-month postoperative follow-up of intact parathyroid hormone and serum calcium levels, was performed. The main outcome measures included evaluation of predictive values of Halle, Miami, Rome, and Vienna IOPTH interpretation criteria. The following overall accuracy, sensitivity, specificity, positive predictive value, and negative predictive values were found, respectively: 65%, 62.9%, 100%, 100%, and 14.2% for Halle criterion; 97.3%, 97.6%, 93.3%, 99.6%, and 70% for Miami criterion; 83.8%, 82,9%, 100%, 100%, and 26.3% for Rome criterion; and 92.3%, 92.2%, 93.3%, 99.6%, and 60.9% for Vienna criterion. Miami criterion followed by Vienna criterion was found to be the best balanced among other criteria, with the highest accuracy in intraoperative prediction of cure. However, Rome criterion followed by Halle criterion was found to be the most useful in intraoperative detection of MGD. Nevertheless, their application in patients qualified for MIP with concordant results of sestamibi scanning and ultrasound of the neck would result in a significantly higher number of negative conversions to bilateral neck explorations and only a marginal improvement in the success rate of primary operations.

                Author and article information

                J Cardiothorac Surg
                J Cardiothorac Surg
                Journal of Cardiothoracic Surgery
                BioMed Central
                31 March 2014
                : 9
                : 62
                [1 ]Department of Thoracic Surgery, 424 General Military Hospital, Eukarpia Ring Road, Thessaloniki Gr 564 29, Greece
                [2 ]Department of Surgery, 424 General Military Hospital, Eukarpia Ring Road, Thessaloniki Gr 564 29, Greece
                [3 ]Department of Endocrinology, Hippokration Hospital, Konstantinoupoleos 49, Thessaloniki Gr 546 42, Greece
                [4 ]Department of Orthopaedic Surgery and Rehabilitation, University Hospital of Ioannina, Stavrou Niarchou Avenue, Ioannina Gr 45 500, Greece
                Copyright © 2014 Daliakopoulos et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Case Report


                ectopic parathyroid adenoma, 99mtc sestamibi, gamma probe


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