PARATHYROID SURGERY: INDICATIONS AND MANAGEMENT

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PARATHYROID SURGERY INDICATIONS AND MANAGEMENT

• Edward J. Krowiak, MD
• Center for Ear, Nose, Throat Allergy
• CENTA
• Carmel, Indiana

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Primary HyperparathyroidismDiagnosis

• Vast majority incidental
• Elevated calcium on routine testing
• Stones, moans, groans, etc
• Nice for inservice exams, not reality
• Ca gt10.2 plus elevated PTH hyperparathyroidism
  
• What qualifies as elevated? (normal 10-65)

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PARATHYROID LOCALIZATION

• Sestamibi scan
• Technique and interpretation sensitive
• Look at them yourself
• Fuse with CT
• Sestamibi negative
• Consider repeat study
• Parathyroid ultrasound
• MRI
• SPECT

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PARATHYROID WORKUP

• Calcium and PTH
• 24 hour urine Calcium
• gt400mg/dL
• Bone density studies
• T score lt2.5
• ? 25(OH) Vit D
• Other surgical indications (NIH/NIDDK 2002)
• Age lt50
• No adequate follow up
• 30 reduced renal function
• Calcium gt1mg/dL above normal
• Stones

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Non-Surgical Management

• Cinacalet
• Blocks Ca receptor on parathyroid cells
• Expensive
• Observe
• Guidelines not met
• Asymptomatic patient with negative imaging

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PARATHYROID SURGERY

• 85 single adenoma, 10 double adenoma, 5
  hyperplasia
• High Ca or PTH decreases chance of hyperplasia
• Positive Sestamibi/Ultrasound/MRI
• Good for you
• Negative scans
• Possible hyperplasia
• Start right lower (most common single site)
• Cover all possibilities with all patients

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INFERIOR ADENOMA LOCATION
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SUPERIOR ADENOMA LOCATION
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RIGHT INFERIOR ADENOMA
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PARATHYROID PATHWAY
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STEP 5 1/2

• Repeat imaging studies

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PARATHYROID SURGERY

• Small incision paramedian
• Medial to straps vs anterior to SCM
• Intraoperative PTH
• Baseline in holding
• Post-resection levels (?5,10,15 min)
• 50 reduction and in normal range
• Low Vit D may cause PTH to stay elevated
• 400 per test minimum. Be aware

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PARATHYROID SURGERY

• Methylene blue
• Pulse ox issues. Rare complications
• 5-7.5 mg/kg 1 hour pre-op
• Positive in 95 of adenomas, 85 of hyperplasias,
  8 of normal glands
• Gamma probe
• Activity gt20 above bed background
• 20-30 mCi 2-6 hours pre-op
• Venous sampling

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PT SURGICAL PITFALLS

• Double adenoma
• PTH helps
• Ectopic glands
• Mediastinum
• Intrathyroidal parathyroid
• Thyroid lobectomy if scans were positive
• 1-3 of cases
• Hyperplasia

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PARATHYROID PITFALLS

• 4 Gland Hyperplasia
• Usually negative scans
• Minimal Calcium and PTH elevation
• Explore and identify all 4 glands before any
  resection
• Use frozen sections liberally
• May find a single adenoma
• Re-implantation
• Save ½ of 2 most normal-appearing glands,
  reimplant ½ that looks best before closing
• Dissect into small pieces
• Place into SCM or forearm. Mark SCM with prolene
• 4-14 weeks until implanted tissue produces PTH
• Cryopreserve 1 gland