News on the treatment of HPT

Transcription

1 News on the treatment of HPT G.C. Torre XIV Annual Conference of EES Tourin November 2010

2 Epidemiology Prevalence: Sweeden = 4.3 /1000 Norway = 3/1000 Finland = 21/1000 USA = 1/1000 Italy = 5/1000 Incidence: / / anno

3 Epidemiology Irradiation (acne, fall out, external beans radiotheraphy before 16th birthday) have accouted for a 2/4 fold increase in PHPT William D. Loser, Lancet 374: , 2009

4 Guidelines for the management of asymptomatic primary hiperparathyroidism: summary statement from the third international Workshop (Orlando, Florida May 13, 2008) All patients with biochimically confirmed primary hiperparathyroidism (PHPT) who have specific symptoms or signs of their desease should undergo surgical treatment J Clin Endocrinol Metab, February 2009, 94(2):

5 Guidelines for the management of asymptomatic primary hiperparathyroidism: summary statement from the third international Workshop (Orlando, Florida May 13, 2008) Comparison of new and old guidelines for parathiroid surgery in asynmptomatic PHPT Measurement Serum calcium ( > upper limit of normal) 1 1,6 mg/dl (0,25 0,4 mmol/liter 1,0 mg/dl (0,25 mmol/liter) 1,0 mg/dl (0,25 mmol/liter) 24 h urine for calcium >400mg/d (>10 mmol/liter) >400mg/d (>10 mmol/liter) >400mg/d (>10 mmol/liter) Creatinine clearance (calculated) Reduced by 30% Reduced by 30% Reduced to <60ml/min BMD Z score < -2,0 in forearm Z score < -2,5 at any site Z score < -2,5 at any site Age (yr) < 50 <50 <50 and/or previousfracture fragility J Clin Endocrinol Metab, February 2009, 94(2):

6 Guidelines for the management of asymptomatic primary hiperparathyroidism: summary statement from the third international Workshop (Orlando, Florida May 13, 2008) Comparison of new and old guidelines for patients with asymptomatic primary iperparathyroidism who do not undergo parathyroid surgery Measurement Serum calcium Biannually Biannually Annually 24-h urinary calcium Annually Not recommended Not recommended Creatinine clearance (24-h urine collections) Annually Not recommended Not recommended Serum creatinine Annually Annually Annually Bone density Annually (forearm) Annually (3sites) Every 1-2yr (3 sites) Abdominal X-ray (+/- ultrasound) Annually Not recommended Not recommended J Clin Endocrinol Metab, February 2009, 94(2):

7 Neuropsichiatric symptoms and quality of life (QOL) fatique lassitude mood swings Irritability anxiety depression memory loss difficulty concentrating increased sleep requirement lack of sexual interest

8 Editorial: Parathyroidectomy in asymptomatic Primary Hiperparathyroidism: Improves Bones but not Phychic Moons M.D.Wolker et Al JCEM, 92: , 2007

9 Some cases show improvement after successful parathyroid surgery. However well controlled randomized prospective trials are indicated Ildelsmare et al. JCEM 94: , 2009

10 Cardiovascular patophisiology in phpt PTH NO Hypercalcemia Direct constrictor effect on vascular smooth muscle cells Endothelial disfunction Impaired coronary microcirculation Increased risk of myocardial infarction

11 Cardiovascural symptoms Sophisticated techniques evaluating endothelial and cardiac muscle cells fuction should be used to investigate the potential beneficial effects of surgery E.Ambrogini et al. JCEM 92: ; 2007

12 Dipyridamole Baseline Marini et al Eur J Nucl Med Mol Imaging. 2010;37:22

13 Cost-Effectiveness Analysis for asymptomatic PHPT Three formal analysis to date: Parathyroidectomy is a cost-effective treatment strategy for asymptomatic PHPT Sejcan K. et al. Eur. J. Endocrinol, 2005 Zanocco K. et al. Surgery, 2006 Zanocco K. et al. Surgery 2008

14 Diagnosis In this new era, the success of targeted parathyroid surgery depends not only on an experienced surgeon, but also on a sensitive and accurate imaging technique 2009 EANM parathyroid guidelines

15 Imaging does not identify normal parathyroid glands 2009 EANM parathyroid guidelines

16 SPECT/TC improves accuracy reporter confidence in clinical practice. It is not demonstrated a clear superiority or clinical impact of SPECT/TC over separate SPECT and TC when the end point is success of surgery 2009 EANM parathyroid guidelines

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18 MIP vs OPEN

19 Bilateral neck exploration for all parathyroid patients is an operation that should be confined to the hystory books Denham DW, Norman J, 2003 Patients with primary hyperparathyroidism are best served by a full bilateral neck exploration performed by an experienced endocrine surgeon Schell SR, Dudley NE, 2003

20 Indications for MIP lateral miniaccess Localizzation Sestamibi/TC99m (Spect TC) sensibility 90,7% specificity 98,8% Localizzation US Doppler true positive 50-75% Scintigraphy + US true positive 90% negative imaging or ambiguous 5-10% TC and/or RMN less usefull

21 Preoperatory US mapping Presence of an expert surgeon and US radiologist together Recovery of non-localizzated cases (23% in our experience)

22 Preoperatory US mapping Cutaneous projection of lesion with patient in sugical position

23 Surgical access Trasversal miniincision on the anterior border of the sternocleidomastoideum muscle Longitudinal opening of cervical fascia Lateralizzation of sternocleidomastoideum and vessels of the neck Medializzation prethyroid muscles and lateral border of the thyroid

24 Remove Dissection

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26 Our experience ( ) Total phpt : 161 Open : 98 ( 61%) MIP : 63 (39%) Surgical Time: 61 MIP vs 60 open Conversion: 6 (9,5%) - 4 not localized - 1 double localization - 1 suspected cancer

27 Percutaneous ethanol injection therapy (PEIT) 1985: Solbiati L. et al. Radiology 155:607-10,1985

28 Percutaneous ethanol injection therapy (PEIT) 2003 Japanese Society for parathyroid Intervention : - glands > 1cm in lenght 0,5 cm 3 in volume - individual at high surgical risk (Fukagawa M et al. Nephrol Dial Transplant 18: iii33, 2003)

29 Percutaneous ethanol injection therapy (PEIT) 2006 : Japanese Society for Dialysis Theraphy Guidelines for secondary hyperparathyroidism: INDICATIONS : - 1 Intact PTH 400pg/mL despite medical treatment or poor compliance - 2 Presence of enlarged gland with suspected nodular hiperplasia by U.S. -3 Consent to PEIT

30 Percutaneous ethanol injection therapy (PEIT) 2006 : Japanese Society for Dialysis Theraphy Guidelines for secondary hyperparathyroidism: EXCLUSION CRITERIA: - 1 Glands location where punture needer ultrasonography is impossible - 2 Controlateral recurrent nerve paralysis -3 neck surgery requared for parathyroid tumoror other reasons

31 Percutaneous ethanol injection therapy (PEIT) Postoperative management: - Active vitamin D administration - P and Ca control immediately after PEIT (long term target value of PTH = pg/ml) - Additional PEIT when PTH within 2-4- weeks has not sufficiently decreased or residual U.S. blood flow is detected - Inclusion criteria for initial PEIT are applied for residual glands when PTH level is re-elevated

32 HIFU was introducted by Lynn et al in 1942 A new method for generation and use of focused ultrasound in experiment surgery J Gen Physiol 26 : , 1942

33 HIFU tumor ablation Primary prostat cancer (Ahmed HM et al. Br J Cancer 101:19-26,2009) Uterine fibroids (Ermehauf JH et al. Arch Ginecol Obstet 227: ; 2008) Hepatocellular carcinomas (Zhang L. et al. Eur Radial 19: , 2009) Thyroid nodules (Esnault O. Thyroid 19 : , 2009)

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35 - AJR ( HIFU)

36 Notes Transoral partial parathyroidectomy Karakas et al. Chirurg. May 14,2010

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39 Medical treatment Cinacalcet hidrochloride mantains long term normocalcemia in patients with primary hiperparathyroidism Peacock et al. JCEM 90: , 2005

40 Further studies are needed to establish the long term clinical benefit in primary hiperparathyroidism before cinacalcet is recommended as an alternative to surgery Seminar on hiperparathyroidism, Lancet 2009

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42 Thanks for your attention!