PTH > 60pg/ml PRIMARY HYPERPARATHYROIDISM. Introduction Biochemical Diagnosis. Normal Parathyroid. Parathyroid Glands

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1 next speaker: Declan Neeson Belfast/UK SPECT/CT scanning and parathyroid surgery in Southern Trust, N. Ireland D Neeson M Korda, G Gray, C Leonard, M Fawzy, R Lambon Parathyroid Glands PRIMARY HYPERPARATHYROIDISM Causes Hypercalcaemia 85% due to PT Adenomas Primary Hyperparathyroidism Why Localise? Introduction Biochemical Diagnosis Surgical resection is curative Conclusions Investigations Study PTH > 6pg/ml Crafty little buggers Parathyroid Glands Normal Abnormal Normal Parathyroid Live behind thyroid gland What also lives there?? Recurrent Laryngeal Nerve 1

2 Adenoma Why localise pre-op? Previously bilateral surgical exploration = both RLN at risk Therefore protecting contralateral RLN Evidence shows if scans concordant -> only unilateral exploration needs done

3 Investigations Done SPECT/CT 88% 88% 9-95% Aim Methods Review the accuracy of 99Tc-SPECT/CT scanning in Craigavon Area Hospital over the past years SECTRA records were reviewed to include all SPECT scans over the past years Charts requested and data recorded Any absent data obtained from labs Pathology/Pth levels confirmed with link labs. Total of 64 patients scanned with SPECT in the Southern Trust over past years Age range of 8-86 Results Average age 64.6 years 14 1 Female Male

4 Age and sex of patients Scan results male 8 6 negative Surgical Intervention Surgical Intervention negative scan positive scan surgery no surgery surgery 7 no surgery Positive Scan - No Surgery Why? Surgery 7 patients had a positive scan but did not proceed 5 1.PT REFUSED SURGICAL EXPLORATION.PATIENT ADDED TO W/L 4/7/11 DECEASED.METASTATIC BREAST CANCER DECEASED 4.PT DECLINED SURGERY SUGGESTION OF MEDIASTINAL ADENOMA 5.PT OPERATED ON IN BELFAST 6.ASYMPTOMATIC WITH VASCULAR DEMETIA NOT A SX CANDIDATE 7.VIT D LEVEL 18 NORMOCALCAEMIA

5 Pre Operative Ca levels Pre op Corrected Calcium Number 4,4 Pre-op Average Post-op Average , , Corrected Calcium.99., , Pre-op Parathormone levels in operated patients Average pre and post op parathormone ,, 5, 15, , 55, pre op post op Site of Adenoma at Operation Site of Adenoma at Operation Site Number Positive Negative Left inferior 1 Left superior 5 Right inferior 16 Right superior LI LS RI RS 5

6 SPECT scan accuracy 9.5% Accuracy 9 + scan correlated with surgical site + scan no correlation with surgical site Conclusion SPECT scan 9.5% accurate pre-operative scan in locating parathyroid adenomas Consider that if no lesion can be identified on routine scanning the patient will require bilateral neck explorations with increased intraoperative risk, prolonged inpatient stay and resources required Conclusion References Consideration of specialist radiologist with inital investigation ie/ USS Further review of negative scans with positive adenoma between ENT/Endocrine surgeon, radiologist & pathologist 1. C.N. Patel, H.M. Salahudeen et al. Clinical utility of ultrasound and 99mTc sestamibi SPECT/CT for preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism. Clinical Radiology 1;65: Johnson NA, Tublin ME, Ogilvie JB. Parathyroid imaging: technique and role in the preoperative evaluation of primary hyperparathyroidism. AJR Am J Roentgenol 7;188: Udelsman R. Six hundred and fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg ;5: Lew JL, Solorzano CC. Surgical management of primary hyperparathyroidism: State of the Art. Surg Clin North Am 9;89(5);