Gamma Probe-Guided Parathyroid Cancer Resection : The Endocrinologist

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00019616-200803000-00007ReportThe EndocrinologistThe Endocrinologist© 2008 Lippincott Williams & Wilkins, Inc.18March 2008 p 71-72Gamma Probe-Guided Parathyroid Cancer ResectionCase ReportGedik, Gonca Kara MD; Aksoy, Tamer MD; Bozkurt, M Fani MD; Uğur, Ömer MD; Caner, Biray MDFrom the Department of Nuclear Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey.Reprints: Gonca Kara Gedik, MD, Department of Nuclear Medicine, Hacettepe University Faculty of Medicine, 06100, Sıhhiye, Ankara, Turkey. E-mail: [email protected] invasive radioguided parathyroidectomy using a small incision and intraoperative gamma probe has reduced the need for bilateral neck exploration in the surgery of primary hyperparathyroidism. Although the role of radioguided surgery in parathyroid adenomas is well documented, its use in parathyroid carcinoma is not established. Surgery is the only effective treatment of the parathyroid carcinoma. Reoperations are often required for recurrences. We present 2 patients with parathyroid carcinoma one of whom required 4 reoperations for disease recurrence. Preoperative Tc-99m MIBI scans are useful in defining the location of the parathyroid lesions in both patients. On the day of the surgery Tc-99m MIBI was given and the neck explorations were guided by a gamma probe, which enabled the complete resection of the lesion and prevented more radical surgery.Parathyroid carcinoma is an uncommon cause of primary hyperparathyrodism and accounts for 1% to 3% of the cases.1 Surgery is the definitive and curative method of treatment and a radical enbloc resection at the primary operation offers the best chance of cure. The risk of recurrence after a successful initial operation is high and reoperations are frequent.2 The detection and excision of recurrent parathyroid cancer are difficult in previously operated cases. Numerous studies in the literature have confirmed the usefulness of Tc-99m-sestamibi (MIBI) parathyroid scintigraphy in primary hyperparathyroidism and the use of an intraoperative gamma probe, which facilitates the surgical exploration providing a line of sight for the surgeon, and an operation that can be performed through a smaller incision in a shorter operative time.3,4 Limited data exist regarding the use of the gamma probe for the excision of parathyroid cancer. The following cases illustrate the usefulness of gamma probe-guided surgery in initial and recurrent parathyroid cancer.CASE 1A 52-year-old woman was admitted to the hospital in September 1995 because of bone pain. Thyroid ultrasonagraphy (USG) demonstrated nodules in right and left thyroid lobes and a well-defined mass behind and superior to the right thyroid lobe suggesting a parathyroid adenoma. The serum calcium (15.9 mg/dL, normal range: 8.6–10.2 mg/dL) was high and she underwent right thyroid lobectomy, excision of the parathyroid lesion, and left subtotal thyroidectomy. The diagnosis was parathyroid cancer. Eight years later, calcium and intact parathyroid hormone (iPTH) levels were 12.5 mg/dL and 1269 pg/mL (normal range: 9.5–75 pg/mL), respectively. Tc-99m MIBI parathyroid scintigraphy showed radioactivity retention in the inferior region of the right thyroid lobe and the patient was referred to surgery for the second time in May 2003. This time en bloc resection of the parathyroid mass was performed with the aid of intraoperative gamma probe (Neoprobe 2000, Dublin, OH). Twenty percent rule was used in which tissue that contains 20% or more radioactivity than background is accepted as parathyroid tissue.5 On the day of the surgery the patient received 110 MBq MIBI and operation was performed within 1 to 3 hours. Before incision the counts over 4 quadrants in the neck and mediastinum were recorded. All suspected tissues with high in vivo gamma probe counts compared with background counts were excised. After the operation, a control scintigraphy showed no areas of increased radioactivity uptake suspicious for parathyroid lesion.In March 2005, iPTH was elevated at 500 pg/mL. MIBI scintigraphy showed radioactivity retention in the left thyroid lobe (Fig. 1). Neck magnetic resonance imaging showed a lesion of 1.4 × 1.6 × 1.7 cm superoposterior to the left sternoclavicular joint (Fig. 2). The patient again underwent surgery with intraoperative gamma probe. Blunt dissection was carried down through scar tissue and during surgery gamma probe indicated considerable radioactivity in the inferior portion of the left thyroid lobe. Successful excision of the lesion was performed and the ex vivo counts of the excised lesion contained more than 20% of the background radioactivity. Histopathology revealed parathyroid carcinoma with capsular and vascular invasion. Three months later, in June 2005, serum iPTH levels again rose to 385 pg/mL and MIBI scintigraphy showed radioactivity retention in the inferior region of the right thyroid lobe. In July 2005, the lesion was again resected with the aid of the intraoperative gamma probe and the pathologic findings were consistent with parathyroid carcinoma. The patient is well and alive 8 months after her fourth operation. The iPTH and calcium levels remain within normal range.JOURNAL/endst/04.03/00019616-200803000-00007/figure1-7/v/2021-02-17T201845Z/r/image-tiff A, MIBI scan of case 1 showed radioactivity retention in the inferior region of the left thyroid lobe. B, magnetic resonance imaging of the patient revealed a lesion in the superoposterior of the left sternoclavicular joint (arrow).JOURNAL/endst/04.03/00019616-200803000-00007/figure2-7/v/2021-02-17T201845Z/r/image-tiff MIBI SPECT study of case 2. There was intense radioactivity uptake in the region of the right lobe of the thyroid gland.CASE 2The patient was a 36-year-old woman with the history of 2 separate cleft palate operations. She was diagnosed with primary hyperparathyroidism on the basis of increased serum calcium and iPTH levels (12.03 mg/dL and 1035 pg/mL, respectively). Computed tomography of the neck region revealed a nodule in the right lobe of the thyroid gland. Fine needle aspiration biopsy of this nodule was interpreted as a “neoplastic process” such as a follicular neoplasm of the thyroid gland. Tc-99m pertechnetate pinhole thyroid scan showed a hypoactive multinodular thyroid gland with the right-sided goiter. MIBI scanning showed intense increased radioactive uptake in the right lobe of the thyroid gland suggesting parathyroid tissue (Fig. 2). With these findings, total thyroidectomy and gamma probe-guided excision of the lesion was planned. On the day of the surgery 110 MBq MIBI was injected intravenously. She was taken to the operating room for gamma probe-guided parathyroidectomy. Postoperative pathology was consistent with parathyroid carcinoma in the excised lesion and intrathyroidal papillary carcinoma of the right thyroid lobe. In the postoperative period, serum calcium and iPTH concentrations were 6.64 mg/dL and <3 pg/mL, respectively.DISCUSSIONParathyroid carcinoma is a disease with a high rate of recurrence.6,7 Reoperations are required to keep hypercalcemia under control. However, reoperative surgery is associated with a high complication rate compared with the initial surgery because of the scarring in the operative field.To improve the success rate of parathyroidectomy in the reoperative setting, preoperative, intraoperative imaging, and rapid intraoperative parathyroid hormone assays can be used to confirm successful extirpation of hyperfunctioning parathyroid tissue.8 When intraoperative parathyroid hormone monitoring is not available, the advantages of gamma probe using are considerable.Radioguided surgery is particularly helpful in allowing a more focused intraoperative dissection. Our cases emphasize the applicability of this technique to patients with parathyroid carcinoma, especially those with relapses.9Although definitive cure is never achievable, the clinical and biochemical palliation that reoperations provide is important in patients with parathyroid carcinoma. Our cases indicate that MIBI scintigraphy and radioguided minimally invasive parathyroidectomy are useful tools in the detection and management of parathyroid carcinoma.REFERENCES1. Cheah WK, Rauff A, Lee KO, et al. Parathyroid carcinoma: a case series. Ann Acad Med Singapore. 2005;34:443–446.[Context Link][Medline Link]2. Koea JB, Shaw JH. Parathyroid cancer: biology and management. Surg Oncol. 1999;8:155–165.[Context Link][CrossRef][Medline Link]3. Mariani G, Gulec SA, Rubello D, et al. Preoperative localization and radioguided parathyroid surgery. J Nucl Med. 2003;44:1443–1458.[Context Link][Medline Link]4. Coakley AJ. Nuclear medicine and parathyroid surgery; a change in practice. Nucl Med Commun. 2003;24:111–113.[Context Link][Full Text][CrossRef][Medline Link]5. Berland T, Smith SL, Huguet KL. Occult fifth gland intrathyroid parathyroid adenoma identified by gamma probe. Am Surg. 2005;71:264–266.[Context Link][CrossRef][Medline Link]6. Obara T, Okamoto T, Kanbe M, et al. 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B, magnetic resonance imaging of the patient revealed a lesion in the superoposterior of the left sternoclavicular joint (arrow). MIBI SPECT study of case 2. There was intense radioactivity uptake in the region of the right lobe of the thyroid gland.Gamma Probe-Guided Parathyroid Cancer ResectionGedik Gonca Kara MD; Aksoy, Tamer MD; Bozkurt, M Fani MD; Ugur, Ömer MD; Caner, Biray MDCase ReportCase Report218p 71-72