The accuracy of surgeon-performed preoperative parathyroid ultrasound localization for Renal Hyperparathyroidism patient

INTRODUCTION: Parathyroid surgery for renal hyperparathyroidism (RHPT) is indicated when patients have a progressive disease despite optimal medical therapy. The success of total parathyroidectomy in RHPT lies in accurate localization and excision of all PTGs. Recently, surgeon-performed ultrasound (SPU) has been increasingly used for the preoperative localization of PTGs in the intent of focused approach and reduce morbidity. Thus, we conducted a prospective observational single-center study to determine the accuracy of SPU for PTG localization in RHPT and the factors affecting its accuracy. MATERIALS AND METHODS: This is a prospective, observational, single-center study conducted in University Kebangsaan Malaysia Medical Centre between March 2018 and March 2019. The patients’ preoperative demography, clinical data, and relevant blood laboratory results, including calcium, phosphate, alkaline phosphatase, and intact parathyroid hormone, were recorded. Preoperative USG and surgery were performed by the same endocrine surgery consultant. RESULTS: SPU localization had an overall accuracy of 78.1%, sensitivity of 81.0%, and specificity of 30.0% with a positive predictive value of 94.8% and a negative predictive value of 10.5%. The SPU gland localization rate was significantly higher in patients without goiter (median=0.88, IQR=0.63–1.00) than in those with goiter (median=0.50, IQR=0.25–0.75) (p=0.028). CONCLUSIONS: SPU localization of the PTG in RHPT had an accuracy comparable with that in previous literature with the additional advantage of identifying concurrent unknown thyroid nodules. Considering the high prevalence of concomitant nodular thyroid disease in our RHPT population, we advocate the routine use of preoperative neck ultrasound for RHPT patients undergoing parathyroid surgery

The role of intra-operative parathyroid hormone assay in non-localized adenoma

The incidence of primary hyperparathyroidism (PHPT) is increasing in trend due to more common practice of routine blood investigations especially in the elderly. Surgery is the only curative therapy in symptomatic patients. We present a case of a 63-year-old lady with generalised body weakness associated with occasional muscle cramps. Her biochemical results were consistent with PHPT. As a result of persistent severe hypercalcemia, surgery was planned. However, the pre-operative anatomical and functional radiological imaging (neck ultrasonography, 99mTc-MIBI and FDG-PET scans) failed to identify the abnormal parathyroid gland. Therefore, bilateral neck exploration with intra-operative parathyroid hormone (io-PTH) measurement was performed. The nodular left thyroid and adenomatous right superior parathyroid glands were removed. Possible causes of negative localization and incorporation of io-PTH in under-resourced countries to ensure successful surgery are discussed

Breast Carcinoma Occurring from Chronic Granulomatous Mastitis

Chronic granulomatous mastitis is known as a benign and relatively rare disorder that is often difficult to differentiate from breast carcinoma. We highlight the case of a 34-year-old woman who had recurrent episodes of right breast swelling and abscess for 8 years. These were proven to be chronic granulomatous mastitis by tissue biopsies on 3 different occasions. Her condition improved on similar courses of antibiotics and high-dose prednisolone. However, she subsequently developed progressive loss of vision due to an orbital tumour. She then underwent a craniotomy and left orbital decompression with excision of the tumour, which proved to be a metastatic carcinoma. A trucut biopsy of the right breast was then done and showed features consistent with an infiltrating ductal carcinoma. This case illustrates the possibility that chronic granulomatous mastitis could be a precursor for malignancy and the difficulty in differentiating one from the other. The possible mechanisms of development and the implications for future management are also discussed

Lymphocytic Mastitis Mimicking Breast Carcinoma, Radiology and Pathology Correlation: Review of Two Cases

Lymphocytic mastitis, or diabetic mastopathy, is an unusual finding in early-onset and long-standing diabetes. It can presents as a non-tender or tender palpable breast mass. Mammogram and ultrasound frequently demonstrate findings suspicious of malignancy, thus biopsy and histological confirmation is usually required. We reviewed two cases of lymphocytic mastitis with characteristics findings on mammogram, ultrasound, and histopathology. Diagnoses were confirmed with excision biopsy