Efficacy of localization studies and intraoperative parathormone monitoring in the surgical management of hyperfunctioning ectopic parathyroid glands

Hyperfunctioning ectopic glands remain an operative challenge in patients with sporadic primary hyperparathyroidism. This study examines the incidence of ectopic glands and the utility of sestamibi scans (MIBI), surgeon-performed ultrasonography, and intraoperative parathormone monitoring in such patients undergoing parathyroidectomy. We conducted a retrospective analysis of prospectively collected data from patients who underwent parathyroidectomy from 1980 to 2011 for sporadic primary hyperparathyroidism at a single institution. Demographics, localizing imaging studies, intraoperative parathyroid monitoring dynamics, and surgical outcome for patients with hyperfunctioning ectopic parathyroid glands were studied. Among 1,195 patients who underwent parathyroidectomy for sporadic primary hyperparathyroidism, 120 patients (10%) had hyperfunctioning ectopic glands, which were localized to the neck (n = 66) and mediastinum (n = 54). MIBI had a sensitivity of 85%, specificity of 97%, and positive predictive value (PPV) of 91% for ectopic glands in the neck, whereas in the mediastinum there was a sensitivity of 88%, specificity of 95%, and PPV of 86%. Surgeon-performed ultrasonography had a sensitivity of 81%, specificity of 98%, and PPV of 95% for neck ectopic glands. The overall accuracy of surgeon-performed ultrasonography, MIBI, and intraoperative parathyroid monitoring in the neck or mediastinum was 93%. Overall, operative success was 93% with a multiglandular disease rate of 5%. A high operative success rate for hyperfunctioning ectopic glands can be achieved using localization studies and intraoperative parathyroid monitoring. Nevertheless, surgeon judgment remains paramount in the operative direction of this patient population

Reliability of fine-needle aspiration for thyroid nodules greater than or equal to 4 cm

Fine-needle aspiration (FNA) is considered the diagnostic test of choice in the evaluation of thyroid nodules. Some practice recommendations, however, suggest surgical resection of larger thyroid nodules due to concerns of FNA unreliability in the diagnosis of thyroid malignancy. The purpose of this study was to determine the reliability of FNA in thyroid nodules ≥4 cm. Retrospective review of prospectively collected data of 1068 consecutive patients who underwent FNA and thyroidectomy at a single tertiary medical center from 2003 to 2010 was performed. Patients were divided into two groups: those patients with a dominant thyroid nodule ≥4 cm (n = 212) and those patients with a dominant thyroid nodule <4 cm (n = 856). Sensitivity, specificity, and negative and positive predictive values were calculated for FNA results and final histopathology after thyroidectomy. Of 212 patients with lesions ≥4 cm, 35% had thyroid malignancy on final pathology. Conversely, 54% of 856 patients with dominant thyroid nodules <4 cm had a final diagnosis of thyroid cancer after thyroidectomy. FNA demonstrated similar test characteristics among patients with lesions ≥4 cm and <4 cm, with a specificity of 99% (CI: 96%–100%) and 98% (CI: 96%–99.0%), respectively, and a sensitivity of 35% (CI: 23%–49%) and 42% (CI: 37%–46%), respectively. The positive predictive value of FNA was 82% (CI: 75%–100%) for nodules ≥4 cm and 96% (CI: 92%–98%) for nodules <4 cm. Negative predictive value was significantly different, with a value of 82% (CI: 75%–87%) for lesions ≥4 cm and only 59% (CI: 55%–63%) for lesions <4 cm. The reliability of FNA as a diagnostic test is not affected by the size of thyroid nodules. Routine surgical resection for all thyroid nodules ≥4 cm should not be used as the only independent factor in determining need for surgical resection

A safe and effective protocol for management of post-thyroidectomy hypocalcemia.

BACKGROUND: This study evaluates the outcomes of a protocol to manage hypocalcemia after thyroidectomy (TTX). METHODS: A review of prospectively collected data was performed in 130 patients who underwent TTX after the introduction of a specific protocol. These patients were compared with a control group of 195 patients who underwent TTX the year prior when routine calcium supplementation was utilized and no specific protocol was used. RESULTS: Of the 120 patients in whom the protocol was followed, 44 (37%) patients were classified as high risk, 15 (13%) intermediate risk, and 61 (51%) low risk. The protocol had a sensitivity of 85% and a negative predictive value of 92% for predicting subsequent hypocalcemia. With the implementation of the protocol, there was significant reduction in temporary hypocalcemia events (P = .008) and intravenous calcium drip (P = .49). Also, calcium supplementation was significantly lower in the protocol group (P ≤ .001). CONCLUSIONS: This hypocalcemia protocol identifies patients who do not require additional supplementation and additional monitoring. At the same time, it identifies those who will benefit from supplementation after TTX