Preoperative localisation for parathyroid surgery in primary hyperparathyroidism: a study to evaluate the clinical utility of different imaging modalities

Primary hyperparathyroidism (PHPT) is caused by a solitary benign adenoma in 80‐85% of cases, but may also be due to multi‐gland or ectopic disease, hyperplasia, and rarely parathyroid carcinoma. Preoperative localisation studies are important to identify patients suitable for minimally invasive parathyroid surgery. The aim of this study was to evaluate the accuracy of ultrasound (US), parathyroid scintigraphy (MIBI) and computed tomography (CT) utilised in the preoperative setting in a district general hospital, with limited access to single photon‐emission computed tomography (SPECT)

Outcomes of Patients with Nelson's Syndrome after Primary Treatment: A Multicenter Study from 13 UK Pituitary Centers.

CONTEXT: Long-term outcomes of patients with Nelson's syndrome (NS) have been poorly explored, especially in the modern era. OBJECTIVE: To elucidate tumor control rates, effectiveness of various treatments, and markers of prognostic relevance in patients with NS. PATIENTS, DESIGN, AND SETTING: Retrospective cohort study of 68 patients from 13 UK pituitary centers with median imaging follow-up of 13 years (range 1-45) since NS diagnosis. RESULTS: Management of Cushing's disease (CD) prior to NS diagnosis included surgery+adrenalectomy (n = 30; eight patients had 2 and one had 3 pituitary operations), surgery+radiotherapy+adrenalectomy (n = 17; two received >1 courses of irradiation, two had ≥2 pituitary surgeries), radiotherapy+adrenalectomy (n = 2), and adrenalectomy (n = 19). Primary management of NS mainly included surgery, radiotherapy, surgery+radiotherapy, and observation; 10-year tumor progression-free survival was 62% (surgery 80%, radiotherapy 52%, surgery+radiotherapy 81%, observation 51%). Sex, age at CD or NS diagnosis, size of adenoma (micro-/macroadenoma) at CD diagnosis, presence of pituitary tumor on imaging prior adrenalectomy, and mode of NS primary management were not predictors of tumor progression. Mode of management of CD before NS diagnosis was a significant factor predicting progression, with the group treated by surgery+radiotherapy+adrenalectomy for their CD showing the highest risk (hazard ratio 4.6; 95% confidence interval, 1.6-13.5). During follow-up, 3% of patients had malignant transformation with spinal metastases and 4% died of aggressively enlarging tumor. CONCLUSIONS: At 10 years follow-up, 38% of the patients diagnosed with NS showed progression of their corticotroph tumor. Complexity of treatments for the CD prior to NS diagnosis, possibly reflecting corticotroph adenoma aggressiveness, predicts long-term tumor prognosis

Preoperative localisation for parathyroid surgery in primary hyperparathyroidism: a study to evaluate the clinical utility of different imaging modalities

Background: Primary hyperparathyroidism (PHPT) is caused by a solitary benign adenoma in 80–85% of cases, but may also be due to multi-gland or ectopic disease, hyperplasia, and rarely parathyroid carcinoma. Preoperative localisation studies are important to identify patients suitable for minimally invasive parathyroid surgery. The aim of this study was to evaluate the accuracy of ultrasound (US), parathyroid scintigraphy (MIBI) and computed tomography (CT) utilised in the preoperative setting in a district general hospital, with limited access to single photon-emission computed tomography (SPECT).Methods: A retrospective study of 88 consecutive patients, who underwent parathyroidectomy for PHPT at a single unit between 2010 and 2014, was conducted. Patients were identified using discharge codes from locally held coding data. The sensitivity and specificity of each imaging modality was compared against histology as the gold standard.Results: Eithty-two (93%) patients were first presentations of PHPT and six (7%) were relapses, requiring remedial surgery. At surgery, a solitary adenoma was identified in 72 (82%) patients, eight (9%) had parathyroid hyperplasia and one (1%) had parathyroid carcinoma. Preoperatively 100% of patients had US, 82 (93%) MIBI and 67 (59%) CT. Three (3%) had single image modality, 30 (34%) had two and 43 (49%) had three imaging modalities. 43 (53%) parathyroid adenomas were identified with US, 39 (52%) with MIBI and 31 (67%) with CT. Combined US/MIBI were carried out in 82 patients, yielding a sensitivity of 63%. Paired US/CT had a sensitivity of 75% in 52 patients. 21 patients (24%) with inconclusive imaging were referred to tertiary centres for SPECT which successfully identified ten patients. Thirteen patients (15%) underwent neck exploration due to failure of localisation studies. An overall cure rate of 92% was achieved.Conclusion: Combined US/CT is superior for accurate preoperative localisation of solitary parathyroid adenomas over any single or combination imaging modality

Current management and outcome of pregnancies in women with adrenal insufficiency: experience from a multi-center survey

CONTEXT Appropriate management of adrenal insufficiency (AI) in pregnancy can be challenging due to the rarity of the disease and lack of evidence-based recommendations to guide glucocorticoid- and mineralocorticoid dosage adjustment. OBJECTIVE Multi-center survey on current clinical approaches in managing AI during pregnancy. DESIGN Retrospective anonymized data collection from 19 international centers from 2013-2019. SETTING AND PATIENTS 128 pregnancies in 113 women with different causes of AI: Addison disease (44%), secondary AI (25%), congenital adrenal hyperplasia (25%) and acquired AI due to bilateral adrenalectomy (6%). RESULTS Hydrocortisone (HC) was the most commonly used glucocorticoid in 82.9% (97/117) of pregnancies. Glucocorticoid dosage was increased at any time during pregnancy in 73/128 (57%) of cases. In these cases, difference of the daily dose of HC equivalent between baseline and the third trimester was 8.6±5.4 [range: 1, 30] mg. Fludrocortisone dosage was increased in fewer cases (7/54 during the first trimester, 9/64 during the second trimester and 9/62 cases during the last trimester). Overall, an adrenal crisis was reported in 9/128 (7%) pregnancies. Caesarian section was the most frequent mode of delivery at 58% (69/118). Fetal complications were reported in 3/120 (2.5%) and minor maternal complications in 15/120 (12.5%) pregnancies without fatal outcomes. CONCLUSIONS This survey confirms good maternal and fetal outcome in women with AI managed in specialized endocrine centers. An emphasis on careful endocrine follow up and repeated patient education is likely to have reduced the risk of adrenal crisis and resulted in positive outcomes