Clinical Characterization of Post-parathyroidectomy Patients with Primary Hyperparathyroidism and the Concordance of Preoperative Localization Imaging with Histopathology at a Tertiary Hospital in Manila, Philippines

Keywords: primary hyperparathyroidism,, parathyroidectomy, parathyroid localization

Abstract

Background. Philippine studies on primary hyperparathyroidism (PHPT) and preoperative localization are scarce, making improvements on detection and recognition particularly difficult.

Objective. Describe the clinical profile of post-parathyroidectomy PHPT patients at The Medical City (TMC) and
assess localization rates and concordance of neck ultrasound (UTZ) and 99mTc-sestamibi scan (MIBI) with surgical histopathologic findings.

Methodology. Retrospective chart review of PHPT Filipino patients who underwent parathyroidectomy at The Medical City from January 2004 to August 2018. Clinical profile and presentations were described and compared with international data. Imaging results were compared with surgical histopathology findings and the level of agreement was determined.

Results. Thirty-five patients were analyzed with female predominance (63%) and an average age of 53 years. Our population had more overt manifestations including skeletal abnormalities (51%), renal calculi (49%) and musculoskeletal symptoms (43%) prior to surgery compared to western countries, where symptoms were noted in less than 20%. MIBI had higher rates of detection than UTZ (80% versus 58%) but had similar localization rates (96.4% versus 94%). When performed together, given a positive result from either test, a much higher yield (93.8%) was observed. The level of agreement between MIBI and surgery was 72.5% (κ=0.54) while UTZ and surgery was 54.1% (κ=0.38).

Conclusion. Our Filipino subjects had predominantly overt symptomatic hyperparathyroidism upon diagnosis prior to surgery as opposed to more asymptomatic surgical patients in western countries. Combining UTZ and MIBI is a more successful preoperative localization approach in our setting than performing either imaging alone, especially in patients with nodular goiter.

Downloads

Download data is not yet available.

Author Biographies

Danica Chan Francisco, The Medical City, Pasig City

Section of Endocrinology, Diabetes and Metabolism, Department of Medicine

Elizabeth Paz Pacheco, The Medical City, Pasig City

Section of Endocrinology, Diabetes and Metabolism, Department of Medicine

References

Bilezikian JP, Bandeira L, Khan A, Cusano NE. Hyperparathyroidism. Lancet. 2018;391(10116):168-78. https://www.ncbi.nlm.nih.gov/pubmed/28923463. https://doi.org/10.1016/S0140-6736(17)31430-7.

Wermers RA, Khosla S, Atkinson EJ, et al. Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993-2001: An update on the changing epidemiology of the disease. J Bone Miner Res. 2006;21:171-7. https://www.ncbi.nlm.nih.gov/pubmed/16355286. https://doi.org/10.1359/JBMR.050910.

Heath H 3rd, Hodgson SF, Kennedy MA. Primary Hyperparathyroidism. Incidence, morbidity and potential economic impact in a community. N Engl J Med. 1980;302(4): 189-93. https://www.ncbi.nlm.nih.gov/pubmed/7350459. https://doi.org/10.1056/NEJM198001243020402.

Abood A, Vestergaard P. Increasing incidence of primary hyperparathyroidism in Denmark. Dan Med J. 2013;60(2): A4567. https://www.ncbi.nlm.nih.gov/pubmed/23461985.

Stephen AE, Mannstadt M, Hodin RA. Indications for surgical management of hyperparathyroidism: A review. JAMA Surg. 2017;152(9):878-82. https://www.ncbi.nlm.nih.gov/pubmed/28658490. https://doi.org/10.1001/jamasurg.2017.1721.

Medas F, Erdas E, Longheu A, et al. Retrospective evaluation of the pre- and postoperative factors influencing the sensitivity of localization studies in primary hyperparathyroidism. Int J Surg. 2016;25:82-7. https://www.ncbi.nlm.nih.gov/pubmed/26646659. https://doi.org/10.1016/j.ijsu.2015.11.045.

Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: Why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg. 2012;214(3):260-9. https://www.ncbi.nlm.nih.gov/pubmed/ 22265807. https://doi.org/10.1016/j.jamcollsurg.2011.12.007.

Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: A combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery. 1999;126(6):1016-21. https://www.ncbi.nlm.nih.gov/pubmed/10598182. https://doi.org/10.1067/msy.2099.101433.

Cohen MS, Finkelstein SE, Brunt LM, et al. Outpatient minimally invasive parathyroidectomy using local/ regional anesthesia: A safe and effective operative approach for selected patients. Surgery. 2005;138(4):681-9. https://www.ncbi.nlm.nih.gov/pubmed/16269297. https://doi.org/10.1016/j.surg.2005.07.016.

Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg. 2011;253(3):585-91. https://www.ncbi.nlm.nih.gov/pubmed/21183844. https://doi.org/10.1097/SLA.0b013e318208fed9.

Purcell GP, Dirbas FM, Jeffrey RB, et al. Parathyroid localization with high-resolution ultrasound and technetium Tc 99m sestamibi. Arch Surg. 1999;134(8):824-30. https://www.ncbi.nlm.nih.gov/pubmed/10443804. https://doi.org/10.1001/archsurg.134.8.824.

Șișman P, Gül ÖÖ, Cander S, et al. Sensitivity of localization studies performed by various radiologists in the evaluation of parathyroid lesions. Eur Res J. 2018;4(2):112-7. https://doi.org/10.18621/eurj.308830.

Mohammadi A, Moloudi F, Ghasemi-Rad M. Preoperative localization of parathyroid lesion: Diagnostic usefulness of color doppler ultrasonography. Int J Clin Exp Med. 2012;5(1):80-6. https://www.ncbi.nlm.nih.gov/pubmed/22328952. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3272690.

Kunstman JW, Kirsch JD, Mahajan A, Udelsman R. Clinical Review: Parathyroid localization and implications for clinical management. J Clin Endocrinol Metab. 2013;98(3):902-12. https://www.ncbi.nlm.nih.gov/pubmed/23345096. https://doi.org/10.1210/jc.2012-3168.

Elaraj DM, Sippel RS, Lindsay S, et al. Are additional localization studies and referral indicated for patients with primary hyperparathyroidism who have negative sestamibi scan results? Arch Surg. 2010;145(6):578-81. https://www.ncbi.nlm.nih.gov/pubmed/20566979. https://doi.org/10.1001/archsurg.2010.108.

Chua CC, Rivero W, Gutierrez MJ, Jasul GV Jr. Prevalence of secondary hyperparathyroidism among outpatient type 2 diabetic patients undergoing hemodialysis in a tertiary hospital. Philipp J Int Med. 2010;48(1):4-8.

Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561-9. https://www.ncbi.nlm.nih.gov/pubmed/25162665. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5393490. https://doi.org/10.1210/jc.2014-1413.

Gasser RW. Clinical aspects of primary hyperparathyroidism: Clinical manifestations, diagnosis, and therapy. Wien Med Wochenschr. 2013;163(17-18):397-402. https://www.ncbi.nlm.nih.gov/pubmed/23990260. https://doi.org/10.1007/s10354-013-0235-z.

Bilezikian JP. Primary hyperparathyroidism [Updated 2017 Jan 15]. In: KR Feingold, B Anawalt, A Boyce, et al, eds. Endotext [Internet]. South Dartmouth: MDText.com, Inc.; 2000-. Available from https://www.ncbi.nlm.nih.gov/books/NBK278923.

Silverberg SJ, Bilezikian JP. Primary hyperparathyroidism. In: JAH Wass, P Stewart, eds. Oxford Textbook of Endocrinology and Diabetes, 2nd ed. Oxford: Oxford University Press,

Gopal RA, Acharya SV, Bandgar T, Menon PS, Dalvi AN, Shah NS. Clinical profile of primary hyperparathyroidism from western India: A single center experience. J Postgrad Med. 2010;56(2):79-84. https://www.ncbi.nlm.nih.gov/pubmed/20622385. https://doi.org/10.4103/0022-3859.65279.

Malabu UH, Founda MA. Primary hyperparathyroidism in Saudi Arabia: A review of 46 cases. Med J Malaysia. 2007;62(5):394-7. https://www.ncbi.nlm.nih.gov/pubmed/18705474.

Prasarttong-Osoth P, Wathanaoran P, Imruetaicharoenchoke W, Rojananin S. Primary hyperparathyroidism: 11-year experience in a single institute in Thailand. Int J Endocrinol. 2012;2012:952426. https://www.ncbi.nlm.nih.gov/pubmed/22701120. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3369527. https://doi.org/10.1155/2012/952426.

Padilla-Baraoidan RZM, Capuli-Isidro MJ, Cudal BIB, Embestro-Pontillas AA. Hungry bone syndrome (HBS) in patients operated for primary hyperparathyroidism (PHPT): A six-year experience. Philipp J Otolaryngol Head Neck Surg. 2017;32(2):11-6. https://doi.org/10.32412/pjohns.v32i2.59.

Erbil Y, Barbaros U, Yanik BT, et al. Impact of gland morphology and concomitant thyroid nodules on preoperative localization of parathyroid adenomas. Laryngoscope. 2006;116(4):580-5. https://www.ncbi.nlm.nih.gov/pubmed/16585862. https://doi.org/10.1097/01.MLG.0000203411.53666.AD.

Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133. https://www.ncbi.nlm.nih.gov/pubmed/ 26462967. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4739132. https://doi.org/10.1089/thy.2015.0020.

Carlos-Raboca J, Jimeno CA, Kho SA, et al. The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence of thyroid disorders among adults in the Philippines. J ASEAN Fed Endocr Soc. 2012;27(1):27-33. https://asean-endocrinejournal.org/index.php/JAFES/article/view/9.

Kus LH, Shah M, Eski S, Walfish PG, Freeman JL. Thyroid cancer outcomes in Filipino patients. Arch Otolaryngol Head Neck Surg. 2010;136(2):138-42. https://www.ncbi.nlm.nih.gov/pubmed/20157058. https://doi.org/10.1001/archoto.2009.206.

Rossing MA, Schwartz SM, Weiss NS. Thyroid cancer incidence in Asian migrants to the United States and their descendants. Cancer Causes Control. 1995;6(5):439-44. https://www.ncbi.nlm.nih.gov/pubmed/8547542. https://doi.org/10.1007/bf00052184.

Clark JR, Eski SJ, Freeman JL. Risk of malignancy in Filipinos with thyroid nodules—a matched pair analysis. Head Neck. 2006;28(5):427-31. https://www.ncbi.nlm.nih.gov/pubmed/16287137. https://doi.org/10.1002/hed.20333.

McHugh ML. Interrater reliability: The kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-82. https://www.ncbi.nlm.nih.gov/pubmed/23092060. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3900052.

Published
2020-05-04
How to Cite
Francisco, D. C., Pacheco, E. P., & Wagan, P. A. (2020). Clinical Characterization of Post-parathyroidectomy Patients with Primary Hyperparathyroidism and the Concordance of Preoperative Localization Imaging with Histopathology at a Tertiary Hospital in Manila, Philippines. Journal of the ASEAN Federation of Endocrine Societies, 35(1), 77-84. https://doi.org/10.15605/jafes.035.01.13
Section
Original Articles