Minimally Invasive Radioguided Parathyroidectomy

A safer and less invasive approach to surgically treat hyperparathyroidism

Hyperparathyroidism is a condition that causes high blood-calcium levels in nearly 100,000 Americans every year. The disease is caused if one or more of the four tiny parathyroid glands located behind the thyroid in the neck become enlarged and produce too much parathyroid hormone (PTH). This is usually caused by a benign tumor called a parathyroid adenoma. Hyperparathyroidism is a chronic condition that affects two out of every 1,000 people, and sometimes causes osteoporosis, kidney stones, abdominal problems, depression, and fatigue, among other illnesses. Hyperparathyroidism can be successfully treated by surgically removing the abnormal parathyroid gland—or in some cases—multiple glands.

David Goldenberg, M.D., Professor of Surgery in the Division of Head and Neck Surgery, has been performing minimally invasive radioguided parathyroid surgery to treat primary hyperparathyroidism for more than five years. His patients experience rapid relief with little scarring or side effects.

Dr. Goldenberg is a fellowship-trained head and neck surgeon. He treats patients with all types of cancers of the head and neck, as well as benign and malignant conditions of the thyroid and parathyroid glands.

Q: What is minimally invasive radioguided parathyroidectomy (MIRP)?
A: Minimally invasive radioguided parathyroidectomy, or MIRP, is a surgical procedure used to treat patients diagnosed with primary hyperparathyroidism. A safer and less invasive approach to a traditional parathyroidectomy, MIRP can usually be performed through a 1.5-inch incision in the neck. Before MIRP, surgeons searched for and removed the faulty parathyroid gland through a large incision. This approach often required surgical exploration of the neck.

Q: How is the surgery performed?
A: Before surgery, patients are injected with a radioactive material that washes out quickly from the thyroid. It remains only in the diseased parathyroid gland (adenoma), and is not absorbed readily by healthy parathyroid glands. Two hours later, the parathyroid is viewed on a radioisotope (sestamibi) scan to help locate the abnormal parathyroid gland and is found through the incision using a hand-held radiation detector. Usually, a 1.5-inch incision is made precisely over the spot of the offending gland, and it is surgically removed. While the patient is still asleep, a rapid blood test is taken to look for a drop in PTH levels. Within ten minutes of removing the offending adenoma, the levels will have dropped 50 percent compared to the pre-op test.

Q: How long is the surgery?
A: The procedure takes less than one hour.

Q: How long do patients stay in the hospital after surgery?
A: Because the procedure is minimally invasive, most patients go home the same day of the procedure—usually just a few hours later.

Q: What is recovery like?
A: MIRP is a minimally invasive procedure. Benefits include less pain, less scarring, and shorter recovery time.

Q: Are there any risks involved with this procedure?
A: As with any surgery, there are risks. There is a low risk of nerve damage to the vocal cord, and there is a small risk of developing chronically low calcium levels.

Q: Does MIRP always cure hyperparathyroidism?
A: The cure rate is significantly higher than any other parathyroid operation and the complication rate is near zero (significantly less than 1 percent when performed by expert parathyroid surgeons).

Q: Are all parathyroid problems managed with MIRP?
A: No, there are less common types of hyperparathyroidism that are managed either medically (with medicine) or with other various types of surgical procedures.

If you are a referring physician with questions about MIRP or other parathyroid surgery, or to find out if your patient is a candidate for this procedure, please call 717-531-8945, or our 24-hour MD Network 1-800-233-4082.

If you are a patient diagnosed with hyperparathyroidism and would like to schedule an appointment with Dr. Goldenberg, please call 717-531-6822.
 

Choby G, Trojanowski A, Johnson S, Goldenberg D. Use of double electrode pads for intraoperative monitoring of the recurrent laryngeal nerve. Ann Otol Rhinol Laryngol. 2010 Apr;119(4):233-5.

Pistorio A, Goldenberg D. CT-MIBI-SPECT fusion imaging combined with Gamma probe for minimally invasive radioguided parathyroidectomy (MIRP). Curr Radiopharm. 2010 3:263-6.

Choby G, Hollenbeak CS, Johnson S, Goldenberg D. Surface electrode recurrent laryngeal nerve monitoring during thyroid surgery: normative values. J Clin Neurophysiol. 2010 Feb;27(1):34-7.

Adil E, Adil T, Fedok F, Kauffman G, Goldenberg D. Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism. Otolaryngol Head Neck Surg. 2009 Jul;141(1):34-8.

Ondik MP, Tulchinsky M, Goldenberg D. Radioguided reoperative thyroid and parathyroid surgery. Otolaryngol Clin North Am. 2008 Dec;41(6):1185-98.
 

Advantages of Using SPECT/CT Scan compared to Sestamibi

Until recently, the planar MIBI (or sestamibi) scan was the best available imaging technique for preoperative identification of a parathyroid adenoma (tumor).  The limitations of this scan are that it only shows "front to back" flat images limiting the surgeon’s ability to locate the parathyroid adenoma.  Additionally an enlarged thyroid gland, which sits in front of the parathyroid, may obscure the parathyroid adenoma. To date, many parathyroid surgeons still use this sestamibi scanning (Figure 1). In many modern parathyroid practices Hybrid imaging (combining two imaging techniques) has increasingly been accepted as a modality of choice for the evaluating parathyroid adenomas.

SPECT/CT (single photon emission tomography/computed tomography) in which a 3D MIBI scan and CT scan are superimposed and then fused. This provides superior preoperative visualization of the parathyroid adenoma from all angles (Figure 2). This is the technique we use here at Penn State Hershey.

Vocal Cords are Protected from Damage During the MIRP Procedure

Many patients have been informed the risk of parathyroid surgery (even MIRP) is damage to the nerve that goes to the vocal cords (voice box). This is called the recurrent laryngeal nerve. Should this nerve be damaged, the patient may suffer from temporary or permanent hoarseness. To complicate matters, often the parathyroid adenoma is found directly adjacent to this nerve. Surgical expertise in identifying and avoiding the recurrent laryngeal nerve is key.

Another tool we use to enhance patient safety is intra-operative neural monitoring (IONM). IONM allows the surgeon to monitor the activity of the recurrent laryngeal nerve during surgery and help keep it safe.

In order to access recurrent laryngeal nerve damage, your surgeon should view your vocal cords with a small camera both before and after surgery.