Faculty Bibliography

BACKGROUND:Patients with primary hyperparathyroidism who undergo minimally invasive parathyroidectomy (MIP) may have postoperative symptoms of hypocalcemia or secondary hyperparathyroidism. This study sought to identify factors predictive of these events. METHODS:Between 1998 and 2004, 190 patients with primary hyperparathyroidism underwent MIP with excision of a single adenoma. Age, gender, race, prior head and neck surgery, use of preoperative thyroid hormone or calcium-channel blockers, preoperative levels of calcium, 25-hydroxyvitamin D (25[OH]D) and intact parathyroid hormone (iPTH), the presence of osteopenia or osteoporosis, intraoperative iPTH levels, and adenoma weight were evaluated by univariate analysis as predictors of postoperative symptoms of hypocalcemia and secondary hyperparathyroidism. RESULTS:None of the following were predictors of postoperative symptoms of hypocalcemia: age, gender, race, prior head and neck surgery, preoperative medications, preoperative calcium and iPTH levels, osteopenia or osteoporosis, intraoperative iPTH levels, or adenoma weight. However, patients with postoperative symptoms of hypocalcemia had significantly lower preoperative 25[OH]D levels (P = .01). Further, higher preoperative iPTH levels (P < .01) and lower preoperative 25[OH]D levels (P = .05) were associated with secondary hyperparathyroidism postoperatively. CONCLUSIONS:A low preoperative 25[OH]D level is associated with postoperative symptoms of hypocalcemia and secondary hyperparathyroidism in patients undergoing MIP. One might consider instituting empiric calcium supplementation postoperatively in patients with low 25[OH]D levels.

OBJECTIVE: Parathyroid gland localization and lateralization are important before surgery, particularly for minimally invasive parathyroidectomy (MIP) and recurrent hyperparathyroidism. We hypothesized that readings of Tc sestamibi scans with single photon emission computed tomography (SPECT) by a surgeon and nuclear medicine physician together (NMP+S) compared to a nuclear medicine physician alone (NMP alone) might affect scan interpretation accuracy. METHODS: Between May 1999 and December 2002, 127 hyperparathyroid patients had preoperative localization with sestamibi SPECT. Scans were prospectively interpreted by an endocrine surgeon and nuclear medicine physician attending together (NMP+S) and a nuclear medicine physician attending alone (NMP alone). These readings were compared to intra-operative findings, which served as the 'gold standard'. RESULTS: There were 120 patients with primary hyperparathyroidism (55 underwent MIP) and seven with secondary or tertiary hyperparathyroidism; seven patients had recurrent hyperparathyroidism. Of 127 patients, 83 had single adenomas; 27, double adenomas; 15, hyperplasia; one, MENIIA; and one, parathyroid cancer. Sensitivity and positive predictive values were 58.6% and 67.4% for NMP alone compared to 81.9% and 70.0% for NMP+S. The overall accuracy of correct localization was 45.7% vs. 60.6% (P<0.01) and of correct lateralization was 69.3% vs. 80.3% (P<0.01) for NMP alone versus NMP+S respectively. The most common finding interpreted incorrectly by NMP alone and correctly by NMP+S was an ectopic superior parathyroid adenoma in the inferior position. Ninety-eight per cent of patients were cured of their hyperparathyroidism. CONCLUSIONS: Parathyroid sestamibi SPECT scan interpretation by an endocrine surgeon reading with a nuclear medicine attending resulted in improved accuracy of gland localization and lateralization compared to a nuclear medicine attending reading alone. This improvement may be due to increased awareness of clinical factors and head-and-neck anatomy

BACKGROUND: Technetium 99m ( 99m Tc)-methoxyisobutylisonitrile (MIBI) single photon emission computed tomography (SPECT) is frequently used in the evaluation of patients with hyperparathyroidism. Calcium channel blockers (CACBs) may affect 99m Tc-MIBI uptake by parathyroid cells. This study examines the effect of CACB therapy on the sensitivity of 99m Tc-MIBI SPECT localization for hyperparathyroidism. METHODS: Two hundred fifty-three operated patients with hyperparathyroidism were retrospectively reviewed. The potential effect of CACB therapy on 99m Tc-MIBI scan sensitivity was examined by using logistic regression analysis. Possible confounding factors were considered. RESULTS: Among 235 patients, those with multiple endocrine neoplasia, type I (MEN-I), MEN-IIA, 4-gland hyperplasia, secondary hyperparathyroidism, and tertiary hyperparathyroidism exhibited no difference associated with CACB use. Of the remaining 198 patients with primary hyperparathyroidism, 7/30 (23%) with negative 99m Tc-MIBI SPECT scans compared to 24/168 (14%) with positive scans used CACBs. After correcting for age, gender and gland weight, the odds ratio (OR) for a negative study in patients taking CACBs was 2.88 (95% CI, 1.03-8.10; P = .045). Atherosclerosis, hypertension, diabetes mellitus, preoperative calcium and parathyroid hormone levels, and thyroid hormone use were not confounding factors. CONCLUSIONS: CACB therapy reduces the sensitivity of 99m Tc-MIBI parathyroid SPECT in patients with primary hyperparathyroidism. Further studies are required to determine the potential reversibility of this effect with termination of CACB therapy

The incidence of malignant melanoma is rising concomitantly with dramatic changes in our healthcare system. Primary care physicians (PCPs) are responsible for an increasing number of skin-related healthcare visits. Therefore, PCPs must be on the forefront of early detection of suspicious pigmented lesions. Understanding the PCPs' screening and referral patterns for pigmented lesions is the first step in ensuring that atypical pigmented lesions will be properly evaluated within the confines of the present healthcare system. To develop a better understanding of how PCPs (internists, family practitioners, and pediatricians) manage pigmented lesions in their practice, we mailed a 28-question survey to 999 PCPs in Connecticut. Fewer than half of the 248 respondents indicated they 'often' performed full skin examinations. However, when suspicious lesions were found, most PCPs referred patients to a dermatologist for a biopsy of the lesion. PCPs did not feel pressure from managed care companies to limit these referrals. However, many PCPs did not feel highly confident in their ability to recognize melanoma and thought their training was not adequate to prepare them to diagnose and manage pigmented lesions. Family practitioners were more likely than internists and pediatricians to manage suspicious pigmented lesions and to perform a biopsy on their own. Family practitioners also were more confident in performing these tasks and were more likely to think their training in these areas was adequate. Very few PCPs reported sending their biopsy specimens to a dermatopathology laboratory. In fact, many PCPs seemed unaware of who interpreted the histopathology. PCPs do not emphasize full skin examinations in their practice and seem unaware of the advantages inherent in using dermatopathologists in the histopathologic interpretation of pigmented lesions. Furthermore, lack of confidence on the part of PCPs, as well as their concern about adequate training in the management of pigmented lesions, suggest there is need for improvement in the education of primary care residents and physicians

Cutaneous melanoma is the seventh most common newly diagnosed cancer among Americans. It frequently metastasizes and is difficult to treat. Accurate disease staging is important for optimizing therapy and selecting appropriate patients for experimental trials. Positron emission computed tomography (PET) using 18F-fluorodeoxyglucose (FDG) has been studied extensively since 1991 and shows great promise in the detection of metastatic cutaneous melanoma. Cumulative data from the last 13 years is reviewed in this article and suggest that FDG-PET is the modality of choice for evaluating patients who fit into one of four categories: 1) individuals with a high risk for distant metastases based on extent of locoregional disease, 2) patients with findings that are suspicious for distant metastases, 3) individuals with known distant tumor deposits who still stand to benefit from customized therapies if new lesions are discovered or treated lesions regress, and 4) patients at high risk for systemic relapse who are considering aggressive medical therapy. Despite the overall superiority of FDG-PET in the detection of melanoma metastases, limitations exist with respect to detection of small lung nodules and brain metastases, which are better evaluated by computed tomography and magnetic resonance imaging, respectively

In this article, dermoscopy, an in vivo technique that allows the clinician to evaluate subsurface structures, is described. Dermoscopy is used in the evaluation of pigmented lesions of the skin and is a helpful tool in the differential diagnosis. This article discusses research on dermoscopy, as well as other imaging techniques including confocal microscopy, digital dermoscopy, and computer-assisted diagnosis