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Endocrine Surgery

Emerging Imaging Technologies for Parathyroid Gland Identification and Vascular Assessment in Thyroid SurgeryA Review From the American Head and Neck Society Endocrine Surgery Section

To identify the key insights or developments described in this article

1 Credit CME

JAMA Otolaryngology–Head & Neck Surgery

Published Online: January 12, 2023

Review

Article Information and Disclosures

Amanda L. Silver Karcioglu, MD^1,2,3;

Frédéric Triponez, MD⁴;

Carmen C. Solórzano, MD⁵;

Ayaka J. Iwata, MD, MS⁶;

Amr H. Abdelhamid Ahmed, MBBCH, MMSc¹;

Martin Almquist, MD, PhD⁷;

Peter Angelos, MD, PhD⁸;

Fares Benmiloud, MD⁹;

Eren Berber, MD, MBA¹⁰;

Anders Bergenfelz, MD, PhD¹¹;

Jaepyeong Cha, PhD^12,13;

C. Alessandra Colaianni, MD, MPhil¹⁴;

Louise Davies, MD, MS^15,16;

Quan-Yang Duh, MD^17,18;

Dana Hartl, MD, PhD¹⁹;

Emad Kandil, MD, MBA²⁰;

Wan Wook Kim, MD, PhD²¹;

Peter A. Kopp, MD^22,23;

Whitney Liddy, MD²⁴;

Anita Mahadevan-Jansen, PhD^25,26;

Kang-Dae Lee, MD²⁷;

Michael Mannstadt, MD²⁸;

Caitlin P. McMullen, MD²⁹;

David C. Shonka Jr, MD³⁰;

Jennifer J. Shin, MD, SM^31,32;

Michael C. Singer, MD³³;

Cristian M. Slough, MD³⁴;

Brendan C. Stack Jr, MD³⁵;

Guillermo Tearney, MD, PhD^36,37;

Giju Thomas, MBBS, PhD^38,39;

Neil Tolley, MD, DLO⁴⁰;

Jordi Vidal-Fortuny, MD^41,42;

Gregory W. Randolph, MD, MD^1,43

Author Affiliations

¹Division of Thyroid and Parathyroid Endocrine Surgery, Department of Otolaryngology–Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston
²Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, Evanston, Illinois
³The University of Chicago, Pritzker School of Medicine, Chicago, Illinois
⁴Thoracic and Endocrine Surgery, Department of Surgery, University Hospitals and Faculty of Medicine of Geneva, Geneva, Switzerland
⁵Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
⁶Department of Otolaryngology–Head and Neck Surgery, Kaiser Permanente, Santa Clara, California
⁷Department of Surgery, Skane University Hospital, Lund, Sweden, Institution for Clinical Sciences, Lund University, Lund, Sweden
⁸MacLean Center for Clinical Medical Ethics, Department of Surgery, The University of Chicago, Chicago, Illinois
⁹Endocrine Surgery Unit, Hôpital Européen Marseille, Marseille, France
¹⁰Department of Endocrine Surgery, Cleveland Clinic, Cleveland, Ohio
¹¹Department of Clinical Sciences-–Lund, Lund University, Lund Sweden
¹²Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC
¹³Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
¹⁴Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, Oregon Health & Science University, Portland
¹⁵The VA Outcomes Group, White River Junction, Vermont
¹⁶Section for Otolaryngology–Head & Neck Surgery, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
¹⁷Section of Endocrine Surgery, Department of Surgery, University of California, San Francisco
¹⁸VA Medical Center, San Francisco, California
¹⁹Department of Surgery, Thyroid Surgery Unit, Gustave Roussy Cancer Campus and University Paris-Saclay, Paris, France
²⁰Endocrine and Oncological Surgery Tulane University School of Medicine, New Orleans, Louisiana
²¹Department of Surgery, Breast and Thyroid Division, Kyungpook National University, South Korea
²²Division of Endocrinology, Diabetology and Metabolism, University of Lausanne, Lausanne, Switzerland
²³Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
²⁴Thyroid and Parathyroid Surgery, Department of Otolaryngology–Head and Neck Surgery, Northwestern Medicine, Chicago, Illinois
²⁵Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
²⁶Department of Surgery, Otolaryngology and Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
²⁷Department of Otolaryngology–Head and Neck Surgery, Kosin University Gospel Hospital, Busan, Korea
²⁸Endocrine Unit, Massachusetts General Hospital, Harvard Medical School, Boston
²⁹Moffitt Cancer Center, Department of Head & Neck–Endocrine Oncology, Tampa, Florida
³⁰Division of Head and Neck Surgery, Department of Otolaryngology–Head and Neck Surgery, University of Virginia, Charlottesville
³¹Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts
³²Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, Massachusetts
³³Division of Thyroid & Parathyroid Surgery, Department of Otolaryngology–Head and Neck Surgery, Henry Ford Health System, Detroit, Michigan
³⁴Department of Otolaryngology–Head and Neck Surgery, Hawke’s Bay Fallen Soldiers’ Memorial Hospital, Hawke's Bay District Health Board, Hastings, New Zealand
³⁵Otolaryngology–Head and Neck Surgery, Southern Illinois University School of Medicine, Springfield
³⁶Department of Pathology and Wellman Center for Photomedicine, Massachusetts General Hospital, Boston
³⁷Harvard Medical School, Boston, Massachusetts
³⁸Vanderbilt Biophotonics Center, Vanderbilt University, Nashville, Tennessee
³⁹Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee
⁴⁰Imperial College NHS Healthcare Trust, London, United Kingdom
⁴¹Department of Thoracic and Endocrine Surgery, University Hospitals of Geneva, Geneva, Switzerland
⁴²Department of Thoracic and Endocrine Surgery, Geneva, Switzerland
⁴³Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston

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Abstract

Importance Identification and preservation of parathyroid glands (PGs) remain challenging despite advances in surgical techniques. Considerable morbidity and even mortality result from hypoparathyroidism caused by devascularization or inadvertent removal of PGs. Emerging imaging technologies hold promise to improve identification and preservation of PGs during thyroid surgery.

Observation This narrative review (1) comprehensively reviews PG identification and vascular assessment using near-infrared autofluorescence (NIRAF)—both label free and in combination with indocyanine green—based on a comprehensive literature review and (2) offers a manual for possible implementation these emerging technologies in thyroid surgery.

Conclusions and Relevance Emerging technologies hold promise to improve PG identification and preservation during thyroidectomy. Future research should address variables affecting the degree of fluorescence in NIRAF, standardization of signal quantification, definitions and standardization of parameters of indocyanine green injection that correlate with postoperative PG function, the financial effect of these emerging technologies on near-term and longer-term costs, the adoption learning curve and effect on surgical training, and long-term outcomes of key quality metrics in adequately powered randomized clinical trials evaluating PG preservation.

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Article Information

Accepted for Publication: November 15, 2022.

Published Online: January 12, 2023. doi:10.1001/jamaoto.2022.4421

Corresponding Author: Amanda L. Silver Karcioglu, MD, Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, NorthShore University HealthSystem, 9669 Kenton Ave, Ste 206, Skokie, IL 60076 (amandalsilver@gmail.com).

Conflict of Interest Disclosures: Dr Triponez reported personal fees (consulting fees paid to institution) from Medtronic, Fluoptics, and Stryker during the conduct of the study. Dr Almquist reported grants from IPSEN and Medtronic outside the submitted work. Dr Benmiloud reported personal fees from Fluoptics (consulting) outside the submitted work. Dr Berber reported personal fees from Aesculap, Medtronic, Johnson & Johnson, and Intuitive outside the submitted work. Dr Cha reported grants from Children’s National Hospital (NIH 2 R44 EB030874-02) during the conduct of the study; grants from Optosurgical (NIH 2 R44 EB030874-02) outside the submitted work; a patent for US17/854,084 pending; and is the founder and scientific advisor for Optosurgical and has a financial interest with the company. Dr Mahadevan-Jansen reported grants from Medtronic (in-kind) during the conduct of the study; in addition, Dr Mahadevan-Jansen has a patent for NIRAF for parathyroid detection that is licensed by her institution to Medtronic. Dr Mannstadt reported grants from Takeda and Calcilytix and personal fees from Amolyt outside the submitted work. Dr Singer is a consultant for Medtronic outside the submitted work. Dr Thomas reported affiliation with Vanderbilt University, which has a licensing agreement for PTeye with Ai Biomed (now officially acquired by Medtronic). Dr Randolph reported grants (research support) from Fluoptics, Medtronic, and Eisai during the conduct of the study; Dr Randolph also reported serving as the president of the International Thyroid Oncology Group and the World Congress on Thyroid Cancer, chair of the Administrative Division of the American Head and Neck Society, and American College of Surgeons Otolaryngology Governor. No other disclosures were reported.

Additional Contributions: We thank Garyfallia Pagonis, BFA, BS (Massachusetts Eye and Ear Infirmary), for her assistance in the preparation of tables and figures, as well as Louise Collins, DVM, MSLIS (Massachusetts Eye and Ear Infirmary), for her assistance with building the search strategy of the literature review. They were not compensated for their contributions. Dr Randolph would like to acknowledge the ongoing support of Mike and Eliz Ruane and of John and Claire Bertucci for his research efforts.

Disclaimer: Dr Davies is an Associate Editor of JAMA Otolaryngology–Head & Neck Surgery but was not involved in any of the decisions regarding review of the manuscript or its acceptance.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.