Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2015 Nov;158(5):1323-30.
doi: 10.1016/j.surg.2015.03.027. Epub 2015 May 6.

Intraoperative guidance in parathyroid surgery using near-infrared fluorescence imaging and low-dose Methylene Blue

Quirijn R J G Tummers  1 , Abbey Schepers  1 , Jaap F Hamming  1 , J Kievit  1 , John V Frangioni  2 , Cornelis J H van de Velde  1 , Alexander L Vahrmeijer  3
Affiliations

Intraoperative guidance in parathyroid surgery using near-infrared fluorescence imaging and low-dose Methylene Blue

Quirijn R J G Tummers et al. Surgery. 2015 Nov.

Abstract

Background: Identification of diseased and normal parathyroid glands during parathyroid surgery can be challenging. The aim of this study was to assess whether near-infrared (NIR) fluorescence imaging using administration of a low-dose Methylene Blue (MB) at the start of the operation could provide optical guidance during parathyroid surgery and assist in the detection of parathyroid adenomas.

Methods: Patients diagnosed with primary hyperparathyroidism planned for parathyroidectomy were included. Patients received 0.5 mg/kg MB intravenously directly after start of anesthesia. During the operation, NIR fluorescence imaging was performed to identify parathyroid adenomas. Imaging results were compared with a previous published feasibility study in which 12 patients received MB after intraoperative identification of the adenoma.

Results: A total of 13 patients were included in the current study. In 10 of 12 patients with a histologically proven adenoma, the adenoma was fluorescent. Mean signal to background ratio was 3.1 ± 2.8. Mean diameter of the resected lesions was 17 ± 9 mm (range 5-28 mm). Adenomas could be identified up to 145 minutes after administration, which was the longest timespan until resection. Interestingly, in 3 patients, a total of 6 normal parathyroid glands (median diameter 2.5 mm) with a signal to background ratio of 1.8 ± 0.4 were identified using NIR fluorescence imaging.

Conclusion: Early administration of low-dose MB provided guidance during parathyroidectomy by identifying both parathyroid adenomas and normal parathyroid glands. In patients in whom difficult identification of the parathyroid adenoma is expected or when normal glands have to be identified, the administration of MB may improve surgical outcome.

PubMed Disclaimer

Conflict of interest statement

CONFLICT OF INTEREST STATEMENT

Quirijn R.J.G. Tummers, M.D.: Nothing to declare

Abbey Schepers, M.D., Ph.D.: Nothing to declare

Jaap F. Hamming, M.D., Ph.D.: Nothing to declare

J. Kievit, M.D., Ph.D.: Nothing to declare

John V. Frangioni, M.D., Ph.D.: FLARE™ technology is owned by Beth Israel Deaconess Medical Center, a teaching hospital of Harvard Medical School. Dr. Frangioni has started three for-profit companies, Curadel, Curadel ResVet Imaging, and Curadel Surgical Innovations, which has optioned FLARE™ technology for potential licensing from Beth Israel Deaconess Medical Center.

Cornelis J.H. van de Velde, M.D., Ph.D.: Nothing to declare

Alexander L. Vahrmeijer, M.D., Ph.D.: Nothing to declare

Figures

Figure 1
Figure 1. Intraoperative NIR fluorescence-guided resection of a parathyroid adenoma located in the neck
During minimally-invasive parathyroid surgery, a 19 mm parathyroid adenoma is identified using NIR fluorescence imaging (arrow).
Figure 2
Figure 2. Intraoperative NIR fluorescence imaging of normal parathyroid glands
A. A 2 mm normal parathyroid gland (arrow) was identified in the right thymus using NIR fluorescence imaging after thymectomy. B. A 1 mm normal parathyroid gland (arrow) was identified in the left thymus using NIR fluorescence imaging after thymectomy. Both glands in A and B could not be identified using visual inspection.
See this image and copyright information in PMC

References

    1. Fraser WD. Hyperparathyroidism. Lancet. 2009 Jul 11;374(9684):145–58. - PubMed
    1. Phillips CD, Shatzkes DR. Imaging of the parathyroid glands. Semin Ultrasound CT MR. 2012 Apr;33(2):123–9. - PubMed
    1. Dudley NE. Methylene blue for rapid identification of the parathyroids. Br Med J. 1971 Sep 18;3(5776):680–1. - PMC - PubMed
    1. Han N, Bumpous JM, Goldstein RE, Fleming MM, Flynn MB. Intra-operative parathyroid identification using methylene blue in parathyroid surgery. Am Surg. 2007 Aug;73(8):820–3. - PubMed
    1. Harrison BJ, Triponez F. Intraoperative adjuncts in surgery for primary hyperparathyroidism. Langenbecks Arch Surg. 2009 Sep;394(5):799–809. - PubMed

Publication types

MeSH terms