Intraoperative verification of parathyroid glands in primary and secondary hyperparathyroidism using near-infrared autofluorescence (IOPA)

  • Henning W. WolfEmail author
  • Bernhard Grumbeck
  • Norbert Runkel
Original Article


Intraoperative verification of parathyroid glands relies on visual identification by the surgeon and, with some time delay, on serum parathormon measurements and frozen section. Fluorescence imaging, however, is an instant on-table method for direct visualization of parathyroid tissue which is known to exhibit increased autofluorescence intensity when exposed to near-infrared light. In this retrospective observational study, we evaluate the clinical use of this method in a series of patients with primary and secondary hyperparathyroidism. A total of 66 adenomatous and hyperplastic parathyroid glands were examined with intraoperative autofluorescence in 39 patients with primary and secondary hyperparathyroidism using a near-infrared system (KARL STORZ GmbH & Co. KG). The specimens were verified by conventional histology. Fifty-seven of 66 histologically proven adenomatous/hyperplastic glands exhibited autofluorescence. The sensitivity of near-infrared autofluorescence was 0.9 in pHPT and 0.83 in sHPT, respectively. The positive predictive value was 0.93 in pHPT and 1.0 in sHPT, respectively. Near-infrared autofluorescence guidance presents an innovative instant surgical imaging tool with sensitivity in detecting adenomatous and hyperplastic parathyroid glands comparable to current intraoperative methods. Due to its elegant and tracer-free design combined with low follow-up costs, this method can be useful for routine use.


Parathyroid surgery Hyperparathyroidism Endocrine surgery Near-infrared autofluorescence 


Compliance with ethical standards


Wolf HW received financial support and technical equipment from Karl Storz GmbH, Tuttlingen, Germany.

Conflict of interest

The authors Runkel N and Grumbeck B declare that thy have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Human and animal rights

This article does not contain any studies with animals performed by any of the authors. As this study is designed as a retrospective study, formal consent is not required.

Informal consent

As data were collected as part of a regular hospital stay and analyzed retrospectively, informed consent was not obtained. The study was approved by the local ethics committee and registered at the German trial register. Trial registration number: DRKS00009840.


  1. 1.
    Khatun Y, Walker A, Jimeno J, Hubbard JG (2015) Role of intraoperative PTH monitoring and surgical approach in primary hyperparathyroidism. Ann Med Surg. 4:301–305. CrossRefGoogle Scholar
  2. 2.
    Paras C, Keller M, White L, Phay J, Mahadevan-Jansen A (2011) Near-infrared autofluorescence for the detection of parathyroid glands. J Biomed Opt 16(6):067012. CrossRefGoogle Scholar
  3. 3.
    Falco J, Dip F, Quadri P, de la Fuente M, Rosenthal R (2016) Cutting edge in thyroid surgery: autofluorescence of parathyroid glands. J Am Coll Surg 223:374–380. CrossRefGoogle Scholar
  4. 4.
    Dudley NE (1971) Methylene blue for rapid identification of the parathyroids. Br Med J 3:680–681CrossRefGoogle Scholar
  5. 5.
    Kuriloff DB, Sanborn KV (2004) Rapid intraoperative localization of parathyroid glands utilizing methylene blue infusion. Otolaryngol Head Neck Surg 131(5):616–622CrossRefGoogle Scholar
  6. 6.
    Prosst RL, Weiss J, Hupp L, Willeke F, Post S (2010) Fluorescence-guided minimally invasive parathyroidectomy: clinical experience with a novel intraoperative detection technique for parathyroid glands. World J Surg 34(9):2217–2222. CrossRefGoogle Scholar
  7. 7.
    Vidal Fortuny J, Karenovics W, Triponez F, Sadowski SM (2016) Intra-operative indocyanine green angiography of the parathyroid gland. World J Surg 40(10):2378–2381. CrossRefGoogle Scholar
  8. 8.
    Zaidi N, Bucak E, Okoh A, Yigitbas H, Berber E (2016) The utility of indocyanine green near infrared fluorescent imaging in the identification of parathyroid glands during surgery for primary hyperparathyroidism. J Surg Oncol 113(7):771–774. CrossRefGoogle Scholar
  9. 9.
    Vidal Fortuny J, Belfontali V, Sadowski SM, Karenovics W, Guigard S, Triponez F (2016) Parathyroid gland angiography with indocyanine green fluorescence to predict parathyroid function after thyroid surgery. Br J Surg 103(5):537–543. CrossRefGoogle Scholar
  10. 10.
    McWade MA, Paras C, White LM, Phay JE, Solórzano CC, Broome JT, Mahadevan-Jansen A (2014) Label-free intraoperative parathyroid localization with near-infrared autofluorescence imaging. J Clin Endocrinol Metab 99(12):4574–4580. CrossRefGoogle Scholar
  11. 11.
    McWade MA, Sanders ME, Broome JT, Solórzano CC, Mahadevan-Jansen A (2016) Establishing the clinical utility of autofluorescence spectroscopy for parathyroid detection. Surgery 159(1):193–202. CrossRefGoogle Scholar
  12. 12.
    Shi Y, Hogue J, Koh Dixit D, Jr Olson JA (2014) Functional and genetic studies of isolated cells from parathyroid tumors reveal the complex pathogenesis of parathyroid neoplasia. Proc Natl Acad Sci USA 111(8):3092–3097. CrossRefGoogle Scholar
  13. 13.
    Corbetta S, Mantovani G, Lania A, Borgato S, Vicentini L, Beretta E, Faglia G, Di Blasio AM, Spada A (2001) Calcium-sensing receptor expression and signalling in human parathyroid adenomas and primary hyperplasia. Clin Endocrinol (Oxf) 52(3):339–348CrossRefGoogle Scholar
  14. 14.
    Riccardi D, Martin D (2008) The role of the calcium-sensing receptor in the pathophysiology of secondary hyperparathyroidism. NDT Plus 1:i7–i11. Google Scholar
  15. 15.
    Cañadillas S, Canalejo A, Santamaría R, Rodríguez ME, Estepa JC, Martín-Malo A, Bravo J, Ramos B, Aguilera-Tejero E, Rodríguez M, Almadén Y (2005) Calcium-sensing receptor expression and parathyroid hormone secretion in hyperplastic parathyroid glands from humans. J Am Soc Nephrol 16(7):2190–2197CrossRefGoogle Scholar

Copyright information

© Italian Society of Surgery (SIC) 2019

Authors and Affiliations

  1. 1.Department of General SurgerySchwarzwald-Baar Klinikum Villingen-SchwenningenVillingen-SchwenningenGermany
  2. 2.Kantonsspital Aarau AGAarauSwitzerland
  3. 3.Department of SurgeryKlinikum Sankt ElisabethStraubingGermany
  4. 4.Schwarzwald-Baar Klinikum Villingen-SchwenningenVillingen-SchwenningenGermany
  5. 5.Sana-Klinikum OffenbachOffenbachGermany

Personalised recommendations