Mild sporadic primary hyperparathyroidism: high rate of multiglandular disease is associated with lower surgical cure rate

With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy (LPX). We investigated whether ultrasonography in the hands of the surgeon (SUS) could improve the localization of abnormal parathyroids when sestamibi scans (MIBI) were negative or equivocal. One hundred eighty patients with sporadic primary hyperparathyroidism (SPHPT) underwent preoperative SUS and MIBI scans before LPX guided by intraoperative parathormone assay. When the sestamibi scans were negative, SUS was used to localize the parathyroid, distinguish parathyroid from thyroid tissue, and to guide the intraoperative jugular venous sampling for differential elevation of parathyroid hormone (PTH). Operative findings, intraoperative hormone dynamics, and postoperative calcium levels determined successful localization. MIBI was negative or equivocal in 36/180 (20%) patients: 1) showed no parathyroid gland in 22 patients, 2) suggested an incorrect location for the abnormal gland in 9, and 3) was insufficient in recognizing multiglandular disease in 5. In these 36 patients, the addition of SUS led to the successful identification of the abnormal tissue in 19/36 (53%). In the remaining 17 patients with negative/equivocal scans, the parathyroid could not be clearly visualized by SUS. In these patients, SUS facilitated LPX by aiding preoperative transcutaneous jugular venous sampling for differentially elevated PTH (n = 3) and identifying questionable thyroid nodule versus parathyroid tissue (n = 1). Overall, SUS was useful in 23/36 (67%) patients with nonlocalizing MIBI scans, thus improving the rate of localization from 80 per cent to 93 per cent ( P < 0.01). Surgeon-performed cervical ultrasonography improved the localization of abnormal parathyroids by MIBI scan, adding to the success of limited parathyroidectomy.

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Surgical Therapy for Familial Hyperparathyroidism

The American Surgeon ◽

10.1177/000313480907500708 ◽

2009 ◽

Vol 75 (7) ◽

pp. 579-583 ◽

Cited By ~ 3

Author(s):

Jyotirmay Sharma ◽

Collin J. Weber

Keyword(s):

Primary Hyperparathyroidism ◽

Cure Rate ◽

Patient Demographics ◽

Initial Surgery ◽

Sestamibi Scanning ◽

Recurrence Patterns ◽

Sporadic Primary Hyperparathyroidism ◽

Intraoperative Parathyroid Hormone ◽

Familial Hyperparathyroidism

Isolated familial hyperparathyroidism (FHPT) not associated with multiple endocrine neoplasia is a rare and aggressive form of primary hyperparathyroidism. The traditional management of FHPT is a bilateral neck exploration with an increased rate of multigland hyperplasia, supernumerary glands, and recurrence. A prospective database was queried, which included 1383 consecutive parathyroidectomies between 1992 and 2008, and 28 patients with FHPT were identified. Patient demographics, pathology, intraoperative parathyroid hormone (IOPTH) kinetics, recurrence patterns, and accuracy of localization studies were analyzed. Twenty-one patients underwent bilateral neck explorations as an initial surgery, and seven patients had nine unilateral neck explorations for recurrent hyperparathyroidism. Overall cure rate was 89.2 per cent with a mean follow-up of 2.9 years (range: 6 months to 9.2 years); 64.3 per cent of patients had multigland disease. IOPTH helped identify supernumerary glands in three (12.5%) patients and accurately lateralized recurrent disease in eight of nine surgeries (88.8%). Tc-99m-Sestamibi failed to identify multigland disease in 11 patients (52.3%). FHPT has a greater prevalence of multigland disease, decreased utility of sestamibi scanning, and a higher recurrence rate than sporadic primary hyperparathyroidism. In FHPT, IOPTH is a useful adjunct in identifying additional tumors and in select cases may play a role in tumor localization.

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Use of Preoperative Imaging in Primary Hyperparathyroidism

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa779 ◽

2020 ◽

Vol 106 (1) ◽

pp. e328-e337

Author(s):

David T Broome ◽

Robert Naples ◽

Richard Bailey ◽

Zehra Tekin ◽

Moska Hamidi ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Ct Scan ◽

Predictive Value ◽

Imaging Modalities ◽

Preoperative Imaging ◽

Multiglandular Disease ◽

Cure Rate ◽

4D Ct ◽

Operative Findings ◽

Double Adenomas

Abstract Context Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. Objective Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. Design, Setting, and Patients This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. Main Outcome Measures Surgical cure rate, concordance of imaging with operative findings, and imaging performance. Results The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. Conclusions Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

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Focused parathyroidectomy guided by intra-operative parathormone monitoring does not miss multiglandular disease in patients with sporadic primary hyperparathyroidism: A 10-year outcome

Surgery ◽

10.1016/j.surg.2009.09.006 ◽

2009 ◽

Vol 146 (6) ◽

pp. 1021-1027 ◽

Cited By ~ 39

Author(s):

John I. Lew ◽

George L. Irvin

Keyword(s):

Primary Hyperparathyroidism ◽

Multiglandular Disease ◽

Focused Parathyroidectomy ◽

Sporadic Primary Hyperparathyroidism

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Negative preoperative localization studies are highly predictive of multiglandular disease in sporadic primary hyperparathyroidism

Surgery ◽

10.1016/j.surg.2003.07.021 ◽

2003 ◽

Vol 134 (6) ◽

pp. 1038-1041 ◽

Cited By ~ 66

Author(s):

Frederic Sebag ◽

Johnathan G.H Hubbard ◽

Sylvie Maweja ◽

Claudia Misso ◽

Laurent Tardivet ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Preoperative Localization ◽

Multiglandular Disease ◽

Sporadic Primary Hyperparathyroidism

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99mTechnetium Sestamibi-123Iodine Scintigraphy Is More Accurate Than 99mTechnetium Sestamibi Alone before Surgery for Primary Hyperparathyroidism

International Journal of Molecular Imaging ◽

10.1155/2015/391625 ◽

2015 ◽

Vol 2015 ◽

pp. 1-9 ◽

Cited By ~ 3

Author(s):

Eeva M. Ryhänen ◽

Jukka Schildt ◽

Ilkka Heiskanen ◽

Mika Väisänen ◽

Aapo Ahonen ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Serum Calcium ◽

Multiglandular Disease ◽

Single Adenoma ◽

Histological Findings ◽

Cure Rate ◽

Single Centre ◽

Primary Surgery ◽

Outcome Of Surgery ◽

Dual Tracer

Objectives. Studies comparing outcome of single-T99mc-methoxyisobutylisonitrile (T99mc-sestamibi) and dual-tracer T99mc-sestamibi scintigraphy in combination with 123I before primary surgery of primary hyperparathyroidism (PHPT) are scarce. Methods. We compared T99mc-sestamibi/123I and T99mc-sestamibi in a single-centre retrospective series of 269 PHPT patients. The results were related to laboratory, surgical and histological findings. Results. T99mc-sestamibi/123I and T99mc-sestamibi were positive in 206 (76.6%) and 111 (41.3%) of 269 patients, respectively (P < 0.001). Accuracies for T99mc-sestamibi/123I and T99mc-sestamibi were 63.4% and 34.9%, respectively (96% CI, P < 0.001). Prevalence of multiglandular disease was 15.2%. In multiglandular disease, T99mc-sestamibi/123I and T99mc-sestamibi revealed 43.8 and 22.1% of pathological glands, respectively (P < 0.001). Cure rate was similar for patients with (191/206; 92.7%) and without (59 of 63; 93.7%) a positive T99mc-sestamibi/123I finding. Duration of targeted surgery (one or two quadrants) was 21 and 15 minutes shorter than bilateral neck exploration, respectively (both P < 0.001). Higher serum calcium (P = 0.014) and PTH (P = 0.055) concentrations and larger tumours (P < 0.001) characterized the 206 patients with a positive preoperative scan who were cured by removal of a single adenoma. Conclusions. T99mc-sestamibi/123I scintigraphy is more accurate than T99mc-sestamibi before surgery of PHPT. However, outcome of surgery is not determined by scintigraphy alone.

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