Abstract
PurposeRepeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse.MethodsA retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated.ResultsNeck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24–48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%.ConclusionThese findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.
Highlights
Primary hyperparathyroidism is the third most common endocrine disorder [1]
2.71 diagnostic procedures were applied to each patient leading to a detection of an adenoma in 25/28 patients (89.3%)
Among the 26 patients having sestamibi scintigraphy, 17 patients (65.4%) showed a focal enhancement suggesting the presence of a parathyroid adenoma
Summary
Primary hyperparathyroidism (pHPT) is the third most common endocrine disorder [1]. It is diagnosed biochemically and is defined as an inappropriately high level of total serum calcium due to maladjusted, elevated levels of parathormone (PTH). In 70–80% of cases, a single solitary parathyroid adenoma is causative for pHPT, while 20–30% of cases are accounted for by multiglandular disease. The therapy of choice and only curative treatment for pHPT is surgical resection of the responsible adenoma or, in cases of multiglandular disease, total or subtotal parathyroidectomy of all glands with reimplantation of parathyroid tissue. Therapeutic success is characterized by the normalization of calcium and PTH levels [1]
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