Localization In Primary Hyperparathyroidism Research Articles

Are 99mTC-Sestamibi Single Photon Emission Computed Tomography Scan Results Associated to the Parathyroid Cell Type in Primary Hyperparathyroidism?

Introduction99mTC-sestamibi scintigraphy (SPECT-CT) is a common imaging modality for parathyroid localization in primary hyperparathyroidism (PHPT). Prior studies have suggested that the cellular composition of parathyroid adenomas influences SPECT-CT imaging results. Other biochemical and anatomical factors may also play a role in false negative results. Therefore, after controlling for confounding variables, we sought to determine whether the histologic composition of parathyroid adenomas is associated to SPECT-CT results in patients with single gland disease causing PHPT. MethodsA retrospective review of patients with PHPT due to confirmed single gland disease was performed over a 2-y period. A 1:1 propensity score matching was done between patients with positive and negative SPECT-CT results with regard to demographical, biochemical, and anatomical characteristics followed by blinded pathologic examination of cell composition in the matched pairs. ResultsFive hundred forty two patients underwent routine four gland exploration and 287 (53%) patients were found to have a single adenoma. Of those, 26% had a negative SPECT-CT result. There were significant differences between groups with regards to biochemical profile, gland location, and gland size. All of which became nonsignificant after propensity score matching. Adenomas were primarily composed of chief cells, with no difference between groups (95% versus 97%, P = 0.30). In the positive SPECT-CT group, chief cells were the dominant cell type in 68% of the cases, followed by mixed type (13%), oxyphil cells (12%), and clear cells (7%). This was similar to the negative SPECT-CT group (P = 0.22). ConclusionsWhile certain patient’s clinical characteristics are associated with SPECT-CT imaging results, histologic cell type is not significantly associated.

Use of dual energy computed tomography versus conventional techniques for preoperative localization in primary hyperparathyroidism: Effect of preoperative calcium and parathyroid hormone levels

BackgroundWe aimed to investigate the association of preoperative calcium and parathyroid hormone (PTH) levels with sensitivity and accuracy of dual energy computed tomography (DECT), single-photon emission CT with 99mTc-sestamibi (CT-MIBI), and ultrasound (US) for pre-operative localization primary hyperparathyroid (PHP) patients. MethodsPatients undergoing parathyroidectomy for PHP at a tertiary care facility who underwent DECT, CT-MIBI and US between 2012 and 2021 were stratified by preoperative calcium and PTH levels. ResultsOf 278 patients, those with high calcium and PTH levels had a higher sensitivity and accuracy with DECT (87.7%, 85.2%) compared to CT-MIBI (82.3%, 79.0%), and US (61.7%, 53.1%). DECT was more sensitive and accurate than other preoperative localization techniques in subgroups with normal PTH (DECT sensitivity 60.9%, accuracy 52.1%) and normal calcium levels (41.7%, 33.3%). ConclusionPreoperative calcium and PTH were associated with sensitivity and accuracy of pre-operative localization in PHP. DECT was sensitive and accurate for preoperative localization compared to other first-line imaging techniques.

Optimum Imaging for Parathyroid Localization in Primary Hyperparathyroidism

Optimum Imaging for Parathyroid Localization in Primary Hyperparathyroidism

Initial experience with 4DCT: Apt Choice for Parathyroid Localization?

Abstract Aims Optimal modality for pre-operative radiological parathyroid localization in primary hyperparathyroidism (PHPT) is controversial. Four-dimensional computed tomography (4DCT) is a newer imaging technique that can provide detailed anatomic information. We aimed to evaluate the performance of 4DCT as a localization tool for patients with PHPT. Methods Between 03/2018 and 05/2021, 121 patients were operated for primary hyperparathyroidism at our institution. 4DCT was used as a second line investigation in patients <60 years due to concerns about radiation. Electronic patient records including operation notes and pathology were reviewed. 80(66%) had 4DCT for localization. Results Mean age of the study population was 68.4 years (Range27–88). Mean tumour size on CT was 16.13mm (range 4–38). Mean serum calcium and PTH levels were 2.89mmol/L and 20.76pmol/L. 4DCT identified a lesion in 61 patients (sensitivity 76.2%) and correctly lateralized a pathological parathyroid in 58/61 patients (specificity 95.1%). Hyperplasia and smaller gland size were non-significantly associated with non-detection (p>0.05). Of the 61 patients with a positive 4DCT, 4 (6.5%) developed persistent disease – in two a lymph node/thyroid nodule was excised and two had multigland disease. In this study 4DCT correctly localized recurrent disease in 4 of 5 patients, and 12 of 15 patients with negative Sestamibi SPECT CT scan. Discussion 4DCT offers accurate localization of abnormal glands in first-time parathyroidectomy for PHPT. Advantages include simplicity and speed of scan. Using 4DCT for first-time localisation is changing conventional practice of ultrasound+sestamibi scanning. It may have an added role in localizing disease in recurrent HPT and in patients who have a negative nuclear scan.

Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism

BackgroundPreoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. MethodsPatients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. ResultsIn 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). ConclusionLong-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.

PRIMARY HYPERPARATHYROIDISM DETECTED BY PARATHYROID INCIDENTALOMA: CLINICAL FEATURES, WORK-UP AND MANAGEMENT.

With the widespread use of neck ultrasound, parathyroid incidentaloma (PI) emerges as an additional opportunity for incidental detection of primary hyperparathyroidism (PHPT). This study aimed to investigate PHPT cases detected by PI and to compare them with other PHPT patients. A retrospective analysis of newly diagnosed PHPT patients between 2014 and 2020 was conducted in our hospital. The cohort of 124 subjects was divided in two groups: 22 (17.7%) PHPT patients detected by PI (PI PHPT group) and the rest of 102 PHPT patients (non-PI PHPT group). Overall, 21 PIs were discovered on ultrasound and one was found during thyroid surgery. Clinical features, work-up and management of two study groups were compared. The PI PHPT group had lower ionized calcium at diagnosis (p=0.034), lower peak serum calcium during follow-up (p<0.01), less fractures (p=0.022) and was less likely to meet the international criteria for parathyroidectomy (p<0.01). Positive sestamibi scan (p=0.022) and confirmed concordant localization in at least two different parathyroid imaging techniques (p=0.033) were more likely in the PI PHPT group. The frequency of surgical management did not differ between groups. PHPT detected by PI is clinically relevant and mostly comparable to PHPT in other patients with some features that correspond more often to a mild disease. Higher rate of positive preoperative localization in PHPT detected by PI might encourage parathyroidectomy even without the international criteria met.

Primer hiperparatiroidide Tc99m-MIBI sintigrafi sonuçlarının biyokimyasal ve histopatolojik bulgular ile ilişkisi

It was aimed to evaluate the relationship between clinical, laboratory, and histopathological findings with the scintigraphy performed with Technetium-99m MIBI in patients with primary hyperparathyroidism (PHPT). 516 patients who applied for parathyroid scintigraphy between 2012-2018 were retrospectively scanned. Files of 105(94 female, 11 male) patients, which were diagnosed as PHPT, were included in the study and laboratory, ultrasonography (USG), and findings were recorded. The scintigraphically parathyroid tissues that can be localized were examined in two groups as MIBI-positive(n=92) and those that could not be MIBI-negative (n=13). Sensitivity and diagnostic accuracy of USG and scintigraphy and combinations were evaluated. The calcium value (11.48±0.75 mg/dl) in MIBI-positive group was higher than MIBI-negative group (11±0.68 mg/dl) (p=0.047). While the sensitivity of USG in lesion detection was 60.2%, and scintigraphy was 89.1%, the sensitivity in the combination of the those was 91.9%. Diagnostic acuity of scintigraphy was 87.6%, USG+scintigraphy was 92%. A positive correlation was found between parathyroid adenoma size and PTH and ALP (p<0.001 r=0.572; p=0.003 r=0.424, respectively). Parathyroid scintigraphy is more likely to define a parathyroid pathology when calcium is high, and the adenoma size increases consistent with increasing PTH. Although scintigraphy is much more effective than USG for preoperative localization in PHPT, its combination with USG contributes to the localization of PHPT.

Accuracy of 4-Dimensional Computed Tomography for Localization in Primary Hyperparathyroidism

BackgroundThe etiology of primary hyperparathyroidism (PHP) is single-gland adenoma in most patients. Imaging localization of single-gland disease allows for a focused operation. We sought to determine the accuracy of imaging for localizing a solitary parathyroid adenoma. MethodsA single-institution retrospective review was performed of adult patients with PHP undergoing parathyroidectomy from January 2017 through December 2018. Surgeon-performed ultrasound (US), four-dimensional computed tomography (4DCT), and sestamibi were assessed for localization of a parathyroid adenoma yielding a single-gland parathyroidectomy. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for each imaging modality. ResultsOne hundred fifty-four patients underwent parathyroidectomy for PHP during the study period, with 100 patients meeting inclusion criteria with a mean age of 61.1 (SD 10) y and 80% women. Mean calcium was 11.1 mg/dL (SD 0.7) and mean PTH was 116 pg/mL (SD 66). All 100 patients had surgeon-performed US with 17 localized, 51 patients had 4DCT with 41 (80%) localized, and 69 patients had sestamibi with 53 (77%) localized. Eighty-two patients underwent successful unilateral parathyroidectomy, 18 required bilateral neck exploration. US was the most specific imaging modality at 94%. Accuracy of imaging localization was 32% for US, 70% for sestamibi, and 86% for 4DCT. ConclusionsSurgeon-performed US is a highly specific imaging modality for preoperative localization of solitary parathyroid adenoma in patients with PHP. 4DCT is the most accurate imaging localization study and should be considered for patients with a nonlocalized US.

Novel Findings on SPECT-CT Tc-99 Sestamibi Imaging for Primary Hyperparathyroidism

BackgroundThe addition of SPECT-CT to Tc-99 sestamibi has become a valuable tool for parathyroid localization in primary hyperparathyroidism (PHP). However, the enhanced sensitivity of this test can lead to unexpected and significant findings. We sought to identify the frequency and types of nonparathyroid detections by SPECT-CT. Materials and methodsWith institutional approval, we reviewed all SPECT-CT studies performed for PHP between October 2012 and August 2018 for incidental nonparathyroid abnormalities. The electronic medical record was referenced to determine the type of lesion confirmed by additional evaluation. ResultsAmong 2413 studies, 652 patients (27%) had 677 (28%) nonparathyroid findings. The most common were thyroid nodules (331/677, 49%), including 47 (6.9%) malignancies to date: 40 papillary thyroid cancers (11 microcarcinomas), five follicular thyroid cancers, one medullary carcinoma, and one noninvasive follicular thyroid neoplasm with papillary-like features. One hundred and seventy-seven patients had pulmonary nodules (26%), of whom nine were diagnosed with primary lung lesions (6 non–small-cell cancers, one small-cell cancer, one carcinoid, and one pulmonary sequestration). SPECT-CT revealed 14 patients (2.1%) with breast abnormalities, including three cancers. Nine patients (1.3%) demonstrated metastatic diseases within the lungs (4), bones (3), and mediastinum (2). One patient was diagnosed with follicular lymphoma. Two intracranial tumors were also identified, as well as dysplastic Barrett's esophagitis (1), hiatal hernia (20, 3%), and aortic aneurysm (13, 1.8%). In all, 72/677 (10.6%) PHP patients exhibited premalignant or malignant nonparathyroid SPECT-CT findings. ConclusionsIn patients undergoing localization for PHP with Tc-99 sestamibi SPECT-CT, nonparathyroid findings are frequent (27%) and can lead to newly diagnosed malignant or premalignant lesions in at least 3% of patients to date.

Localization of primary hyperparathyroidism: a case report

Localization of primary hyperparathyroidism: a case report

4D-Dynamic Contrast-Enhanced MRI for Preoperative Localization in Patients with Primary Hyperparathyroidism.

Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation. Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results. Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%). The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.

Efficacy of Scintigraphy, Ultrasound and Both Scintigraphy and Ultrasonography in Preoperative Detection and Localization of Primary Hyperparathyroidism.

Objective: The aim of our study was to evaluate the efficacy of preoperative dual-phase 99mTc-methoxyisobutylnitrile (MIBI) parathyroid scintigraphy (PS), and ultrasound (US) in primary hyperparathyroidism (pHPT) diagnosis and compare the results with the surgical findings.Methods: Forty-five patients were enrolled in this study. Preoperative serum parathyroid hormone (PTH) levels, calcium (Ca), phosphate (P), and alkaline phosphatase (AP) levels were measured. All parathyroid patients were evaluated by ultrasonography, dual phase 99mTc-MIBI. Surgical findings were used as a reference standard.Results: Of the 45 patients included in this study, 30 were females (66.7%) with an age range between 30 years and 70 years (mean age 41± 13). The sensitivity and specificity of 99mTc-MIBI scintigraphy was 97.4% and 71.4%, respectively, while the sensitivity of ultrasound was 94.4% and specificity 44.4%. The sensitivity, specificity, and accuracy of combined scintigraphy and ultrasound was higher-97.4%, 83.3%, and 95.6%, respectively.Conclusions: The combination of MIBI and US appears promising for localizing parathyroid pathology in patients with primary hyperparathyroidism. The concordance rate is high together with a lower chance of missing concomitant thyroid pathology, which might alter the surgical approach.

Importance of Parathyroid Hormone Needle Aspiration Washout in Adenoma Localization in Primary Hyperparathyroidism.

BackgroundPrimary hyperparathyroidism is an endocrine disease characterized by excessive secretion of parathyroid hormone and hypercalcemia. Although scintigraphy is commonly used for pre-operative localization, it does not always localize the parathyroid lesion. In such patients, ultrasonography can visualize the suspected lesion and needle washout sample for parathyroid hormone titer can be used to confirm parathyroid tissue. The aim of this study was to investigate the accuracy of the parathyroid hormone needle aspiration washout method in detecting the localization of parathyroid adenoma.Material/MethodsPatients with primary hyperparathyroidism who underwent surgery between 2010 and 2017 at the Dicle University Medical Faculty Hospital were retrospectively evaluated using medical records. Patients undergoing parathyroid hormone needle aspiration washout were performed in the suspected lesion were included in the study. Accompanied by ultrasonography, the suspected area was penetrated with needle, and negative aspiration was performed. Pre-operative scintigraphic data of patients were evaluated. Patients with positive scintigraphy, negative scintigraphy or patients who did not undergo scintigraphy were included in our study. Demographic data were presented as continuous data means ± standard deviation. Categorical variables were presented as frequency and percentage.ResultsForty-nine patients (female/male, 40/9) who underwent parathyroid hormone needle aspiration washout were included in the study. Parathyroid hormone washout result was positive in 47 patients (47/49) and negative in 2 patients (2/49), sensitivity/positive predictive value (PPV) 95.91%. Twenty-six patients who had negative/suspicious scintigraphic results were diagnosed using the parathyroid hormone needle aspiration washout method (24/26, 92.3% accuracy). Parathyroid hormone needle aspiration washout without scintigraphy was performed in 13 patients (13/13, 100% accuracy).ConclusionsParathyroid adenoma localization can be easily done using parathyroid hormone needle aspiration washout in centers experienced in adenoma localization in primary hyperparathyroidism cases in which scintigraphic results are negative or scintigraphy cannot be performed. We believe that primary parathyroid hormone needle aspiration washout can be a new localization method for adenoma localization.

Sestamibi SPECT/CT versus SPECT only for preoperative localization in primary hyperparathyroidism: a single institution 8-year analysis

BackgroundPrimary hyperparathyroidism is caused by single gland disease in 85% of cases and by multiglandular disease in 15%. Our aim was to discover if the addition of computed tomography acquisition/fusion on a hybrid scanner to traditional dual-phase single-photon emission tomography improves localization accuracy. MethodsA prospective database was queried for the perioperative data of patients with sporadic primary hyperparathyroidism who had initial exploration from 2006–2014 with ≥6 month follow-up to define anatomy. Prior to 2010, patients had single-photon emission tomography (n = 633); after 2010, they had single-photon emission tomography/computed tomography (n = 755). ResultsIn 1,388 patients, the rates of single gland disease (P = .8), bilateral exploration (P = .4), and negative imaging (145 patients, P = .33) were equal between imaging cohorts. In 1,186 patients with single gland disease, the positive predictive value of single-photon emission tomography/computed tomography was somewhat greater (90% vs 85%) and the accuracy of single-photon emission tomography/computed tomography was superior (83% vs 77%, P = .02). In the 202 patients with multiglandular disease, 20% had negative imaging results with no difference by type (single-photon emission tomography/computed tomography 17%, single-photon emission tomography 23%, P = .3), but single-photon emission tomography/computed tomography was more accurate (36%) than single-photon emission tomography (22%, P = .04) in predicting multiglandular disease. ConclusionIn a large cohort study of patients with sporadic primary hyperparathyroidism undergoing parathyroidectomy, positive single-photon emission tomography/computed tomography results provided more reliable operative guidance than single-photon emission tomography for both single gland disease and multiglandular disease.

Higher circulating parathyroid hormone concentration fascilitates preoperative diagnostic imagings for localization in primary hyperparathyroidism

Higher circulating parathyroid hormone concentration fascilitates preoperative diagnostic imagings for localization in primary hyperparathyroidism

Iodine 125 Seed for Localization in Primary Hyperparathyroidism.

Background Preoperative localization of the parathyroid gland prior to a minimally invasive parathyroidectomy (MIP) is important because of varying locations of the parathyroid gland. Several methods have been described to localize the affected gland. One novel technique is the use of an iodine 125 (I-125) seed as a marker. The aim of this study is to evaluate the feasibility of using an I-125 seed in localizing the diseased parathyroid gland prior to MIP. Materials and methods This is a pilot study of 10 patients performed in the Amphia Hospital, the Netherlands. Patients in whom primary hyperparathyroidism (PHPT) was diagnosed in combination with 1 enlarged parathyroid gland on ultrasound (US) and scintigraphy and who were eligible for MIP were included in this study. These patients underwent a preoperative US-guided I-125 seed placement in the affected parathyroid gland. The main study parameters were the feasibility of the placement, intraoperative localization of the diseased gland and complications. Results A total of 10 patients were included. The US-guided I-125 placement in the affected parathyroid gland was technically feasible in the majority of cases. Because of the anatomical location of the gland, the placement was difficult in 2 patients, resulting in suboptimal position and possible misplacement of the marker. MIP was uncomplicated in most cases. Complications during surgery were mainly intraoperative bleeding. Conclusions The use of an I-125 seed for preoperative localization in PHPT is a relatively safe technique in parathyroid surgery. More research is needed to compare this technique with other preoperative localization techniques.

Clinical efficacy of 2-phase versus 4-phase computed tomography for localization in primary hyperparathyroidism

Four-dimensional computed tomography is being used increasingly for localization of abnormal glands in primary hyperparathyroidism. We hypothesized that compared with traditional 4-phase imaging, 2-phase imaging would halve the radiation dose without compromising parathyroid localization and clinical outcomes. A transition from 4-phase to 2-phase imaging was instituted between 2009 and 2010. A pre-post analysis was performed on patients undergoing operative treatment with a parathyroid protocol computed tomography, and relevant data were correlated with operative findings. Sensitivity, positive predictive value, technical success, and cure rates were calculated. The Fisher exact test or χ(2) test assessed the significance of 2-phase and 4-phase imaging and operative findings. Twenty-seven patients had traditional four-dimensional computed tomography and 35 had modified 2-phase computed tomography. Effective radiation doses were 6.8 mSy for 2-phase and 14mSv for 4-phase. Four-phase computed tomography had a sensitivity and positive predictive value of 93% and 96%, respectively. Two-phase computed tomography had a comparable sensitivity and positive predictive value of 97% and 94%, respectively. Eight patients with discordant imaging had an average parathyroid weight of 240g compared with 1,300g for all patients. Technical surgical success (90% for 4-phase computed tomography versus 91% 2-phase computed tomography) and normocalcemia rates at 6months (88% for both) did not differ between computed tomography protocols. Computed tomography correctly predicted multiglandular disease and localization for reoperations in 88% and 90% of cases, respectively, with no difference by computed tomography protocol. With regard to surgical outcomes and localization, 2-phase parathyroid computed tomography is equivalent to 4-phase for parathyroid localization, including small adenomas, reoperative cases, and multiglandular disease. Two-phase parathyroid computed tomography for operative planning should be consideredto avoid unnecessary radiation exposure.

The impact of combined interpretation of localization studies on image-guided surgical approaches for primary hyperparathyroidism.

The impact of single and combined interpretations of ultrasonography and sestamibi scintigraphy to select the appropriate surgical approach in patients with primary hyperparathyroidism were evaluated retrospectively. A total of 183 patients with primary hyperparathyroidism who were evaluated preoperatively using both ultrasonography and sestamibi scintigraphy were included in the study. The results of preoperative localization studies were correlated with intraoperative findings and postoperative histopathological results. The localization rates of individual and combined interpretations of ultrasonography and sestamibi scintigraphy were evaluated. The overall sensitivity and the positive predictive value of ultrasonography and sestamibi scintigraphy were 76% and 90%, and 81% and 91%, respectively. Both imaging studies were concordant for the same localization(s) in 121 (66%) of 183 patients. The prevalence rates of single-gland and multiglandular disease were 90% (N.=109) and 10% (N.=12), respectively, in patients with concordant results (P=0.0001). The overall rate of localization was 91% (N.=110) in these patients. In these patients with concordant results, the sensitivity and the positive predictive value of imaging were 91% and 100%, respectively. The localization rates were 96% and 42% for single-gland and multiglandular disease, respectively (P=0.0001). Of the remaining 62 patients, 50 had negative imaging with either ultrasonography (N.=29) or MIBI (N.=21). Of the 29 patients with negative ultrasonography results, sestamibi scintigraphy was positive in 23. Of the 21 patients with negative sestamibi scintigraphy imaging, ultrasonography was positive in 15. Thus, 38 patients had a single positive imaging result. The majority (95%) of these 38 patients had single-gland disease, and the rate of multiglandular disease was 5% (P=0.0001). The rate of localization was 95% (36/38) in patients with a single positive imaging study. Eighteen patients had discordant imaging results. The overall rate of localization in primary hyperparathyroidism is greater than 90% if ultrasonography and sestamibi scintigraphy are concordantly positive for the same localization, and the prevalence of multiglandular disease is low in patients with concordant imaging. An image-guided surgical approach and selective parathyroidectomy exhibit high cure rates in the setting of concordantly positive sestamibi and ultrasonography results, even if intraoperative parathormone monitoring is not used.

Ultrasound for Localization in Primary Hyperparathyroidism

To evaluate the capability of ultrasound for preoperative localization in primary hyperparathyroidism. Prospective study. Multi-institutional Midwest Head and Neck Cancer Consortium. Two hundred twenty patients who underwent preoperative localization and had parathyroid surgery were evaluated. The findings of preoperative localization studies were correlated with surgical findings. Preoperative ultrasonography, sestamibi scintigraphy, or both were obtained in 77%, 93%, and 69% of the patients, respectively. Preoperative ultrasonography and sestamibi scintigraphy localized an abnormality in 71% and 79% of patients, respectively. At the time of surgery, the localization by ultrasound was accurate in 82%. The accuracy of localization was similar for sestamibi scintigraphy (85%). In patients with inaccurate ultrasound localization, the sestamibi scintigraphy correctly identified the site of disease in only 45%. In patients with a nonlocalizing ultrasound, sestamibi scintigraphy was able to localize disease in only 47%, with 2 being in the mediastinum. Ultrasonography is an acceptable initial localization study for patients with primary hyperparathyroidism. In patients with nonlocalizing ultrasound, sestamibi scintigraphy should be obtained, but can be expected to detect an abnormality in less than 50% of patients.

Early-phase technetium-99m sestamibi scintigraphy can improve preoperative localization in primary hyperparathyroidism

BackgroundIn hyperparathyroidism, dual-phase technetium-99m sestamibi scintigraphy is important for parathyroid adenoma localization. We hypothesized that reviewing early-phase scans can increase localization in patients with primary hyperparathyroidism (PHPT). MethodsWe reviewed our prospectively maintained database for patients with sestamibi scans before parathyroidectomy for PHPT from 2001 to 2011. Early-phase scans were read and compared with the location of the gland(s) removed at operation. ResultsOf 902 patients identified, radiologists read 693 scans as positive. Of 209 negative scans, 141 (67%) were positive in the early phase; 135 (96%) correctly identified the side of the adenoma. Using radiologist reads, 35% of patients with negative scans and 41% of patients with falsely localized glands required bilateral exploration compared with 5% of patients with correctly localized glands. ConclusionsA review of early scans in patients with negative imaging increases accurate adenoma localization and allows for minimally invasive operations in more patients.