Preoperative Imaging Localization Research Articles

Preoperative identification of small parathyroid adenomas-better done by fluorocholine positron emission tomography/computed tomography.

Preoperative localization imaging studies are crucial for safe and successful parathyroidectomy in patients with primary hyperparathyroidism (pHPT), especially in focused approaches. A common imaging sequence is ultrasound followed by scintigraphy. These techniques, but not 18F-fluorocholine positron emission tomography/computed tomography (PET/CT), show lower detection rates in multiglandular disease (MGD), which is associated with smaller adenomas. In this study, we evaluate the accuracy of these modalities in small parathyroid adenomas (PAs) and discuss the potential sequence of preoperative localization diagnostics. Patients undergoing parathyroidectomy for pHPT were retrospectively categorized into small adenoma (specimen diameter <10 mm) and large adenoma. The groups were compared for accuracy of preoperative imaging studies, short-term and long-term outcomes. Among 147 patients retrospectively analyzed in this study, 38 small PAs were found. Preoperative correct quadrant prediction for small adenomas was significantly lower for ultrasound (P=0.03) and single-photon emission computed tomography/CT (SPECT/CT) (P<0.01) but not for choline PET/CT. While PET/CT was performed significantly more often in small PAs (P<0.01), it showed highly significant superiority over the other imaging modalities in accurate preoperative localization in both small (P<0.0001) and large PAs (P<0.01). There was no difference in calcium and parathyroid hormone (PTH) levels at latest follow-up with slightly more recurrences in small adenomas (P=0.08). Choline PET/CT showed a better diagnostic yield especially for small and multiple adenomas and was better in prediction of the correct localization. It could therefore serve as a second-line imaging modality.

SAT193 Double Trouble: A Case of Ipsilateral Double Parathyroid Adenoma

Abstract Disclosure: J.P. Suelto: None. G.D. Wassmer: None. Background: Eighty percent of the cases of Primary Hyperparathyroidism is caused by a single adenoma and only about 15% are multiglandular adenoma. Parathyroid imaging like Sestamibi is less sensitive in detecting multiglandular disease. Clinical Case: A 63 year-old female presented with intermittent left lower back pain for 7 years. There was no joint pain, weakness, urinary symptoms, constipation and abdominal pain. In 2019, due to persistence of left back pain, abdominal ultrasound done showed a right non-obstructing nephrolithiasis. Ionized and total calcium were elevated at 1.53 meq/L (NV 1.12-1.32 meq/L) and 11.35 ng/dl (NV 8.42-10.23 ng/dl) respectively with normal creatinine, phosphorus and albumin. PTH was elevated at 116.6 pg/ml (NV 10-65 pg/ml). Primary Hyperparathyroidism probably secondary to parathyroid adenoma was considered. Thyroid ultrasound showed right thyroid cyst but no enlarged parathyroid gland. Parathyroid imaging using Dual Isotope Subtraction Method neither showed evidence of adenoma. Patient was advised parathyroidectomy but did not consent hence started on Cinacalcet. In 2021, ionized calcium was still elevated to 1.58 meq/L with elevated PTH 151 pg/ml and low Vitamin D level 22.76 ng/ml (&amp;gt;30 ng/mL). Patient was given Vitamin D3 2000 IU daily and Cinacalcet was up-titrated to 60mg daily. Sestamibi/SPECT CT showed faint focus of radioactivity in the right thyroidal bed area suspicious for parathyroid adenoma or hyperplasia. She then agreed to have parathyroidectomy. There was no decrease in PTH after removal of the right inferior parathyroid gland (measuring 1.8x0.6x0.6cm, weighs 500mg), hence re-exploration was done. It was only after the removal of the right superior parathyroid gland (measuring 2.8x0.9x0.7cm, weighs 1 gram) when the 5 and 10 minute post excision PTH decreased to 123.91 and 76.01 pg/ml respectively from preincision PTH of 407.19 pg/ml. Histopathology showed Parathyroid adenoma of right inferior and superior parathyroid glands. No further evidence of hypercalcemia was noted at 6-month follow-up. Conclusion: Double adenoma is reported in 2% to 12% of patients with primary hyperparathyroidism. This occurs predominantly as bilateral superior in 45% and on same side of the neck in 18%. Sestamibi scanning is poor in the presence of multiglandular disease. It was observed that the presence of oxyphil cells may cause longer sestamibi retention in parathyroid tissues. Given the same amount of oxyphil cells in ipsilateral adenomas, the tracer may be distributed hence faintly seen on imaging. Addition of SPECT/CT/4D CT may improve the anatomical localization. Another reason for false negative imaging in this patient can be due to use of Cinacalcet which may decrease scintigraphy uptake of parathyroid adenoma. The combination of preoperative imaging localization and intraoperative PTH monitoring permits successful surgical outcome. Presentation: Saturday, June 17, 2023

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.

Long-term outcome of surgical techniques for sporadic primary hyperparathyroidism in a tertiary referral center in Belgium.

Surgery remains the only permanent treatment option for primary hyperparathyroidism (pHPT). To date, the number of long-term outcome studies of parathyroidectomy is limited. This study aims to compare different surgical approaches and evaluate the importance of preoperative localization imaging in the treatment of pHPT. All 200 consecutive patients with a parathyroidectomy for sporadic pHPT without planned concomitant surgery between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were enrolled. All patients underwent at least two preoperative localization imaging studies (neck ultrasound, CT, SPECT, and/or Sestamibi scintigraphy) of the parathyroid glands. The main outcomes were the (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve palsy, return to theater for bleeding, and wound morbidity). Most patients were referred with concordant positive imaging (82%, n = 164). Only nine patients (4.5%) had double negative imaging, not revealing a possible adenoma. The remaining 27 (13.5%) were referred with discordant imaging. Parathyroidectomy was performed via traditional cervicotomy (30%), mini-open approach (39.5%), or endoscopic approach (30.5%). Morbidity was low with no persistent hypocalcemia, one return to theater for bleeding, and no 30-day mortality. In the concordant imaging population, 13 patients (8%) had multiglandular disease. Overall, 97.5% was considered cured. Long-term recurrence was 12% with a minimal follow-up of 5years. This consecutive, single-surgeon, single-center cohort with extensive data collection and long-term follow-up confirms the safety and excellent cured proportions of minimally invasive parathyroidectomy. Disease recurrence becomes more important long after surgery.

Less Than Subtotal Parathyroidectomy for Multiple Endocrine Neoplasia Type 1 Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis.

Multiple endocrine neoplasia type 1 (MEN1)-associated primary hyperparathyroidism (pHPT) is classically associated with an asymmetric and asynchronous parathyroid involvement. Subtotal parathyroidectomy (STP), which is currently the recommended surgical treatment, carries a high risk of permanent hypoparathyroidism. The results of less than subtotal parathyroidectomy (LSTP) are conflicting, and its place in this setting is still a matter of debate. The aim of this study was to identify the place of LSTP in the surgical management of patients with MEN-associated pHPT. A systematic literature review was conducted in accordance with PRISMA and MOOSE guidelines, for studies comparing STP and LSTP for MEN1-associated pHPT. The results of the two techniques, regarding permanent hypoparathyroidism, persistent hyperparathyroidism and recurrent hyperparathyroidism were computed using pairwise random-effect meta-analysis. Twenty-five studies comparing STP and LSTP qualified for inclusion in the quantitative synthesis. In total, 947 patients with MEN1-associated pHPT were allocated to STP (n = 569) or LSTP (n = 378). LSTP reduces the risk of permanent hypoparathyroidism [odds ratio (OR) 0.29, confidence interval (CI) 95% 0.17-0.49)], but exposes to higher rates of persistent hyperparathyroidism [OR 4.60, 95% CI 2.66-7.97]. Rates of recurrent hyperparathyroidism were not significantly different between the two groups [OR 1.26, CI 95% 0.83-1.91]. LSTP should not be abandoned and should be considered as a suitable surgical option for selected patients with MEN1-associated pHPT. The increased risk of persistent hyperparathyroidism could improve with the emergence of more efficient preoperative localization imaging techniques and a more adequate patients selection.

Correlation between Surgical Outcomes of Primary Hyperparathyroidism with Neck Ultrasound and Parathyroid Scan-Tc99m/MIBI Localization Studies in Dubai Hospital

Objective: The aim of this study is to assess the correlation between the findings in preoperative localization studies and biochemical parameters with the surgical outcome in patients with primary hyperparathyroidism. Design and Methods: In patients with hyperparathyroidism, preoperative localization imaging studies are considered important for their role in surgical cure, operative length, and extent of surgical incision. Sometimes discordant imaging studies lead to further extensive diagnostic work-up to avoid operative risks and may result in delay to surgical referral. In this single-center retrospective study at a tertiary referral center in Dubai, we evaluated the concordance of presurgical imaging modalities in primary hyperparathyroidism with the surgical outcome after parathyroidectomy. Results: This study included n = 59 patients. 74.6% were female, and the mean age was 52.59 years (SD = 13.6). Preoperative parathyroid sestamibi scans were done on n = 50 patients with 68% having a positive result. A radiology department neck ultrasound was done on n = 42 patients, 52% of whom had a positive finding for a parathyroid adenoma, while n = 17 patients required an endocrinology department neck ultrasound scan with 71% having a positive finding. Complete concordance of findings with the postoperative pathology result was found in 78% of patients who had a preoperative parathyroid sestamibi, 78% of patients who had a preoperative radiology department neck ultrasound, and 86% of patients with a preoperative endocrinology department ultrasound. There was no correlation between the preoperative laboratory values of calcium and PTH with the scan findings based on our data. Conclusion: Our results showed a high degree of complete concordance between the usual imaging modalities and surgical findings.

Transoral endoscopic parathyroidectomy vestibular approach (TOEPVA) for primary hyperparathyroidism: Turkey's experience.

Parathyroid surgery has witnessed a significant evolution with the introduction of more efficacious preoperative localization imaging techniques and the use of rapid intraoperative parathormone assays. Parathyroid surgery can now be performed with the minimum of invasion. Through the adaptation of the transoral endoscopic thyroidectomy vestibular approach (TOETVA), the technique has now been adopted for parathyroid surgery, known as the transoral endoscopic parathyroidectomy vestibular approach (TOEPVA). We present here the initial experiences of 11 centers carrying out TOEPVA surgery in Turkey. Participating in the study were 11 centers, all of which were tertiary care institutions carrying out endocrine surgery. A retrospective review was made of 35 primary hyperparathyroidism patients who underwent the TOEPVA procedure between July 2017 and January 2020. Of the total 35 patients, 32 patients underwent the TOEPVA procedure successfully. All patients but one were female, and the mean age was 47.2 (20-73) years. According to localization studies, 18 of the lesions were lower left, 12 were lower right, 3 were upper right and 2 were upper left. The mean operative time was 116 (30-225) min, and three cases were converted to an open procedure. Simultaneous thyroidectomy was performed in seven cases. The average PTH level dropped to normal within 20min. after the resection in all cases. The complication rate was 19% (ecchymosis, subcutaneous emphysema, nasal bleeding, surgical site infection and seroma). There were neither recurrent nerve palsies, nor mental nerve root or branch injuries. The average hospital stay was 1day. No persistence was documented on follow up. TOEPVA is a "hidden scar" parathyroidectomy procedure that can be safely performed on parathyroid adenomas, in cases that have scar-related concerns. Having its own procedure-related complications, the procedure provides satisfactory objective results, particularly in centers experienced in endoscopic and endocrine surgery.

Identification of Occult Adenomas in Primary Hyperparathyroidism With 18F-Fluorocholine PET/CT

IntroductionSingle parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. MethodsA prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical, and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. ResultsHyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia, and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2 groups. ConclusionIn our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery.

Clinical Characterization of Post-parathyroidectomy Patients with Primary Hyperparathyroidism and the Concordance of Preoperative Localization Imaging with Histopathology at a Tertiary Hospital in Manila, Philippines

BackgroundPhilippine studies on primary hyperparathyroidism (PHPT) and preoperative localization are scarce, making improvements on detection and recognition particularly difficult.ObjectiveDescribe the clinical profile of post-parathyroidectomy PHPT patients at The Medical City (TMC) and assess localization rates and concordance of neck ultrasound (UTZ) and 99mTc-sestamibi scan (MIBI) with surgical histopathologic findings.MethodologyRetrospective chart review of PHPT Filipino patients who underwent parathyroidectomy at The Medical City from January 2004 to August 2018. Clinical profile and presentations were described and compared with international data. Imaging results were compared with surgical histopathology findings and the level of agreement was determined.ResultsThirty-five patients were analyzed with female predominance (63%) and an average age of 53 years. Our population had more overt manifestations including skeletal abnormalities (51%), renal calculi (49%) and musculoskeletal symptoms (43%) prior to surgery compared to western countries, where symptoms were noted in less than 20%. MIBI had higher rates of detection than UTZ (80% versus 58%) but had similar localization rates (96.4% versus 94%). When performed together, given a positive result from either test, a much higher yield (93.8%) was observed. The level of agreement between MIBI and surgery was 72.5% (κ=0.54) while UTZ and surgery was 54.1% (κ=0.38).ConclusionOur Filipino subjects had predominantly overt symptomatic hyperparathyroidism upon diagnosis prior to surgery as opposed to more asymptomatic surgical patients in western countries. Combining UTZ and MIBI is a more successful preoperative localization approach in our setting than performing either imaging alone, especially in patients with nodular goiter.

Identificación de adenomas ocultos en hiperparatiroidismo primario con PET-TC 18F-fluorocolina

IntroductionSingle parathyroid adenomas are the most common cause of primary hyperparathyroidism (PHP) in our population. Parathyroidectomy is still the only potentially curative treatment and requires preoperative localization imaging studies to perform selective surgery. In patients with negative results on conventional tests, PET/CT has demonstrated higher sensitivity rates. MethodsA prospective cohort study was designed, including 34 patients diagnosed with PHP between 2017 and 2019, candidates for surgery with negative preoperative localization tests with scintigraphy and MIBI SPECT/CT. All patients underwent PET/CT with 18F-Fluorocholine. The clinical, biochemical and postoperative outcome results were compared with a control group of 30 patients with positive standard tests. ResultsHyperfunctional parathyroid tissue was detected in 85% of the patients that had undergone choline PET/CT. The selective resection of the adenoma identified in these patients achieved curative criteria in 87% of the cases without undergoing bilateral cervical surgical exploration. The preoperative levels of PTH, calcemia and gland weight were significantly lower in this group compared to the control group. No differences were identified in cure criteria or approach between the 2groups. ConclusionIn our study, choline PET/CT showed higher detection rates compared to the gold standard. The increase provides the opportunity to perform unilateral selected adenoma resection, especially in patients with smaller adenomas associated with lower calcemia and PTH levels and patients with previous cervical surgery.

Preoperative Imaging Localization and Intraoperative Indocyanine Green-Enhanced Fluorescence Guidance for Focused Transoral Endoscopic Parathyroidectomy Vestibular Approach

Abstract Background: Focused parathyroidectomy evolves the preferable surgical policy for primary hyperparathyroidism (PHPT).1–3 Transoral endoscopic vestibular approach furnishes a scarless choice...

Long-Term Outcomes of Parathyroidectomy in Hyperparathyroidism-Jaw Tumor Syndrome: Analysis of Five Families with CDC73 Mutations.

Hyperparathyroidism-jaw tumor syndrome (HPT-JT) is a rare disease caused by CDC73 germline mutations, with familial primary hyperparathyroidism (pHPT), ossifying jaw tumors, genito-urinary neoplasms. The present study was aimed at determining the long-term postoperative outcome of parathyroidectomy in HPT-JT. A retrospective analysis of a single-center series of 20 patients from five unrelated HPT-JT families undergoing parathyroid surgery was performed. Pathology confirmed a single-gland involvement in 95% of cases at onset. Parathyroid carcinoma occurred in three patients undergoing en-bloc parathyroidectomy and thyroid lobectomy: parathyroid benign lesions in 17 patients undergoing subtotal parathyroidectomy for evident multiglandular involvement (n = 1) or selective parathyroidectomy for single-gland involvement (n = 16), during bilateral (n = 13) or targeted unilateral neck exploration (n = 7). At a median overall follow-up of 16years (range 2.5-42), patients with parathyroid carcinoma had a persistent/recurrent disease in 66.6%; patients with benign lesions had recurrent pHPT in 23.5% after a prolonged disease-free period; recurrent benign pHPT occurred slightly more often in cases of discordant preoperative localization (60% vs 9%; p = 0.06). pHPT in HPT-JT is generally characterized by a benign and single-gland involvement, with a relatively increased risk of malignancy (15%). Parathyroid carcinoma needs extensive surgery because of high risk of permanent/recurrent disease (66.6%). In benign involvement, targeted unilateral exploration with selective parathyroidectomy may be effective in cases of concordant single-gland localization at preoperative localization imaging techniques. Bilateral neck exploration with subtotal parathyroidectomy might be preferred in cases of negative or discordant preoperative localization, because of the increased risk of multiglandular involvement and long-term recurrences (23.5%).

Neck Exploration Versus Imaging Localization of Parathyroid in Secondary Hyperparathyroidism

The aim of this study is to evaluate the effectiveness of preoperative imaging localization of hyper functioning parathyroid glands and comparing it with operative neck exploration in secondary hyperparathyroidism. This study was performed in Minia University Hospital between January 2017 and May 2018. Twenty patients with secondary hyperparathyroidism were included in this study. Ultrasonography was done for all patients, and then we classify our patients into two groups: in group 1 patients, Technetium-99 m sestamibi scan and computed tomography were done preoperatively while in group 2, patients underwent operation with neck exploration directly without other preoperative localization procedures. Mean age in our cases was 45.2 ± 9.46, while the most affected age group was (40–49) years by (35%), then (30–39) years by (30%), then (50–59) years by (25%), and then (≥ 60) years by (10%), while females were more affected than male by (75%) of cases. CT sensitivity in detection of parathyroid disease was 70%, and sestamibi detects 80% while neck exploration detection sensitivity was 100%. Neck exploration is the only reliable localization procedure in the cases of secondary hyperparathyroidism.

Discussion of “Dual energy computed tomography should be the first line preoperative localization imaging test for primary hyperparathyroidism patients”

•Dual energy CT – first line preoperative parathyroid localization in hyperparathyroidism patients. •Dual energy CT and neck ultrasound – standard for surgical planning in hyperparathyroidism patients. •Dual energy CT – sensitive salvage localization test in hyperparathyroidism patients.

Dual energy computed tomography should be a first line preoperative localization imaging test for primary hyperparathyroidism patients

BackgroundThe objective of this study was to evaluate the performance of dual-energy computed tomography (DECT) for preoperative parathyroid tumor (PT) localization in primary hyperparathyroid (PHP) patients. MethodsA retrospective review was carried out of the medical records of all PHP patients who underwent ultrasound (US), Tc-99m sestamibi noncontrast single photon emission computed tomography (CT-MIBI), DECT and parathyroidectomy at a single center. ResultsThe sensitivities and accuracies for preoperative PT localization in the 97 patient study population were: US 40% and 93%, CT-MIBI 64.0% and 97%, and DECT 84% and 96%, respectively. In the one third of the study population that did not localize preoperatively with CT-MIBI and US, DECT correctly localized a PT in 21 cases (66%). DE-CT and US correctly localized a PT in 86% of cases, and only 5 (8%) of the cases that were accurately localized by a combination of CT-MIBI and US were not identified by DE-CT. ConclusionsDECT should be utilized as a first line preoperative PT localization study in PHP patients, and is also a sensitive salvage localization test.

Analysis of diagnosis and treatment of 89 patients with primary hyperparathyroidism

Objective To summarize the clinical manifestations, diagnosis and treatment of the primary hyperparathyroidism(PHPT). Methods The clinical data of 89 patients with PHPT admitted during 1991 to 2013 were retrospectively analyzed. Results The mean age of the 89 patients was(44.7±15.8)years(13-86 years), male to female ratio was 1∶2.1. 79% of the 89 patients were symptomatic. 62% of the 89 patients had been misdiagnosed. 52% had been misdiagnosed as kidney stones or bone diseases(fracture, tumor, and metabolic bone disease). The remaining subjects had been misdiagnosed as peptic ulcer, rheumatoid arthritis or pancreatitis. The median serum parathyroid hormone(PTH)level in 88 patients was 697.3 pg/ml(26.4-5 000.0 pg/ml, n=88), the mean serum calcium level was(3.03±0.56)mmol/L(n=88). The 24 h urine calcium was(10.02±4.73)mmol/24 h(n=36). The sensitivity of localization of the parathyroid lesions with technetium-99mmethoxy-isobutyl-isonitrile(99mTc-MIBI)was 96%, being higher than ultrasound(71%), CT(71%), and MRI(72%)(P<0.05, respectively). 79 cases had been treated surgically. The median serum PTH level was 748.2 pg/ml(46.1-5 000.0 pg/ml)before surgery, 79.9 pg/ml(11.35-838.0 pg/ml)15 minutes after surgical removal of the lesions(P<0.05 vs preoperative)and 22.9 pg/ml(2.3-1 203.0 pg/ml)on the first postoperative day(P<0.05 vs preoperative). Serum calcium was(3.03±0.56)mmol/L before surgery, (2.25±0.37)mmol/L on the first postoperative day(P<0.05 vs preoperative)and(2.08±0.36)mmol/L on the second postoperative day(P<0.05 vs preoperative). After the operation, 42 cases(53%)had perioral and limb numbness, 2 cases(3%)had hoarseness of voice and bucking while drinking, 1 case(1%) had tetany. All these symptoms were improved after calcium supplementation. 67 patients(85%)had been diagnosed as parathyroid adenoma pathologically, 7 patients(9%)as hyperplasia, 3 patients(4%)as cysts, and 2 patients(3%)as carcinoma. Among 67 cases of adenomas, 62 cases had a single parathyroid adenoma, 1 case with multiple parathyroid adenomas, and 4 cases with ectopic parathyroid adenomas. The ectopic lesions were located below the thyroid, in the rib cage, left mediastinum, and above the sternum. Conclusions The majority of domestic PHPT was symptomatic. Delayed diagnosis of PHPT is still very frequent. The clinical presentations of PHPT are variable, determination of serum calcium and PTH level simultaneously is the keypoint for early identification and diagnosis of PHPT. The clinician should be familiar with the various clinical manifestations of PHPT and thus enhance understanding of pathogenesis of the disease. 99mTc-MIBI scintigraphy remained the first choice of preoperative imaging localization of the parathyroid lesions, followed by ultrasound, CT, and MRI. Surgical removal of the lesions is effective and safe. (Chin J Endocrinol Metab, 2015, 31: 300-305) Key words: Primary hyperparathyroidism; Diagnosis; Treatment

The role of preoperative ultrasonography, computed tomography, and sestamibi scintigraphy localization in secondary hyperparathyroidism.

PurposeThe role of preoperative localization studies is controversial in surgery of secondary hyperparathyroidism (sHPT). The aim of study was to evaluate the accuracy of preoperative ultrasonography (USG), CT, and 99mTc sestamibi scintigraphy (MIBI) in localizing enlarged parathyroid glands and to find the impact of correct localization in successful parathyroidectomy.MethodsWe compared operative findings with the preoperative localization of ultrasonography, computerized tomography and sestamibi scintigraphy in 109 patients with sHPT and identified well-visualized locations of abnormal parathyroid glands by evaluating the sensitivity of each imaging study with regard to typical locations of glands. We investigated the effect of preoperative imaging localization on the surgical outcomes by measuring the intraoperative parathyroid hormone (ioPTH) decrement for positive or negative imaging localization.ResultsUSG (91.5%) had the highest sensitivity and MIBI (56.1%) had the lowest among 3 modalities. The sensitivity of combined USG and CT (95.0%) was the highest among combined 2 modalities. The combination of all 3 modalities (95.4%) had the highest sensitivity among the combinations of modalities. The reduction of ioPTH in patients with positive imaging localization (86.6%) was greater than negative imaging localization (84.2%), with no significant difference (P = 0.586). The recurrence or persistence of sHPT was not correlated with preoperative imaging localization (19 patients in negative, 16 in positive; P = 0.14).ConclusionPreoperative imaging localization contributed to surgical success but not to surgical outcomes. The combination of ioPTH measurement with imaging localization might be valuable for better surgical results in sHPT.

11C-methionine PET/CT imaging of 99mTc-MIBI-SPECT/CT-negative patients with primary hyperparathyroidism and previous neck surgery.

(99m)Tc-Methoxy-isobutyl-isonitrile (MIBI) scintigraphy is a standard preoperative localization imaging modality in patients with primary hyperparathyroidism (pHPT). Its accuracy in localizing a hyperactive parathyroid gland after previous cervical surgery is limited. Recently, (11)C-methionine has been introduced as a promising radiotracer for pHPT imaging. Yet, few data exist for this technique in patients with persisting or recurrent pHPT before reoperation. We aimed to investigate the ability of (11)C-methionine positron emission tomography (PET)/computed tomography (CT) to localize a parathyroid disorder after cervical surgery and negative postsurgical (99m)Tc-MIBI single-photon emission CT (SPECT)/CT. Fifteen patients (6 males, 9 females; age range, 36-85 years) with pHPT and negative (99m)Tc-MIBI SPECT/CT who had undergone earlier neck surgery because of pHPT and/or thyroid disorder were recruited. Twelve of the 15 patients had thyroidectomy for goiter or differentiated thyroid carcinoma. Ten patients had previous parathyroid surgery for pHPT, and 2 patients had a history of parathyroid carcinoma. Thirteen of 15 patients showed elevated levels of intact PTH at the time of PET/CT imaging, whereas all patients had elevated serum calcium values. Pathological results of contrast-enhanced (11)C-methionine PET/CT and surgical results were evaluated. In 6 of 15 patients (11)C-methionine PET/CT showed a hypermetabolic focus in the upper mediastinum in 2 patients, in the thoracic outlet in 1 patient, and in the cervical region in 3 patients. In 9 of the 15 patients, no hyperactive parathyroid gland could be visualized. Reoperation was performed in 5 of 6 patients without surgical complications. One patient refused surgery. In 2 of the 5 patients, a transsternal procedure was performed. Correlating with the (11)C-methionine PET/CT results, a single parathyroid adenoma was found in 4 patients and parathyroid carcinoma metastasis in 1 patient. (11)C-Methionine PET/CT is a useful complementary imaging technique to localize parathyroid adenoma or carcinoma in (99m)Tc-MIBI SPECT/CT-negative patients.

Surgical Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common endocrine disorder in which the inappropriate elevation in serum parathyroid hormone level results in hypercalcemia. Most cases are caused by a single adenomatous parathyroid gland and less than 15% are caused by multiglandular disease. The incidence of PHPT appears to be increasing. More patients are being identified earlier and often before symptoms develop. Parathyroidectomy is the only definitive management; with it, the patient can achieve biochemical homeostasis and symptom relief, and sequelae are prevented. Even for asymptomatic patients with PHPT, there is a growing trend to recommend early surgical intervention. Controversy continues regarding the role of and reliance on various technologies, such as preoperative localization imaging, intraoperative parathyroid hormone level measurements, and minimally invasive surgery. Although both traditional bilateral 4-gland exploration and targeted approaches are accepted surgical techniques, there is a growing trend in unilateral targeted operations often using these technologies. Regardless of surgical approach, the expected success rate is greater than 95%. This article provides an overview of the contemporary surgical management of PHPT.

A Meta-analysis of Preoperative Localization Techniques for Patients with Primary Hyperparathyroidism

Reported accuracy of preoperative localization imaging for primary hyperparathyroidism (pHPT) varies. The purpose of this study is to determine the accuracy of ultrasound, sestamibi-single photon emission computed tomography (SPECT), and four-dimensional computed tomography (4D-CT) as preoperative localization strategies. A meta-analysis was performed of studies investigating the accuracy of ultrasound, sestamibi-SPECT, and 4D-CT for preoperative localization in pHPT. Electronic databases were systematically searched, and two independent reviewers reviewed results using specific criteria. Study quality was assessed using a validated measure for diagnostic imaging studies. Study heterogeneity and pooled results were calculated. 43 studies met criteria for inclusion, and data were available for extraction in 19 ultrasound, 9 sestamibi-SPECT, and 4 4D-CT studies. Ultrasound had pooled sensitivity and positive predictive value (PPV) of 76.1% (95% CI 70.4-81.4%) and 93.2% (90.7-95.3%), respectively. Sestamibi-SPECT had pooled sensitivity and PPV of 78.9% (64-90.6%) and 90.7% (83.5-96.0%), respectively. Only two 4D-CT studies investigated patients undergoing initial parathyroidectomy. Results suggested sensitivity and PPV of 89.4% and 93.5%, respectively. Ultrasound and sestamibi-SPECT are similar in ability to preoperatively localize abnormal parathyroid glands in pHPT. Accuracy may be improved with 4D-CT; however, further investigation is required. Choice of preoperative imaging strategy depends on numerous patient, institutional, and economic factors of which the surgeon must be aware.