Preoperative Sestamibi Scan Research Articles

SAT185 Parathyroid Adenoma Localized By Cytogenetic Testing

Abstract Disclosure: S. Khadija: None. A. Rao: None. Introduction: Primary hyperparathyroidism can be caused by a parathyroid adenoma, hyperplasia or rarely by parathyroid carcinoma. Most patients have few or no symptoms. Diagnosis of primary hyperparathyroidism can be challenging in the setting of secondary/tertiary hyperparathyroidism. Correct diagnosis can be reached by clinical evaluation, biochemical and radiological tests. We describe a case that was diagnosed by cytogenetic testing of the biopsy specimen. Case Report: We report a case of a 64-year-old man. He was referred to the endocrine clinic for an incidental thyroid nodule on CT scan. He had hypothyroidism after I-131 treatment for Graves’ disease 15 years back. He had a long history of hypertension with renal failure. He had a renal transplant in 2017 and had hypercalcemia intermittently with elevated PTH since 2012. Ultrasound of thyroid reported a 1.6 x 1.7 x 2.0 cm nodule in the left thyroid lobe. He denied any compressive symptoms and was euthyroid on levothyroxine. An ultrasound guided FNA of the left thyroid nodule was reported as Bethesda III FLUS and sent to Veracyte for Affirma, which indicated a parathyroid adenoma. A sestamibi scan indicated a left lower parathyroid adenoma. He had surgery and intraoperative parathyroid hormone (PTH) dropped from 122pg/ml to 35.8pg/ml(29.1-79.7 pg/ml). Pathology confirmed parathyroid adenoma 3.8 grams in weight. Postoperatively calcium normalized with drop in PTH to 36.1pg/ml. After 2 weeks his calcium remained normal. Discussion: Parathyroid adenoma is a relatively rare condition and causes a majority of cases of primary hyperparathyroidism. A few cases are due to hyperplasia, more common in secondary hyperparathyroidism due to renal disease. Parathyroid adenoma is difficult to diagnose in patients with underlying hyperplasia due to chronic renal disease. Sonography and 99mTc preoperative sestamibi (MIBI) scan are the primary imaging modalities utilized for the visualization of diseased glands. MIBI scan is approximately 90% sensitive for localizing a parathyroid adenoma. Ultrasonography is the first-line imaging modality and parathyroid adenomas are nearly always homogeneously hypoechoic to the overlying thyroid gland and are commonly detected using gray-scale imaging alone when they are larger than 1 cm in diameter. Nodular goiter or enlarged lymph nodes are causes of false-positive results. Biopsy is very rarely used to diagnose a parathyroid adenoma with cytogenetic testing. Conclusion: Parathyroidectomy is the main stay in management of primary hyperparathyroidism due to parathyroid adenoma. Cervical sonography and sestamibi imaging are used for prediction of adenoma location. Both are limited by increased thyroid volume. Biopsy with cytogenetic testing can help in diagnosis in difficult patients. Presentation: Saturday, June 17, 2023

Diagnostic value of Sestamibi Scan in the preoperative localization of parathyroid lesions in patients with primary hyperparathyroidism.

Abstract Introduction: Preoperative localization modalities for patients with primary hyperparathyroidism today play an important role in clinical decision making, surgical procedure, and the prognosis of patients. One of the most common preoperative imaging modalities is the sestamibi scan labeled with Technetium-99m, which is capable of determining the location of parathyroid lesions in primary hyperparathyroidism patients with high sensitivity. Methods: In this cross-sectional study, 25 patients with primary hyperparathyroidism, referred to endocrine clinic of Tabriz University of Medical Siences during 2016-2018 were enrolled. All patients underwent a preoperative Sestamibi scan. Comparing the results of the scan with the surgical findings as a standard gold method for diagnosis, the diagnostic value of the scan was evaluated for the localization of parathyroid lesions. Results: According to the items observed in surgery and pathologic findings, the sensitivity of Sestamibi scan for the localization of parathyroid lesions was 84.6%. Specificity and positive predictive value and negative predictive value were 95.6%, 89.6%, and 94.8%, respectively. A significant relationship was observed between the type of lesion and the sensitivity of Sestamibi scan (p=0.002). Conclusion: Sestamibi scan has high sensitivity and diagnostic and therapeutic value for patients with primary hyperparathyroidism. However, the existence of other pre- and intraoperative localization modalities, at the request of surgeons, is useful and warranted to reduce the rate of recurrent surgery as well as to minimize false negatives.

Are Tc-99m-Sestamibi Scans in Patients With Secondary Hyperparathyroidism and Renal Failure Needed?

BackgroundParathyroidectomy for patients with secondary hyperparathyroidism (sHPT) generally requires a four-gland exploration. Some groups have strongly recommended routine preoperative Tc-99m-sestamibi scans; others practice scanning for only selected patients. To determine the utility of sestamibi scans in this patient population, we reviewed our experience. MethodsWe performed a retrospective review of patients who underwent parathyroidectomy for sHPT by one surgeon between 2000 and 2018. Data reviewed included patient demographics, laboratory results, pathology and radiology reports, and clinical and operative notes. ResultsOf the 72 patients in the cohort, mean age was 47.2 ± 15.6, and 50% were female. The preoperative mean calcium and parathyroid hormone levels were 9.6 ± 1.1 mg/dL and 1192.1 ± 914.1 pg/mL, respectively. Sestamibi scans were performed in 21 patients (29%). Of these, 17 were reoperative cases. Of all sHPT patients, 27.8% had ectopic glands. In the sestamibi cohort, only four patients had ectopic glands identified on the scan. Among the 51 patients without preoperative imaging, 16 had ectopic glands (26.2% of nonimaged patients). All these 16 ectopic glands were found by the surgeon at the time of operation without the need for preoperative imaging. All patients in the series were cured with a minimum follow-up of 6 mo. ConclusionsEctopic parathyroid glands are commonly seen in patients undergoing parathyroidectomy for sHPT. The majority of ectopic glands were successfully identified during the operation without preoperative sestamibi scan. Therefore, routine preoperative Tc-99m-sestamibi scans are not needed for successful parathyroidectomy for sHPT.

Ectopic Parathyroid Adenoma Presented with Recurrent Kidney Stone and Hypercalcemic Crisis

Diagnosis and treatment of ectopic parathyroid adenoma are challenging. Herein, we report the cases of two male patients who had ectopic parathyroid adenomas located in the thymus. Both the patients had recurrent kidney stones and life-threatening hypercalcemia. Their parathyroid adenomas were localized through preoperative Tc-99m sestamibi scanning and successfully resected through unilateral neck exploration. Primary hyperparathyroidism can be overlooked inpatients with recurrent kidney stones or refractory cardiovascular diseases. Preoperative imaging studies, such as Tc-99m sestamibi scanning, can localize ectopic parathyroid adenoma and facilitate a successful and minimally invasive parathyroidectomy.

Are preoperative sestamibi scans useful for identifying ectopic parathyroid glands in patients with expected multigland parathyroid disease?

BackgroundThe role of preoperative localization studies in patients with hyperparathyroidism and expected multigland disease remains poorly defined. Our study investigates the usefulness of obtaining preoperative sestamibi scans and ultrasonography of the neck in identifying ectopic glands in this group of patients. MethodsUnder Institutional Review Board approval, we performed a retrospective review of patients who underwent operation for secondary hyperparathyroidism, tertiary hyperparathyroidism, lithium-induced hyperparathyroidism, and multiple endocrine neoplasia syndrome at a tertiary institution between 2004 and 2015. We reviewed patient demographics, laboratory, radiology, pathology, and operative reports. ResultsOf 2,975 parathyroidectomies performed during this period, 154 operations were performed in 149 patients who met the criteria. Of the 149 patients, 82 (55.0%) had secondary, 31 (20.8%) had tertiary, 23 (15.4%) had lithium-induced HPT, and 13 (10.1%) had multiple endocrine neoplasia syndrome; 86 ectopic glands were identified in 64 patients (43.0%). Sensitivity for identification of ectopic glands was 29% for sestamibi scan and 7% for ultrasonography, while 89% of mediastinal glands were localized by sestamibi scans and thoracotomy, thoracoscopy, or sternotomy occurred in 4.7% of patients. ConclusionWe found a greater rate of preoperative localization of ectopic glands than reported previously. Because the sensitivity of sestamibi for identification of ectopic glands is 23.0%, the implication of missing mediastinal glands warrants preoperative imaging.

Indocyanine green fluorescence-guided parathyroidectomy for primary hyperparathyroidism

BackgroundOur aim was to evaluate the ease and utility of using indocyanine green fluorescence angiography for intraoperative localization of the parathyroid glands. MethodsIndocyanine green fluorescence angiography was performed during 60 parathyroidectomies for primary hyperparathyroidism during a 22-month period. Indocyanine green was administered intravenously to guide operative navigation using a commercially available fluorescence imaging system. Video files were graded by 3 independent surgeons for strength of enhancement using an adapted numeric scoring system. ResultsThere were 46 (77%) female patients and 14 (23%) male patients whose ages ranged from 17 to 87 (average 60) years old. Of the 60 patients, 43 (71.6%) showed strong enhancement, 13 (21.7%) demonstrated mild to moderate vascular enhancement, and 4 (6.7%) exhibited little or no vascular enhancement. Of the 54 patients who had a preoperative sestamibi scan, a parathyroid adenoma was identified in 36, while 18 failed to localize. Of the 18 patients who failed to localize, all 18 patients (100%) had an adenoma that fluoresced on indocyanine green imaging. The operations were performed safely with minimal blood loss and short operative times. ConclusionIndocyanine green angiography has the potential to assist surgeons in identifying parathyroid glands rapidly with minimal risk.

Use of intraoperative parathyroid hormone assay in primary hyperparathyroidism: A selective approach

AimThe routine use of intraoperative parathyroid hormone assay (IOPTH) in minimally‐invasive parathyroidectomy (MIP) for primary hyperparathyroidism has been questioned. In the present study, we selectively employed IOPTH only to cases that did not show concordant results in sestamibi scan, ultrasound and operative findings.Patients and MethodsA total of 100 patients received MIP with selective use of IOPTH for primary hyperparathyroidism from March 2006 to June 2015 (selective IOPTH group). These patients were compared with a historical cohort of 57 patients who received MIP with mandatory IOPTH between March 2002 and February 2006 (mandatory IOPTH group). For the selective IOPTH group, all cases had preoperative sestamibi scan and ultrasound performed. If there were concordant results in the sestamibi scan, ultrasound and operative findings, IOPTH would not be performed. The surgical cure rate and operative time of the two groups were compared.ResultsWe found no significant difference in the surgical cure rate between the selective IOPTH group and the mandatory IOPTH group (short‐term, 6‐month postoperative cure rate: 99 vs 100 per cent, respectively, P = 1.0; long‐term cure rate: 99.0 vs 98.2 per cent, P = 1.0). However, the operative time was significantly shorter in the selective IOPTH group when compared with the mandatory IOPTH group (64 vs 92 min, respectively, P < 0.05).Conclusion MIP can be performed with selective use of IOPTH, which can be limited to cases where there are discordant results between sestamibi scan, ultrasound and operative findings.

Transoral Excision of a Right Pyriform Sinus Parathyroid Adenoma

Abstract Introduction: The pyriform sinus is a rare but known site of ectopic parathyroid adenoma within the upper aerodigestive tract. This entity reflects failure of the inferior parathyroid gland to descend during embryologic development. Surgical excision through a transoral endoscopic approach was performed in a patient with a right pyriform sinus parathyroid adenoma.1 Materials and Methods: A 50-year-old woman with primary hyperparathyroidism underwent a parathyroid gland exploration. Her preoperative sestamibi scan and ultrasonography failed to localize a parathyroid adenoma. Three normal parathyroid glands were identified but the right inferior parathyroid gland was not encountered. She then underwent a 4D CT scan, which identified a right pyriform sinus parathyroid adenoma. She subsequently underwent an uncomplicated transoral endoscopic excision of the parathyroid adenoma with resolution of her primary hyperparathyroidism. Results: The patient's baseline parathyroid hormone (PTH) level was 157.2...

Tc99m Sestamibi Scan in Parathyroid Surgery: Positive Scan Obviates Routine Intra‐operative Parathormone Monitoring

Objectives: Parathyroid surgery for hyperparathyroidism has moved from traditional four gland exploration to a minimally invasive procedure with advent of better imaging tools, intraoperative parathyroid hormone (PTH0 monitoring, and endoscopic techniques. In our hospital parathyroid operation is accomplished with preoperative sestamibi and serum PTH monitoring at D1 post-op. Intra-operative PTH assay is done only in selected patients. Methods: Analyze the outcome of parathyroid surgery at our hospital and correlate pre-operative sestamibi localisation of adenoma with operative findings. Retrospective chart review of 40 patients who had parathyroid operations from 2009 to 2012. Results: The majority of referrals came through GP and were seen at Joint Endocrinology and ear, nose, and throat (ENT) clinic but there were occasional referrals from renal, urology, orthopedics and surgical admissions. Half presented with incidental hypercalcemia and other half had varied clinical presentations like calculi, renal failure, fractures, fatigue, dehydration, acute abdomen etc. Majority (30/40) were females. Age ranged from 22 to 88 with mean of 58. Average operating time was 50 minutes with incision length from 2.5 to 4 cms. Two patients needed 2nd exploration. Postoperative PTH and calcium levels returned to normal in 38/40 patients. 36 had sestamibi scan and localization was positive in 24/36 patients (66.6%) and correlated 100% with surgical findings. In patients with negative scan, 4 gland explorations were done. Inferior gland pathology was found in two thirds with left inferior in majority. Conclusions: In our view, a preoperative sestamibi scan is sufficient in majority of patients. 4 gland explorations with intraoperative PTH assay are useful in selective patients with negative scan.

Use of a Sestamibi-only Approach to Routine Minimally Invasive Parathyroidectomy

We performed this study to compare a sestamibi-only radio-guided approach (MIBI) versus using intraoperative parathyroid hormone monitoring (IOPTH) in the performance of minimally invasive parathyroidectomy (MIP) in patients with a clearly positive preoperative sestamibi scan from January 2000 to June 2010. Five of 81 patients in the MIBI group required additional surgery, three at the time of MIP when the intraoperative findings were in conflict with the preoperative sestamibi scan and two required a second operation as a result of an undiscovered second adenoma. In the IOPTH group, five patients had an unnecessary bilateral neck exploration as a result of an inadequate drop in PTH levels, whereas six had their disease cured because the PTH levels predicted additional pathology. One patient in the IOPTH group remains hypercalcemic and represents the only surgical failure in this study. The MIBI group had a shortened operating room time and less cost (P < 0.001). No deaths or complications, including recurrent laryngeal nerve injuries, occurred in this study. Although both strategies are effective in managing hyperparathyroidism, a MIBI-only approach is less expensive and has shorter operative times with an occasional need for reoperation, whereas the IOPTH group results in more extensive surgery that will occasionally be unnecessary.

The diagnostic value of parathyroid hormone washout after fine‐needle aspiration of suspicious cervical lesions in patients with hyperparathyroidism

We aimed to study the diagnostic value of parathyroid hormone (PTH) concentration in the needle washout of fine-needle aspiration (FNA) compared to cytology of suspicious lesions suggestive of culprit parathyroid glands in patients with recurrent or persistent primary hyperparathyroidism (PHPT). Retrospective review. Patients with recurrent or persistent PHPT, who were referred to one surgeon and underwent FNA of the culprit parathyroid lesion preoperatively, were included in this study. All patients underwent comprehensive neck ultrasound, and suspicious lesions underwent ultrasound-guided FNA by the same surgeon. The aspiration cytology was read by a single dedicated cytopathologist blinded to the PTH washout results. A positive cutoff value for PTH washout concentration was defined as superior to serum PTH level obtained at the same time. The final diagnosis after reoperative surgery was confirmed by the same cytopathologist. Twenty-four consecutive patients were included. The mean serum PTH and calcium were 111.5 ± 106.25 pg/mL (normal: 15-65 pg/mL) and 10.8 ± 0.5 mg/dL (normal: 8.6-10.2 pg/mL), respectively. Twenty-two patients (91.6%) had elevated PTH washout concentrations with a positive predictive value (PPV) of 100%. Cytopathology was successful in confirming parathyroid tissue only in seven patients (29%). An adenoma was identified in 19 patients (79.1%); however, five patients (20.8%) were found to have multiglandular disease. An elevated PTH washout concentration can help identify culprit parathyroid gland lesions with a high PPV in patients requiring reoperative parathyroid surgery. This diagnostic technique allows for targeted surgical approach in reoperative settings, especially in patients with negative preoperative sestamibi scans. 4.

Minimally Invasive/Focused Parathyroidectomy in Patients With Negative Sestamibi Scan Results

To examine the feasibility of minimally invasive/focused parathyroidectomy in patients with primary hyperparathyroidism and negative results on preoperative sestamibi scanning. Retrospective review. Hospital. A total of 452 patients with primary hyperparathyroidism underwent parathyroidectomy between January 2005 and December 2009. Preoperative sestamibi scans were reviewed, and their influence on the surgical outcome was examined. Records of the intraoperative and postoperative findings were also reviewed. Seventy-seven patients (17.0%) were found to have negative results on preoperative sestamibi scans, and these patients formed our cohort study group. In this group, neck ultrasonography performed as an adjunct was able to preoperatively localize an area that was suggestive of a single adenoma in 61 patients (79.2%), 53 of whom were confirmed to have a single adenoma intraoperatively (sensitivity, 80.3%; specificity, 27.3%; positive predictive value, 86.9%; and negative predictive value, 18.8%). In total, 66 of 77 patients (85.7%) were confirmed to have a single adenoma at the time of surgery. Negative results on sestamibi scans should not be used as exclusion criteria for minimally invasive/focused parathyroidectomy in patients with primary hyperparathyroidism. In our study, 66 patients with negative results on preoperative scans were found to have a single adenoma and were surgically cured by minimally invasive/focused parathyroidectomy.

Is pre-operative 99M-TC SESTAMIBI scanning preferable to no pre-operative scanning in patients with primary hyperparathyroidism?

Is pre-operative 99M-TC SESTAMIBI scanning preferable to no pre-operative scanning in patients with primary hyperparathyroidism?

Thoracoscopic Removal of Mediastinal Parathyroid Lesions: Selection of Surgical Approach and Pitfalls of Preoperative and Intraoperative Localization

Thoracoscopic surgery has replaced conventional sternotomy or thoracotomy for resection of mediastinal parathyroid lesions. We review our experience with this type of surgery with reference to selection of the appropriate approach and the pitfalls of lesion localization before and during surgery. During a 14-year period, we treated 14 patients with hyperparathyroidism, in whom a mediastinal lesion had been localized preoperatively by sestamibi scan. Primary hyperparathyroidism was present in 12 patients (single adenoma in 11, associated with MEN 1 in one) and secondary hyperparathyroidism in 2. Thoracoscopic procedures were performed by the three-port method. The thoracoscopic procedure was successful in eight patients who were shown preoperatively to have a deep-seated (5 anterior, 3 middle) mediastinal lesions. Intraoperative visual confirmation of parathyroid adenoma was difficult only in a 19-year-old patient with a tumor embedded in the thymus, necessitating partial thymectomy. One of the eight mediastinal lesions resected thoracoscopically was a sestamibi-positive thymoma. Secondary hyperparathyroidism recurred 4years after thoracoscopic mediastinal parathyroidectomy in one patient, necessitating additional thoracoscopic removal of this supernumerary lesion. However, seven patients with mediastinal parathyroid lesions localized at the aortic arch or upper region were treated successfully via a cervical approach. None of the patients suffered any surgical complications. Thoracoscopic surgery is safe and feasible for resection of deep mediastinal parathyroid lesions. Such lesions localized preoperatively at the aortic arch or upper region can be treated via a cervical approach. Preoperative sestamibi scan can sometimes give a false-positive result in cases of concurrent thymoma.

Bilateral IJV Sampling for Parathyroid Adenoma Localization

Objective: 1) Study the accuracy and utility of direct intraoperative internal jugular vein (IJV) sampling of parathyroid hormone (PTH) for localization of parathyroid adenoma. 2) Compare the accuracy of intraoperative IJV PTH sampling to that of preoperative Sestamibi scanning for lateralization. Method: A retrospective chart review of 51 consecutive neck explorations for primary hyperparathyroidism between 2007 and 2011. Direct bilateral IJV PTH sampling was performed prior to excision in all cases. Laterality based on IJV samples was compared with preoperative Sestamibi scans and operative findings. Results: There were no complications associated with sampling. 50 patients had single parathyroid adenomas, and 1 patient had ipsilateral double adenomas. All IJV sampling value difference was considered lateralizing. In 39 cases, IJV sampling successfully predicted laterality of adenoma, yielding a positive predictive value (PPV) of 76.5%. Sestamibi scans correctly lateralized in 37 cases (72.5%), 12 (23.5%) were nonlocalizing, and 2 (3.9%) were incorrect. PPV of Sestamibi scanning was 95%. IJV sampling successfully predicted the laterality of adenoma in 9 (75%) of the nonlocalizing Sestamibi scans and in 1 of the 2 incorrect scans. Conclusion: In patients with unilateral parathyroid adenomas, intraoperative bilateral IJV PTH sampling is a safe means of determining laterality of adenomas with a positive predictive value of 76.5%. This can be a valuable adjunct in cases where preoperative localization studies were unsuccessful or inaccurate in localizing the adenoma.

Minimally Invasive Parathyroidectomy

Minimally invasive parathyroidectomy (MIP) for primary hyperparathyroidism can be successfully performed using preoperative sestamibi scan and intraoperative radioguidance without the need of measurement of intraoperative parathyroid hormone (PTH) levels. The purpose of our study was to review the outcomes of MIPs performed in a community hospital without measuring PTH levels intraoperatively and to demonstrate that this is an effective therapeutic modality with comparable success rates. We performed a retrospective medical record review of patients undergoing MIPs from April 1, 1998, through May 31, 2005, in a 500-bed community hospital. A total of 188 parathyroidectomies for primary hyperparathyroidism were performed by a single surgeon during the study period, 111 of which were MIPs. In this series of 111 patients, we found 2 recurrences, achieving a success rate of 98.2%. Higher preoperative PTH levels and gland weight had a direct correlation with the successful performance of MIP.

Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas

Background Technetium sestamibi scanning is the most accepted method of imaging used for preoperative localization of parathyroid adenomas. Four-dimensional computed tomography (4D-CT) scanning is a relatively new localization technique that has not been as rigorously evaluated. Methods One hundred thirty-five consecutive patients who underwent preoperative sestamibi scanning, 4D-CT scanning, and parathyroidectomy for primary hyperparathyroidism were evaluated. Patient characteristics, parathyroid gland weights, and the probability of having positive preoperative localization were examined. Results Four-dimensional computed tomography scanning was significantly more accurate than sestamibi (73% vs 62%, P = .016). In those with serum calcium levels less than 10.8 mg/dL, 4D-CT scanning was significantly more accurate than sestamibi scanning for the quadrant (45% vs 29%, P = .013) and hemisphere (66% vs 48%, P = .012). Also, 4D-CT scanning was more accurate among patients with parathyroid gland weights less than 500 mg (69% vs 45%, P < .001). Conclusions Four-dimensional computed tomography scanning provides better preoperative localization than sestamibi scanning, particularly in patients with mild hypercalcemia and smaller parathyroid adenomas.

Primary Hyperparathyroidism Patients with Positive Preoperative Sestamibi Scan and Negative Ultrasound Are More Likely to Have Posteriorly Located Upper Gland Adenomas (PLUGs)

BackgroundStandard preoperative imaging for primary hyperparathyroidism usually includes sestamibi scanning (MIBI) and ultrasound (US). In a subset of patients with a positive MIBI and a negative US, we hypothesize that the parathyroid adenomas are more likely to be located posteriorly in the neck, where anatomically they are more difficult to detect by US.MethodsWe retrospectively reviewed the records of 661 patients treated for primary hyperparathyroidism between 2004 and 2009 at a tertiary referral center. We included patients who for their first operation had a MIBI that localized a single lesion in the neck and an US that found no parathyroid adenoma. We excluded patients with persistent or recurrent hyperparathyroidism, and patients with MIBIs that were negative, that had more than one positive focus, or that had foci outside of the neck. Sixty-six cases were included in the final analysis.ResultsA total of 54 patients (83%) had a single adenoma, 4 (6%) had double adenomas, and 7 (11%) had hyperplasia. Thirty-three patients (51%) had a single upper gland adenoma; 19 of these (58%) were posteriorly located upper gland adenomas (PLUGs). PLUGs occurred more often on the right side than on the left (P = 0.048, Fisher’s test). PLUGs were also larger than other single adenomas (mean 1.85 vs. 1.48 cm, P = 0.021, t-test). Seventy-six percent of patients successfully underwent a unilateral or focused exploration. Six patients (9%) had persistent disease, which is double our group’s overall average (4–5%).ConclusionsPrimary hyperparathyroid patients with preoperative positive MIBI and negative US are more likely to have PLUGs.

Are Additional Localization Studies and Referral Indicated for Patients With Primary Hyperparathyroidism Who Have Negative Sestamibi Scan Results?

Additional imaging studies are useful to select patients who are candidates for minimally invasive parathyroidectomy, and referral is not indicated when results from a preoperative sestamibi scan are negative. Prospective analysis of 492 operations for primary hyperparathyroidism from May 2005 to May 2007 at a tertiary care center. Accuracy of imaging studies, pathologic findings, and biochemical cure. Among the patients, 96% were cured. Of the sestamibi scan results, 91% were positive and 82% were true-positive. Ultrasonography results were positive in 51% of patients with negative sestamibi scan results, and 43% were true-positive. Patients with positive sestamibi scan results compared with those with negative sestamibi scan results had a higher rate of single-gland disease (87% vs 63%, respectively) and lower rates of double adenoma (6% vs 22%, respectively) and asymmetric hyperplasia (7% vs 15%, respectively) (P<.001). In patients with positive sestamibi scan results compared with those with negative sestamibi scan results, there was no significant difference in the rate of ectopic parathyroid glands (18% vs 12%, respectively) but there was a significant difference in cure rate (97% vs 89%, respectively) (P=.008). Additional imaging with neck ultrasonography is helpful for selecting minimally invasive parathyroidectomy in most patients with primary hyperparathyroidism who have negative sestamibi scan results. Referral for parathyroidectomy may be considered in patients with negative sestamibi scan results because these results are associated with multigland disease and lower cure rates.

The Impact of Baseline Intact Parathyroid Hormone Levels on Severity of Primary Hyperparathyroidism and Outcomes in Patients Undergoing Surgery

To determine the impact of intact parathyroid hormone (iPTH) baseline levels on severity of primary hyperparathyroidism (PHPT) and outcomes following parathyroidectomy for PHPT. Single institution retrospective review. Academic tertiary care center. A total of 447 consecutive patients undergoing parathyroid surgery for PHPT. Comparison of patients with high (> or =150 pg/mL) and low (<150 pg/mL) baseline iPTH values; preoperative serum calcium, alkaline phosphatase, and 25-hydroxyvitamin D levels; and 6-month postoperative serum calcium and iPTH levels. A total of 304 patients had baseline iPTH values of at least 150 pg/mL (high baseline group), and 143 patients had baseline iPTH values lower than 150 pg/mL (low baseline group). Patients in the high baseline group had significantly higher levels of preoperative serum calcium, serum alkaline phosphatase, and adenoma weights (P < .001 for all comparisons). Serum 25-hydroxyvitamin D levels were significantly lower in patients in the high baseline group (P < .001). Sestamibi scans were more likely to localize an adenoma in the high baseline group (83.7%) than in the low baseline group (68.9%) (P < .01). There were no differences in the serum calcium and iPTH levels between the 2 groups 6 months after surgery. Patients in the high baseline group undergoing surgery for PHPT had higher baseline levels of serum calcium, serum alkaline phosphatase, and parathyroid adenoma weights and lower serum 25-hydroxyvitamin D levels compared with the lower baseline group. Sestamibi scans were more likely to localize an adenoma in the high baseline group (83.7%) than in the low baseline group (68.9%) (P < .01). Despite an apparently lower rate of positive preoperative sestamibi scans for the low baseline group, patients were able to achieve a similar rate of disease cure as other patients with higher baseline iPTH levels. It seems that baseline iPTH level should not be used as a criterion to perform surgery or not perform surgery for patients with PHPT.