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

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Introduction: Focused parathyroidectomy is the treatment of choice for patients with concordant positive imaging. Bilateral cervical exploration is performed for cases with discordant imaging, yet more than 70% of those cases are the result of a single-gland disease. As focused parathyroidectomy is generally costless and harmless, for cases with discordant imaging, we tried to determine whether preoperative characteristics can lead to a diagnosis of single-gland disease. Methods: This study included 182 patients treated for primary hyperparathyroidism by bilateral exploration from 2009 to 2012 at La Timone Hospital, Marseille, France. We classified patients based on preoperative images and pathological results (single-gland or multiglandular disease). We then compared the demographical, laboratory and imaging results. We also asked a senior nuclear medicine practitioner who was blind to the ultrasound and pathological results to perform a second reading. Results: Of the total number of patients, 15.4% had negative, 54.4% discordant and 30.2% concordant imaging. After reviewing the scintigraphy results, 8% of the cases with discordant imaging would have been classified as concordant with ultrasound. Subtraction scintigraphy obtained better results than dual-phase scintigraphy (concordance with ultrasound in 50 vs 31% with classical scintigraphy). For the cases of discordant imaging, no predictive factors of single-gland disease could be identified. Ultrasound and scintigraphy were similarly effective in determining the correct location of the abnormal gland. Conclusion: Discordant results of preoperative imaging modalities do not discriminate between uniglandular and multiglandular diseases in hyperparathyroidism. Diagnostic differentiation between the different causes of hyperparathyroidism requires improvements in imaging techniques and might benefit from subtraction scintigraphy.

Section: Discussionsupporting

confidence: 75%

Section: Introductionmentioning

confidence: 99%

Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

Philippon

Guérin

Taïeb

et al. 2014

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“…In our series, the incidence of MGD was 18%, which was within the range of 3-24% reported in the literature (20). The rate of MGD in cases of negative PS has been reported as w25% (21,22,23). Therefore, negative localization with sestamibi infers a highly selected patient population with small parathyroid adenomas and/or MGD.…”

Section: European Journal Of Endocrinologysupporting

confidence: 77%

Preoperative imaging for focused parathyroidectomy: making a good strategy even better

Guérin

Lowery

Gabriel

et al. 2015

Objective: Surgical treatment for primary hyperparathyroidism (pHPT) has undergone a major paradigm shift during the last decades from bilateral cervicotomy with four-gland neck exploration to image-guided focused approaches. The primary objective of the present study was to compare the performances of parathyroid scintigraphy (PS), parathyroid ultrasonography (US), and the combination of both procedures for guiding a focused approach on the basis of modified interpretation criteria. Methods: Data from 199 patients operated for apparent sporadic pHPT and evaluated with US and PS using dual-isotope 123 I/ 99m Tc-sestamibi planar pinhole and single-photon emission computed tomography (SPECT) acqusitions were evaluated. Results: A total of 127 patients underwent a focused approach and the remainder had bilateral cervicotomy. In 42 cases, a focused approach was not performed due to the absence of concordant results between US and PS for a single-gland abnormality. Four patients had persistent disease and three had recurrent disease. A localizing preoperative PS had a sensitivity of 93.3%, positive predictive value of 85.8%, negative predictive value of 73.0%, and accuracy of 83.4% for predicting uniglandular disease. Additional SPECT images accurately localize posterior adenomas that are often missed by US. Compared with PS, US had a lower sensitivity (P!0.01). Our imaging protocol also enabled diagnosis of multiglandular disease in 60.6%. Conclusions: PS using a highly sensitive dual-tracer subtraction method is the most accurate technique for directing a focused approach. PS could be sufficient for directing a focused approach in the presence of a negative US in two major circumstances: posterior locations due to acquired ectopia that could be missed by US, and previous history of thyroidectomy due to interpretation difficulties.

“…This is reported to occur in 12-18% of cases (47,48) and is a portent of both smaller tumors (49) and MGD, which accounts for one-third of cases (47,48 patients to occur 17% of the time (50). In this series, MGD accounted for 22% of cases and the median weight of excised tissue was only 350 mg. Of concern, the rate of negative explorations in this group was 13% and the rate of persistent hyperparathyroidism was a worrisomely high 18%.…”

Section: Localization Is Unreliable For Small Parathyroid Tumorsmentioning

confidence: 57%

Imaging of the parathyroid glands in primary hyperparathyroidism

Minisola¹,

Cipriani²,

Diacinti³

et al. 2016

Primary hyperparathyroidism (PHPT) is one of the most frequent endocrine diseases worldwide. Surgery is the only potentially curable option for patients with this disorder, even though in asymptomatic patients 50 years of age or older without end organ complications, a conservative treatment may be a possible alternative. Bilateral neck exploration under general anaesthesia has been the standard for the definitive treatment. However, significant improvements in preoperative imaging, together with the implementation of rapid parathyroid hormone determination, have determined an increased implementation of focused, minimally invasive surgical approach. Surgeons prefer to have a localization study before an operation (both in the classical scenario and in the minimally invasive procedure). They are not satisfied by having been referred a patient with just a biochemical diagnosis of PHPT. Imaging studies must not be utilized to make the diagnosis of PHPT. They should be obtained to both assist in determining disease etiology and to guide operative procedures together with the nuclear medicine doctor and, most importantly, with the surgeon. On the contrary, apart from minimally invasive procedures in which localization procedures are an obligate choice, some surgeons believe that literature on parathyroidectomy over the past two decades reveals a bias towards localization. Therefore, surgical expertise is more important than the search for abnormal parathyroid glands.