What is the link between nonlocalizing sestamibi scans, multigland disease, and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy

BACKGROUND: We hypothesized that nonlocalizing sestamibi scans would correlate with multigland disease and persistent primary hyperparathyroidism. METHODS: We reviewed records for 401 consecutive patients who underwent parathyroidectomy from 1999 to 2004. Gender, age, preoperative imaging, surgical findings, gland weight and volume, and 6-month calcium levels (Ca) were examined. RESULTS: We identified 289 women and 112 men, 297 of whom had a preoperative sestamibi scan localized to a single gland (localized group; LG). Ninety-six percent of the LG were found to have single-gland disease, and 4% had multigland disease (MGD). In the nonlocalized group (NLG), 76% had single-gland disease and 24% MGD. Mean gland weight was greater in the LG than in the NLG (1128 mg vs 699 mg; P < .05). Mean gland volume was larger in the LG (1.34 cc vs 0.89 cc; P < .05). A localizing sestamibi scan had a positive predictive value (PPV) of 96% and a likelihood ratio of 2.29 for predicting "curative" intraoperative parathyroid hormone drop after removal of a single abnormal gland. Patients were stratified into normocalcemic (NCa) and hypercalcemic (HCa) groups based on 6-month postoperative serum calcium data (n = 328). HCa incidence at 6 months did not differ significantly between the LG (5%) and NLG (3%). A localizing scan had a PPV of 95% for normocalcemia at 6 months. A nonlocalizing scan had a PPV of 21% for HCa at 6 months. CONCLUSIONS: Nonlocalizing sestamibi scans were more common in primary hyperparathyroidism with MGD and were associated with smaller-volume abnormal glands found at operation. Preoperative sestamibi scan-results did not predict HCa at 6 months.     

Unilateral open and minimally invasive procedures for primary hyperparathyroidism: a review of selective approaches

The currently established procedure for surgical treatment of primary hyperparathyroidism is bilateral exploration and visualization of all four glands to identify an adenoma and exclude multiglandular disease. With the development of improved preoperative localization imaging of the parathyroids using high-resolution ultrasonography and sestamibi scintigraphy, on the one hand, and perioperative control of surgical success with a rapid parathyroid hormone assay on the other, unilateral and minimally invasive techniques have become feasible. For patients with unequivocal localization in preoperative sestamibi scintigraphy and high-resolution ultrasonography of the parathyroid adenoma in probable single-gland disease, the unilateral and minimally invasive parathyroidectomy present a therapeutic option. Perioperative rapid parathyroid hormone assays, although costly, offer immediate supervision of adenoma extirpation and differentiation of single- and multiglandular disease. These methods demonstrate advantages with favorable cosmetic results and lower reported rate of postoperative hypoparathyroidism. These methods are already being practiced in some places under local anesthesia and in an ambulatory setting. This contribution provides an introduction and overview of the currently practiced unilateral and minimally invasive techniques of parathyroidectomy for primary hyperparathyroidism, discussing indications, advantages and disadvantages, and technical differences in the practiced methods. Received: 26 April 1999 Accepted: 22 November 1999     

Intraoperative sestamibi scanning in reoperative parathyroidectomy

BACKGROUND: Reoperative neck exploration for hyperparathyroidism is often difficult even for experienced surgeons. Recent advances in preoperative and intraoperative localization techniques have improved successful resection rates. This prospective study evaluates the accuracy and clinical utility of intraoperative technetium 99m sestamibi scanning for localizing hyperfunctioning parathyroid tissue in reoperative neck explorations. PATIENTS AND METHODS: Eleven patients underwent reoperative neck exploration for hyperparathyroidism. Two patients had 3 prior neck explorations, 1 had 2 prior neck explorations, and 8 patients had 1 prior neck operation. Preoperative studies included sestamibi scintigraphy and ultrasound in all patients, magnetic resonance imaging in 4, computed tomography scan in 3, parathyroid arteriogram in 1, and selective venous sampling in 1. All patients underwent intraoperative technetium 99m sestamibi scanning and parathyroid hormone assay. RESULTS: Preoperative technetium 99m sestamibi scanning and ultrasound each successfully localized 7 of 11 hyperfunctioning glands (64%). Intraoperative technetium 99m sestamibi scanning correctly localized 10 of 11 hyperfunctioning glands (91%). Intraoperative parathyroid hormone assay confirmed successful excision of hyperfunctioning tissue in all 11 patients. Postoperatively, all 11 patients had low-normal or normal calcium levels. CONCLUSIONS: Intraoperative technetium 99m sestamibi correctly localized 91% of hyperfunctioning glands compared with 64% localization for preoperative technetium 99m sestamibi and preoperative ultrasound. Intraoperative technetium 99m sestamibi scanning and parathyroid hormone monitoring are useful in reoperative neck explorations for hyperparathyroidism.     

Heterogeneous gland size in sporadic multiple gland parathyroid hyperplasia

BACKGROUND: The success rate for bilateral exploration in patients with primary hyperparathyroidism approaches 95%. Multiglandular parathyroid hyperplasia accounts for approximately 10% to 30% of primary hyperparathyroidism. The incidence of recurrent or persistent hyperparathyroidism is highest in familial forms of the disease, in which multiglandular disease is more common; this may be due to asymmetric enlargement of parathyroid glands. Because of improvements in tumor-imaging capability, some surgeons are now advocating unilateral exploration for primary hyperparathyroidism, but there is limited experience concerning how often these imaging methods fail. STUDY DESIGN: The outcomes of 7 patients who had sporadic primary hyperparathyroidism with multigland hyperplasia were reviewed. We gathered demographic data and laboratory values and reviewed radiologic tests, surgical findings, pathologic findings, and postoperative followup. RESULTS: All patients underwent preoperative localization with ultrasonography and technetium/sestamibi scans. The sensitivity of these two tests for the dominantly enlarged gland was 100% for both, but dropped to 0% and 5%, respectively, for all other enlarged glands. The sensitivity of CT and MRI for the dominant tumor was 67% (2 of 3) and 50% (1 of 2), respectively. Six of 7 patients underwent subtotal (3(1/2) gland) parathyroidectomy. The mean volume of all glands was 1.51+/-5.89 cm3 compared with a mean of 5.66+/-11.4 cm3 for all dominant glands and 0.123+/-0.1 cm3 for all nondominant hyperplastic glands. There was a large amount of variability between the volumes of dominant and other glands as demonstrated by large SDs from the mean. CONCLUSIONS: There is a marked heterogeneity in gland size in patients with sporadic multigland hyperplasia, which is similar to that found in multiple endocrine neoplasia type I. This heterogeneity may result in failure to recognize multigland disease if a unilateral neck exploration is performed. Intraoperative parathyroid hormone assay may prove to be an important adjunct in this population of patients who have unsuspected multigland disease.     

Minimally invasive open parathyroidectomy in an endemic goiter area: a prospective study.

HYPOTHESIS: Single-gland disease identified by preoperative localization studies in combination with rapid intraoperative parathyroid hormone monitoring seems to allow a limited exploration of the neck in sporadic primary hyperparathyroidism. Minimally invasive open parathyroidectomy by lateral approach (oMIP) in sporadic primary hyperparathyroidism seems feasible in an endemic goiter region. DESIGN: One hundred consecutive patients with sporadic primary hyperparathyroidism underwent preoperative double-phase technetium Tc 99m sestamibi scanning with single-photon emission computed tomography and high-resolution ultrasonography with color Doppler imaging of the cervical region. All patients were operated on with the use of quick parathyroid hormone assay to confirm the surgical success "on-line." Patients with localized single-gland disease, irrespective of additional ipsilateral thyroid disease requiring surgery, were selected for oMIP. Success of the preoperative localization studies, postoperative (at least 6 months) serum calcium levels, and operating time were analyzed. SETTING: University hospital, section of endocrine surgery. RESULTS: Of 100 patients, 83 (83%) were considered suitable for oMIP. In 69 patients, oMIP was finished successfully. Nine of these had had previous neck surgery, and another 24 underwent additional ipsilateral thyroid resection. Permanent normocalcemia was achieved in 67 (97.1%) of 69 patients and 98 (98%) of 100 patients. CONCLUSION: The oMIP in combination with quick parathyroid hormone assay may become the treatment of choice for sporadic primary hyperparathyroidism in an endemic goiter region in centers with high experience in thyroid and parathyroid surgery. It allows treatment of concomitant ipsilateral thyroid disease and is feasible in reoperations.     

Magnitude of parathyroid hormone elevation in primary hyperparathyroidism: Does time of day matter?

BackgroundParathyroid hormone demonstrates a circadian rhythm in nondiseased patients, but it is unclear if this diurnal variation persists in the context of primary hyperparathyroidism. We anecdotally noticed that parathyroid hormone levels drawn early on the morning of parathyroid surgery (preincision parathyroid hormone), were of lower magnitude than values obtained at later times in the day. If present, a time-of-day based variation in parathyroid hormone could have important clinical implications on intraoperative surgical decision making.MethodsWe performed an Institutional Review Board-approved, retrospective chart review of patients undergoing parathyroidectomy for primary hyperparathyroidism between October 2019 and February 2022 at a quaternary care referral center. Demographic, laboratory, imaging, and operative parameters were extracted. Analysis was performed using mixed models for repeated measures with a first order autoregression correlation structure. Parathyroid hormone values were compared before and after hourly intervals between 6:00 A.M. and 12:00 P.M.ResultsOf 418 patients, the mean age was 61 years old, 80% of patients were female, and two-thirds had single-gland disease. A total of 933 parathyroid hormone levels were included in the analysis and median parathyroid hormone was 97.3 pg/mL. Parathyroid hormone levels were noted to be significantly lower if they were drawn before 7:00 A.M. This diurnal variation persisted in patients with single-gland and advanced hyperparathyroidism but was abrogated in multi-gland and low-baseline-parathyroid hormone disease.ConclusionIn patients with primary hyperparathyroidism, parathyroid hormone levels were significantly lower in the early morning hours, especially in patients with single-gland and high-baseline-parathyroid hormone hyperparathyroidism. This may have implications for intraoperative decision making when utilizing an early morning, preincision parathyroid hormone value.     

Minimal Incision Parathyroidectomy: Cure, Cosmesis, and Cost

The goals of operative treatment of primary hyperparathyroidism are (1) cure; (2) minimal invasion; and (3) cost-effectiveness. The optimal strategy is controversial. Retrospective review of was undertaken 66 previously unoperated patients having minimal-incision, full-neck exploration by one surgeon over 29 months. A group of 51 women and 15 men had open full neck exploration under general anesthesia through a small (25–40 mm) incision using specifically selected instruments; patients remained hospitalized overnight. Preoperative sestamibi scans were obtained before referral for 17 patients: 11 had localized disease, and 6 did not (65% sensitivity). Four parathyroid glands were identified in 98% of patients; intraoperative frozen section was used selectively on a median of one gland per patient. About 76% of patients had single-gland disease, 6% had two-gland disease, and 18% had four-gland hyperplasia. One patient had four normal cervical parathyroid glands and an aortopulmonary window parathyroid adenoma resected at thoracotomy 1 week later; preoperative sestamibi scans failed to localize his disease. There were no nerve injuries and a 98% cure rate after initial cervical exploration. Excluding the cost of the sestamibi scans, there was no difference between those who had preoperative localization and those who did not; 60% of hospital costs were operating room time-related. Minimal-incision parathyroidectomy is effective for curing hyperparathyroidism and has excellent cosmetic results with negligible scar. Preoperative sestamibi scanning had no impact on cure or treatment costs. Strategies to improve cost-effectiveness must address the substantial costs of anesthesia and operating room services.     

An analysis of sestamibi-positive versus -negative patients with primary hyperparathyroidism.

We performed this study to evaluate two patient groups with primary hyperparathyroidism depending on whether their abnormal gland(s) could be preoperatively imaged with sestamibi. Patients with primary hyperparathyroidism evaluated by preoperative sestamibi examination from January 1999 to June 2000 were divided into two groups depending on the ability of sestamibi to localize their disease. Records were reviewed to determine pre- and postoperative biochemical data, weight of the excised glands, and total operating room time. When the sestamibi imaging was positive a minimally invasive parathyroidectomy was performed; however, when sestamibi scanning was negative patients underwent a formal bilateral neck exploration. All 40 patients in the sestamibi-positive group and 17 of 18 patients in the sestamibi-negative group were cured of their primary hyperparathyroidism as a result of surgery. Sestamibi scanning with a minimally invasive parathyroidectomy shortens operating room time and is most effective when adenomas are large. The results of this study suggest that strategies to preoperatively increase the activity of adenomas may improve the sensitivity of sestamibi scan localization of parathyroid adenomas.     

Ultrasound facilitates minimally invasive parathyroidectomy in patients lacking definitive localization from preoperative sestamibi scan

BACKGROUND: Sestamibi scanning is commonly used for preoperative localization in patients with hyperparathyroidism. However, 12% to 15% of these studies are equivocal or negative. Ultrasound may also be used to identify patients suitable for a minimally invasive parathyroidectomy. METHODS: Data from patients treated for hyperparathyroidism between January 2000 and April 2006 were reviewed retrospectively. Sestamibi and ultrasound results were scored as definitive, suggestive, or negative. Patients with suggestive or negative sestamibi scans were included in the analysis. RESULTS: A total of 261 patients underwent operation without a definitively localizing sestamibi scan. Preoperative neck ultrasound was performed in 80 of these patients. Overall, ultrasound was either conclusive or suggestive in 45 of 80 patients (56%) without a definitively localizing sestamibi scan and correctly correlated with the surgical findings in 38 of 45 (84%) of these patients. CONCLUSION: In patients with nonlocalizing sestamibi scans, neck ultrasound increases the number of patients suitable for minimally invasive parathyroidectomy.     

Chasing ��Shadows��: Discovering the Subtleties of Sestamibi Scans to Facilitate Minimally Invasive Parathyroidectomy

Background  

With the advent of sestamibi scans, high-resolution ultrasonography (US), and intraoperative intact parathyroid hormone (PTH) measurements, minimally invasive parathyroidectomy (MIP) is considered the standard of care for patients with primary hyperparathyroidism (PHPT). Preoperative imaging, however, can be negative more than 20% of the time.     

Utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing in guiding patients with a negative sestamibi scan for minimally invasive parathyroidectomy—a randomized controlled trial

Background and aims  The purpose of this study was to determine the utility of bilateral internal jugular venous sampling with rapid parathyroid hormone assay (BIJV–IOPTH) in comparison to endocrine surgeon-performed ultrasonography of the neck as an alternative localizing modality in guiding patients with primary hyperparathyroidism (pHPT) and negative sestamibi scans for minimally invasive parathyroidectomy (MIP). Patients and methods  Seventy eight consenting patients with a negative subtraction sestamibi scan planned for parathyroidectomy underwent additional ultrasound parathyroid imaging and were randomized to undergo surgery without vs. with additional BIJV–IOPTH; n = 39 in each group. The patients with a positive alternative imaging test were qualified for video-assisted MIP, whereas the others underwent open neck explorations. The primary outcome measure was the number of patients with true-positive results of alternative imaging tests. Results  Of the 78 patients, 50 (64%) had a single adenoma, eight (10.3%) had double adenomas, and 20 (25.7%) demonstrated four-gland hyperplasia. Ultrasonography alone vs. combined with BIJV–IOPTH was true positive in detecting a solitary parathyroid adenoma in 8/24 (33.3%) vs. 17/26 (65.4%) patients, respectively (p = 0.023). Curative video-assisted MIP was successfully performed in all the patients with true-positive results. The remaining individuals were cured by more extensive open neck explorations (unilateral—4/39 vs. 4/39, respectively; p = 1.0 or bilateral—27/39 vs. 18/39, respectively; p = 0.039). Conclusions  Most patients with pHPT and a negative subtraction sestamibi scan (64%) have a single adenoma. BIJV–IOPTH as an addition to a surgeon-performed ultrasound of the neck allows for more accurate guiding for MIP in patients with a solitary parathyroid adenoma and negative subtraction sestamibi scans. Presented at the 3rd Workshop of the European Society of Endocrine Surgeons (ESES), “Modern techniques in primary hyperparathyroidism surgery: An evidence based perspective”, 19-21 of March 2009, Lund, Sweden. “Best of Endocrine Surgery in Europe 2009”     

Prospective evaluation of the efficacy of technetium 99m sestamibi and iodine 123 radionuclide imaging of abnormal parathyroid glands.

BACKGROUND. Technetium 99m sestamibi is an isonitrile radionuclide imaging agent that, when used with subtraction iodine 123 thyroid scans, has the potential for imaging abnormal parathyroid glands. METHODS. We prospectively evaluated 20 patients with hyperparathyroidism to study the efficacy of Tc 99m sestamibi and 123I subtraction radionuclide scanning for the imaging of abnormal parathyroid glands. All patients underwent neck exploration and histologic confirmation of all parathyroid glands identified. RESULTS. The solitary adenomas in 11 of 16 patients with primary hyperparathyroidism were localized with sestamibi scans. The scans in four of five patients with diffuse parathyroid hyperplasia showed bilateral localization consistent with enlarged glands. The fifth patient previously underwent a subtotal parathyroidectomy, and a fifth supernumerary gland was localized with the sestamibi scan. Four patients had hyperparathyroidism related to kidney disease. Three of these had bilateral localization of enlarged glands. The fourth patient had undergone two previous operations, and a fifth supernumerary gland was localized with the sestamibi scan. CONCLUSIONS. The preliminary data indicate that Tc 99m sestamibi in combination with 123I radionuclide scanning may be useful in the preoperative localization of abnormal parathyroid glands. This technique localized all of the solitary adenomas that were subsequently resected, and in two reoperative cases it identified the remaining solitary gland causing persistent hypercalcemia.     

Radioguided parathyroidectomy via VATS combined with intraoperative parathyroid hormone testing: the surgical approach of choice for patients with mediastinal parathyroid adenomas?

Despite the excellent results with bilateral exploration, minimally invasive parathyroidectomy has become the procedure of choice for patients with hyperparathyroidism in which a single parathyroid lesion can be localized preoperatively. In this article, we discuss a patient who presented with primary hyperparathyroidism for the first time and had a Tc-99m sestamibi scan to localize a single parathyroid lesion in the left, anterior mid-mediastinum. We subsequently performed a radioguided parathyroidectomy via video-assisted thoracoscopic surgery (VATS) to resect this parathyroid adenoma and used intraoperative parathyroid hormone (PTH) testing to confirm cure and avoid neck exploration. We concluded that radioguided parathyroidectomy via VATS combined with intraoperative PTH testing is an effective approach for patients with primary hyperparathyroidism and mediastinal parathyroid lesions, and perhaps should be the technique of choice.     

Sestamibi Scan–directed Parathyroid Surgery: Potentially High Failure Rate without Measurement of Intraoperative Parathyroid Hormone

The present study evaluated sestamibi scan–directed parathyroidectomy with intraoperative parathyroid hormone (PTH) assessment (ioPTH). The preoperative sestamibi scintigraphies were compared with the intraoperative findings for 103 patients undergoing first exploration for sporadic primary hyperparathyroidism (pHPT). Data were collected prospectively. Ninety-nine patients (96%) were cured. Patients with persistent pHPT (n = 4) all had an incorrect scintigram as well as an insufficient decline of ioPTH. At operation, 90 patients (87%) had solitary parathyroid adenoma; 12 patients had multiglandular disease. In one patient no enlarged parathyroid gland was found. Overall 77 of 118 abnormal glands (65%) were correctly identified by sestamibi scintigraphy. The sensitivity for localizing a single parathyroid adenoma was 80%. Patients with incorrect scintigrams had a higher proportion of upper pole adenomas than patients with correct scans. High glandular weight and high level of serum PTH were important factors for detectability. Sestamibi scintigraphy did not predict multiglandular disease. However, the use of ioPTH identified 8 of the 9 patients with a positive scan (a solitary focus) and multiglandular disease. In contrast, false-negative ioPTH led to four unnecessary bilateral explorations in the 63 patients with a scan-identified adenoma. With the help of ioPTH, a focused parathyroidectomy was accomplished in 43% of scan-negative patients with a solitary adenoma. In conclusion, sestamibi scintigraphy is an acceptable method for localizing a solitary parathyroid adenoma. However, the technique alone does not reliably predict multiglandular disease. Potentially the failure rate in scan-directed parathyroidectomy could increase, with up to 10% of patients without ioPTH.This article was presented at the International Association of Endocrine Surgeons meeting, Uppsala, Sweden, June 14-17, 2004.     

Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy

BACKGROUND: A focused surgical approach for primary hyperparathyroidism relies on the ability of preoperative imaging and intraoperative parathyroid hormone monitoring (IOPTH) to detect multiple gland disease (MGD). The study objective was to determine the best predictor for MGD. METHODS: First time parathyroidectomy was performed on 233 patients with primary hyperparathyroidism who underwent preoperative sestamibi imaging, ultrasound, and IOPTH between December 1999 and January 2004. RESULTS: Single gland disease (SGD) was found in 204 (88%) and MGD in 23 (10%) patients. Hyperparathyroidism persisted in 6 of 233 patients (2.6%). For patients with MGD, sestamibi imaging correctly predicted MGD in 2 of 23 (9%) patients, incorrectly showed SGD in 9 of 23 (39%), and was negative in 12 of 23 (52%). Ultrasound correctly predicted MGD in 6 of 23 (26%) patients, incorrectly predicted SGD in 6 of 23 (39%), and was negative in 8 of 23 (35%). Together sestamibi imaging and ultrasound predicted MGD in 7 of 23 (30%) patients, incorrectly predicted SGD in 7 of 23 (30%), was negative in 7 of 23 (30%), and was discordant in 10 of 23 (5%). IOPTH indicated MGD in 15 of 18 (83%) patients but falsely predicted cure after single gland excision in 3 of 18 (17%). The combination of sestamibi imaging, ultrasound, and IOPTH detected MGD in 16 of 18 (89%) patients. CONCLUSION: Ultrasound was more sensitive for detecting MGD than sestamibi imaging. Ultrasound and sestamibi imaging together provided information warranting a bilateral approach in 70% of patients with MGD. IOPTH was the most sensitive for MGD, but combining all 3 tests was the best predictor, identifying the majority of patients with MGD.     

Diminished dose minimally invasive radioguided parathyroidectomy: a case for radioguidance

Minimally invasive radioguided parathyroidectomy (MIRP) has been established as an alternative to bilateral neck exploration (BNE) for primary hyperparathyroidism. We investigate whether a diminished dose of technetium-99m sestamibi gives similar results to the standard dose. One hundred one patients were offered MIRP or diminished-dose MIRP (ddMIRP). Patients received intravenous Tc-99m sestamibi at a dose of either 25 mCi 1.5 hours or 5 mCi 1 hour preoperatively. The procedure was terminated when the 20 per cent rule was satisfied. All tissue was confirmed to be parathyroid tissue by frozen section analysis. In addition, intraoperative parathyroid hormone levels were measured in a majority of patients. Patients who failed IOM underwent BNE. Frozen section analysis and intraoperative parathyroid hormone monitoring were also performed in the BNEs. Postoperatively, serum calcium levels were measured at 1 week and 6 months. Fifteen per cent of patients were male and 85 per cent were female. The median age was 63 years (range, 25-89 years). The first 58 patients had the standard dose of 25 mCi, whereas 43 patients had ddMIRP. Six patients (10%) failed intraoperative mapping in the MIRP group and were found to have single-gland disease. Five patients (12%) failed intraoperative mapping in the ddMIRP group. However, two patients were identified to have multigland disease making the true failure rate of intraoperative mapping 7 per cent (three patients). Median operative times for MIRP, ddMIRP, and BNE were 40 minutes, 46 minutes, and 105 minutes, respectively. The 20 per cent rule was satisfied in 96 per cent of patients undergoing MIRP and 98 per cent of patients undergoing ddMIRP. Frozen section analysis and intraoperative parathyroid hormone monitoring did not result in a change in management. Median follow up was 193 days and serum calcium levels at 6 months were normal. Diminished-dose MIRP is a feasible alternative to standard-dose MIRP without compromising surgical outcomes.     

Limited versus radical parathyroidectomy in familial isolated primary hyperparathyroidism

BACKGROUND: Familial isolated primary hyperparathyroidism (FIHPT) is characterized by earlier onset, higher incidence of multiglandular disease, and higher recurrence rate when compared with sporadic primary hyperparathyroidism. Excision of 3.5 or 4 glands with autotransplantation has been recommended; however, these approaches lead to permanent hypoparathyroidism in 13% to 41% of patients. It is reported that many patients with FIHPT return to normocalcemia after single-gland excision. The use of preoperative localization and intraoperative parathyroid hormone assay permits limited resection of only hypersecreting glands. We report the outcome of this operative approach. METHODS: Fifteen consecutive patients with FIHPT underwent limited parathyroidectomy with resection guided by intact parathyroid hormone secretion in 2 university centers. Patients were followed up postoperatively for serum calcium and intact parathyroid hormone levels. RESULTS: With an operative success of 93%, 14 patients had only single-gland excision and 80% had unilateral neck exploration. All initial patients had their hypercalcemia corrected. In 4 reoperations, permanent hypoparathyroidism occurred in 2 patients. One recurrence was observed in 40 (8-122) months of follow-up. CONCLUSION: Limited parathyroidectomy allows successful single-gland excision in many patients with FIHPT, thus decreasing the risk of hypoparathyroidism. In these patients, a low incidence of hypoparathyroidism may be preferable to the possibility of late recurrence.     

How does the operative strategy for primary hyperparathyroidism impact the findings and cure rate? A comparison of 800 parathyroidectomies

BACKGROUND: We hypothesized that a higher frequency of multigland disease and higher cure rate would result if routine four-gland exploration (4GL) was used as compared with focused parathyroidectomy (FP) for treatment of primary hyperparathyroidism. STUDY DESIGN: During a 5-year period, data from two academic endocrine surgical practices were retrospectively reviewed for patients having an operation for primary hyperparathyroidism. Three hundred ninety-five consecutive patients underwent 4GL at one institution (A), and 405 consecutive patients underwent FP with selective use of 4GL at the other institution (B). The main outcomes measures were gender, preoperative imaging, surgical findings, gland weight, and operative success. RESULTS: Three hundred ten (78%) patients at institution A were women, and 292 (72%) at institution B were women (p < 0.05). Routine 4GL strategy at institution A yielded a 16.5% frequency of multigland disease; and an FP strategy at institution B yielded 11.1% multigland disease (p = 0.028). At both institutions, single adenomas weighed more than multigland disease. Gland weights were not significantly different between the two institutions. Nine of 395 (2.3%) patients at institution A remained hypercalcemic postoperatively compared with 15 of 405 (3.7%) at B (p = 0.24; not significant). CONCLUSIONS: A greater frequency of multigland disease was found with routine 4GL. There was no statistically significant difference in operative success between the two approaches. Sound surgical technique and intraoperative judgment, including interpretation of intraoperative parathyroid hormone values, will result in a high success rate, regardless of the operative strategy chosen for primary hyperparathyroidism.     

Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism

BACKGROUND: The aim of this study was to determine the ability of localizing studies and rapid intraoperative parathyroid hormone (PTH) to predict the success of a limited approach in patients who then underwent bilateral exploration. METHODS: Preoperative sestamibi-iodine subtraction scan and neck ultrasonography (US) were used to direct a focal (1-gland) and unilateral (1-sided) parathyroid exploration by using rapid intraoperative PTH determinations in 350 patients with sporadic primary hyperparathyroidism. Regardless of the findings, the contralateral side was then explored. RESULTS: A single gland was predicted by sestamibi in 290 patients (83%), US in 298 patients (85%), and concordance of both in 205 patients (59%). Unilateral parathyroid exploration, directed by these studies, would correctly identify single-gland disease in only 68%, 74%, and 79%, respectively. The addition of intraoperative PTH would increase the success rate to 73%, 77%, and 82%, respectively. The finding of 2 normal or 2 abnormal glands on 1 side would force bilateral exploration, and additional unsuspected pathology was found in 13%, 13%, and 9%, respectively. This failure rate would increase to 21%, 18%, and 15%, respectively, if the analysis assumed a focal rather than unilateral approach to the initial exploration. CONCLUSIONS: Even in patients with concordant sestamibi and US scans, and an appropriate PTH drop, additional abnormal parathyroid glands were found on complete exploration in 15%. A bilateral approach offers the best opportunity for the long-term cure of primary hyperparathyroidism.     

The false negative technetium-99m-sestamibi scan in patients with primary hyperparathyroidism: correlation with clinical factors and operative findings

False negative (FN) results limit the efficacy of technetium-99m-sestamibi scanning for parathyroid localization. We determined the incidence of FN results and attempted to correlate it with clinical and operative findings. One hundred forty-six patients underwent parathyroidectomy; 89 had primary hyperparathyroidism (76 single adenoma and 13 multiglandular disease) and underwent sestamibi scanning. The false negative rate was 22 per cent with an overall sensitivity of 77 per cent and a positive predictive value of 99 per cent. Patients with single adenomas were more likely to have a true positive scan than those with multiglandular disease [83% vs 38%; odds ratio (OR) = 7.754, 95% confidence interval (CI) = 2.184-27.524; P < or = 0.0001]. Inferior adenomas (90% vs 59%; OR = 6.261, 95% CI = 2.037-19.243; P < or = 0.0001) and larger adenomas (1422.3 +/- 1576.2 vs 474.6 +/- 193.2 g; P < or = 0.0001) were more likely to be detected by sestamibi imaging. Patients with normal preoperative calcium levels were more likely to have an FN sestamibi scan. Sestamibi parathyroid imaging is limited by a 22 per cent FN rate and is less accurate for detecting abnormal parathyroid tissue in patients with small adenomas, multiglandular disease, superior adenomas, or preoperative normocalcemia.