Nonlocalizing Imaging Studies for Hyperparathyroidism: Where to Explore First?

Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA.
Journal of the American College of Surgeons (Impact Factor: 5.12). 12/2011; 213(6):793-9. DOI: 10.1016/j.jamcollsurg.2011.09.011
Source: PubMed

ABSTRACT For patients with primary hyperparathyroidism (pHPT), imaging studies are obtained to facilitate minimally invasive parathyroidectomy. If imaging studies are nonlocalizing, it is not known if exploration should begin on a particular side or gland location.
A retrospective review of a prospective parathyroid database was performed. The cohort consists of pHPT patients who underwent initial parathyroidectomy between December 1999 and July 2010 and had all preoperative imaging studies reported as nonlocalizing (negative or indeterminate).
Of 880 patients, 151 (17%) had nonlocalizing imaging studies. Reasons for starting exploration on a particular side were identified in 78 (52%) patients and included concomitant thyroid pathology (53%), suspicion on surgeon re-review of imaging (38%), or earlier thyroidectomy (9%). Exploration began on the right in 52%, the left in 42%, and was unknown in 6%. The surgeon had suspicion on imaging in 30 patients and correctly started on the side of pathology in 19 (63%). Hyperfunctioning glands were in eutopic locations in 144 patients (95%) and 3 had intrathyroidal glands. In 111 patients (74%) with single gland disease, median adenoma weight was 320 mg (range 80 to 8,210 mg). There was no difference in adenoma laterality (p = 0.7) or location (p = 0.8). Intraoperative parathyroid hormone criteria were met in 145 (96%) patients and 149 are eucalcemic at last follow-up; 2 (0.7%) patients have persistent disease.
In pHPT patients with nonlocalizing imaging, hyperfunctioning glands are not more frequently located on a particular side or anatomic position. Eutopic location is common and intraoperative parathyroid hormone monitoring should be used to guide the extent of surgery.

Download full-text


Available from: Tina W F Yen, Oct 06, 2014
25 Reads
  • Source
    • "The accuracy of the imaging modality used for detecting parathyroid adenomas can impact the percentage of adenomas that are localized prior to operative management . Previous studies have suggested the sensitivities for MIBI and US to range from 54% to 88% and 59% to 89% respectively [1] [7], while others have found variable results. Grant et al. reported the sensitivity of MIBI scans in localizing adenomas in those with primary hyperparathyroidism to be 86% compared to 61% with utilizing US [11]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Patients with primary hyperparathyroidism routinely undergo preoperative imaging to localize the abnormal gland to facilitate a guided parathyroidectomy. These techniques include neck ultrasound (US), dual phase planar technetium-99 m (99mTC) sestamibi (MIBI) scans, single photon emission computed tomography (SPECT), combined SPECT/CT, and four dimensional CT scans (4D CT). Despite appropriate preoperative imaging, non-localization of abnormal glands does occur. This study aims to determine whether non-localization is the result of radiologic interpretive error or a representation of a subset of truly non-localizing parathyroid adenomas.Materials and methodsA retrospective study was performed; two senior radiologists reinterpreted the preoperative imaging (US and MIBI scans) of 30 patients with initially non-localizing studies. All patients underwent parathyroidectomy for primary hyperparathyroidism at a tertiary referral center. Both radiologists were blinded to the scores of his colleague. The results were compared for inter-reader reliability using Cohen’s kappa test.ResultsTwenty-nine of thirty nuclear studies were found to be negative on reinterpretation. The readers agreed in 86.67% of their observations, with a kappa (κ) value of 0.706 (SE = ± 0.131, 95% confidence interval for κ = 0.449–0.962). One of eighteen ultrasounds had positive localizations on reexamination, however, the inter-observer agreement was only 55.6%, with a kappa value of 0.351 (SE = ± 0.139, and 95% confidence interval for κ = 0.080–0.623). Overall, no statistically significant difference in preoperative and retrospective interpretation was found.Conclusion This study identifies a subset of parathyroid adenomas that do not localize on preoperative imaging despite sound radiographic evaluation.
    American Journal of Otolaryngology 11/2014; 36(2). DOI:10.1016/j.amjoto.2014.10.036 · 0.98 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background: Intrathyroidal parathyroid adenomas (ITPAs) are a rare entity. The aim of this study is to describe the experience of 2 endocrine surgery centers and to distinguish characteristics of intrathyroidal parathyroid adenoma and nonintrathyroidal parathyroid adenomas. Methods: We included patients who had undergone operations for primary hyperparathyroidism who had intrathyroidal parathyroid adenomas. Patients with single intrathyroidal parathyroid adenomas were also compared to age- and sex-matched controls with nonintrathyroidal parathyroid adenomas. Results: Of 4,868 patients who underwent parathyroidectomy between January 2002 and June 2011, we identified 53 (1%) patients with intrathyroidal parathyroid adenoma. Sestamibi and ultrasound scans correctly identified the adenoma in 35 (70%) and 11 (61%) cases, respectively. Single adenomas were identified in 44 (83%) patients, double adenomas in 4 (8%) patients, and hyperplasia in 5 (9%) patients. Lobectomy was performed in 17 (32%) patients; enucleation was used in 36 (68%) patients. Cure was achieved in all patients and no patients experienced a recurrence. Patients with single intrathyroidal parathyroid adenomas had significantly smaller glands than patients with nonintrathyroidal parathyroid adenomas (325 ± 47 vs 772 ± 61 mg; P < .0001); however, no significant difference was identified between the groups with regard to demographics, symptoms, preoperative laboratory values, or outcomes. Conclusion: Single intrathyroidal parathyroid adenomas are smaller than nonintrathyroidal parathyroid adenomas, but patients with intrathyroidal parathyroid adenomas present with similar laboratory values and symptoms. Recognition of this rare entity can lead to a successful surgical outcome.
    Surgery 10/2012; 152(6). DOI:10.1016/j.surg.2012.08.026 · 3.38 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Intraoperative parathyroid hormone (iPTH) monitoring has significantly altered the approach to surgical management of hyperparathyroidism, from the traditional four-gland exploration to minimally invasive parathyroidectomy. Several published criteria for iPTH predict operative cure with good accuracy, though iPTH should always be interpreted against the background of a surgeon’s suspicion for multigland disease. Preoperative calcium and PTH levels as well a thorough understanding of the preoperative imaging modalities and their limitations is crucial. Current surgical strategies and iPTH utilization for four distinct patient populations are discussed.
    03/2014; 2(3). DOI:10.1007/s40137-014-0046-1
Show more