Abstract
Purpose
To compare the accuracy of preoperative parathyroid adenoma localization in patients with primary hyperparathyroidism (pHPT) due to a single adenoma using a detailed 4-quadrant analysis and to identify patient and tumor characteristics associated with accurate preoperative localization.
Materials and Methods
Retrospective review of 203 patients who underwent parathyroidectomy for pHPT due to a single adenoma between 2008 and 2011. Results from preoperative ultrasound and Tc-99 m-sestamibi were compared to operative findings to determine accuracy of localization studies. Associations between clinicopathologic features and accurate preoperative adenoma localization were evaluated.
Results
Ultrasound was performed on 198 patients, sestamibi on 177 patients, and both on 172 patients. Accurate localization occurred significantly more often for ultrasound than sestamibi (63% vs. 41%, P < 0.001). For ultrasound, accurate localization was found in patients with larger or heavier adenomas, those with adenomas located inferiorly, patients not having a reoperative procedure, and patients with higher post-operative serum calcium levels. For sestamibi, greater adenoma size or weight, adenomas located inferiorly, and patients with associated thyroid cancer on pathology were most predictive of accurate preoperative localization.
Conclusions
Our results provide evidence that ultrasound is more accurate in localizing parathyroid adenomas in patients with pHPT due to a single adenoma when compared to sestamibi scan using 4-quadrant location analysis and may be the preferred preoperative imaging modality in these patients. No significant preoperative patient factors were associated with accurate localization by ultrasound or sestamibi, but adenoma size, weight, and location in an inferior position were predictive of accurate preoperative localization.
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Introduction
Historically, surgical treatment of primary hyperparathyroidism (pHPT) has consisted of a four gland neck exploration . In experienced hands, this approach has yielded an effective cure rate of 97%–99% . In 80%–90% of cases of pHPT, a single adenoma has been identified as the cause of the disorder . This fact has led to the development of a minimally invasive surgical approach that relies on pre-operative radiologic identification of the hyperfunctioning adenoma. Utilizing this minimally-invasive technique, decreased hospital stay, improved cosmetic results, shorter operative time, quicker recovery, lower costs, and lower morbidity have been achieved, with cure rates comparable to those of the traditional 4-gland exploration .
Ultrasonography and Tc-99-m Sestamibi scanning are the most commonly employed techniques in pre-operative identification of adenomas. Intraoperative PTH monitoring has been used as a supplemental technique to improve the success rate of the minimally invasive approach . Early reports claimed a > 90% sensitivity rate for parathyroid adenoma detection using ultrasound when combined with sestamibi scanning . Subsequent reports have shown significantly less sensitivity (33%–92%) .
Unfortunately, many patients who have been clinically diagnosed with pHPT undergo ultrasound and/or sestamibi scanning which fails to identify or agree on the site of a lesion. This study attempts to identify patient factors and tumor factors that are likely to be associated with accurate pre-operative radiologic imaging. Conversely, this study attempts to look at patient and tumor factors that are likely to result in a negative study, and to identify patients which would benefit from additional radiologic testing or a traditional four gland exploration.
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