Elsevier

Surgery

Volume 136, Issue 6, December 2004, Pages 1303-1309
Surgery

American Association of Endocrine Surgeon
Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy

https://doi.org/10.1016/j.surg.2004.06.062Get rights and content

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.

Section snippets

Methods

Patients (N = 358) undergoing parathyroidectomy at one institution (Froedtert Memorial Lutheran Hospital/Medical College of Wisconsin)4 starting from December 1999 through January 2004 were prospectively entered into a database. Of these, 233 met the criteria of having (1) primary hyperparathyroidism, (2) no prior parathyroid operation, and (3) preoperative sestamibi imaging (MIBI), ultrasound, and IOPTH. Fourteen patients were excluded because of secondary and tertiary hyperparathyroidism; 28

Results

Of the 233 patients studied, 173 (74%) were female, and 60 (26%) were male. Their mean age was 56 years (range, 16-91 years). The mean preoperative calcium concentration was 11.2 mg/dL (range, 9.6-14 mg/dL; reference range, 8.4-10.5 mg/dL), and PTH level was 132 pg/mL (range, 41-571 pg/mL; reference range, 10-65 pg/mL). None had multiple endocrine neoplasia, and 7 had prior thyroid operations. There were 23 (10%) patients with MGD, 204 (88%) with SGD, and 6 (2.6%) had persistent

Discussion

A focused approach to parathyroid surgery has been increasingly utilized since the introduction of IOPTH and the gamma probe. Although this approach is ideal for SGD, its ability to produce long-term cure rates equivalent to 4-gland exploration has been questioned by some, citing the possibility of missed MGD with a lesser exploration.16 The success of a focused or minimally invasive approach is dependent on the detection of MGD with the various modalities including preoperative imaging with

Conclusion

The detection of MGD with preoperative imaging is poor with either ultrasound or MIBI alone. The combination of ultrasound and MIBI provided information (MGD, discordant, nonlocalizing) warranting a bilateral approach in most patients with MGD. IOPTH was the most sensitive test but still failed to detect some cases of MGD. The combination of preoperative imaging and IOPTH is the best predictor of MGD. Further refinement and experience with these methods will hopefully lead to improvement in

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      Importantly, FPTx is associated with decreased rates of recurrent laryngeal nerve injuries, postoperative pain, and transient or permanent hypocalcemia as well as shorter operative time, length of stay, improved cosmesis, and cost-effectiveness.19,30–33,41,42 The potential shortcoming of the FPTx is the failure in patients with unrecognized MGD of 16% with and 22%43 without ioPTH and the low sensitivity of preoperative imaging to detect MGD.25,44,45 FPTx should be avoided in patients with discordant or negative localization studies and used very selectively in those with known propensity to multiple gland disease, that is, known or suspected multiple endocrine neoplasia types 1 and 2a, familial PHPT, or lithium-induced disease due21,22,46,47 or those with other aspects that may contribute to missed lesions on imaging (eg, thyroid nodularity, thyroiditis).

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    Presented at the 25th Annual Meeting of the American Association of Endocrine Surgeons, Charlottesville, Virginia, April 4-6, 2004.

    Supported in part by the Geiger Foundation.

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