Accuracy of Parathyroid Adenoma Localization by Preoperative Ultrasound and Sestamibi in 1089 Patients with Primary Hyperparathyroidism

Abstract

Background Primary hyperparathyroidism (pHPT) is well treatable surgically. Sonography (US) and sestamibi scintigraphy (MIBI) are used routinely, but it is unclear how valuable they are in determining Parathyroid glands’ different locations. This study aimed to evaluate the prognostic value of US and MIBI in relation to the different localization of parathyroid adenomas in one of the largest study populations analyzed to date. Methods 1089 patients with pHPT who had treatment in one tertiary referral center between 2007 and 2016 were analyzed. Preoperative US and MIBI reports were compared with the parathyroid adenoma's intraoperative localization. All parathyroid glands were confirmed by histological diagnosis. Results No gland was detectable in 22.5% and 27.7% of all patients, by US or by MIBI, respectively. In relation to the different adenoma locations, the sensitivity of US ranged from 21.3% (upper right) to 68.9% (lower left) and of MIBI ranged from 23.5% (upper right) to 72% (lower left). The specificity for US ranged from 85% (lower right) to 99.2% (upper right) and for MIBI ranged from 86.1% (lower right) to 99.1% (upper right. Positive predictive values for all gland sites were 54% and 59% for MIBI and US, respectively. The value increased for side‐only prediction to 73% and 78%, respectively. Neither the parathyroid hormone level nor the calcium value level influenced the sensitivity or specificity of the two test methods. Conclusions The validity of preoperative US and MIBI depends crucially on the specific localization of adenomas. This should be considered when planning the extent of parathyroid surgery.

Mediastinal Parathyroid Cancer

“…A larger size of parathyroid lesions favors their detection by sestamibi scans (MIBI) [ 72 ], whilst PTH and calcium excess do not [ 73 ] and lymph nodes often remain unapparent on such scans [ 29 ]. A detailed examination in limited-size PC cohorts show that a combination of US with CT and MIBI or CT with MIBI achieves a higher accuracy in localization of PC [ 30 ], but do such tests not convincingly aid in the diagnosis of malignancy unless expert and, as yet, unconfirmed criteria are applied [ 31 ].…”

“…In contrast to the current dearth of indicators in PC, our exploration of simple and available criteria to gauge the risk of malignancy prior to surgery has yielded useful outcomes. Information on both criteria will invariably be available: determination of corrected serum calcium levels is an integral component of the initial assessment of pHPT [ 82 ], whilst some form of cross-sectional imaging is a pre-requisite in the pre-operative localization foregoing surgery [ 73 ].…”

Fine needle aspiration biopsy of parathyroid; is it meaningful? A cytologic study of 81 cases with histological and clinical correlations

“…6,23,24 Imaging techniques are often used simultaneously, 20,24 and US may be useful to confirm the localization of a parathyroid lesions detected by Tc99 m-MIBI. 27,28 Tc99 m-MIBI complemented by single emission CT (Tc99 m-MIBI-SPECT), is other widely used, highly sensitive and accurate imaging technique for the preoperative localization of pathologic parathyroid glands. 22,23 However, these techniques have lower sensitivity for visualizing of small or multiple parathyroid gland pathology, parathyroid glands with deviant anatomical positions and in patients with persistent hypercalcemia after failed surgery.…”

“…Common limitations of US are the identification of normal parathyroid glands and small or ectopic parathyroid lesions and to distinguish them from thyroid nodules, small lymph nodes and thymic or adipose tissue 6,23,24 . Imaging techniques are often used simultaneously, 20,24 and US may be useful to confirm the localization of a parathyroid lesions detected by Tc99 m‐MIBI 27,28 . Tc99 m‐MIBI complemented by single emission CT (Tc99 m‐MIBI‐SPECT), is other widely used, highly sensitive and accurate imaging technique for the preoperative localization of pathologic parathyroid glands 22,23 .…”

Pitfalls of DualTracer 99m-Technetium (Tc) Pertechnetate and Sestamibi Scintigraphy before Parathyroidectomy: Between Primary-Hyperparathyroidism-Associated Parathyroid Tumour and Ectopic Thyroid Tissue

“…Of note, the clinical decision involving both endocrinology and surgery levels remains the core of this multidisciplinary management. While a skilled surgeon relates to the optimum parathyroidectomy outcome with regard to PHP and secondary (tertiary) hyperparathyroidism relates to the post-operatory success rate, complications and operation time, pre-operatory imaging diagnosis is mostly helpful, also allowing a minimally invasive/selective procedure, thus playing a role in the modern era in the parathyroid domain since this minimal surgical act in addition to the pre-operatory localisation of the tumour provides similar cure rates to bilateral neck exploration [18][19][20]. Nevertheless, many parathyroid surgeons may currently perform 4-gland exploration routinely, precisely to avoid the shortcomings of preoperative localisation.…”