Bilateral neck exploration in patients with primary hyperparathyroidism and discordant imaging results: a single-centre study

Abstract

Introduction: Focused parathyroidectomy is the treatment of choice for patients with concordant positive imaging. Bilateral cervical exploration is performed for cases with discordant imaging, yet more than 70% of those cases are the result of a single-gland disease. As focused parathyroidectomy is generally costless and harmless, for cases with discordant imaging, we tried to determine whether preoperative characteristics can lead to a diagnosis of single-gland disease. Methods: This study included 182 patients treated for primary hyperparathyroidism by bilateral exploration from 2009 to 2012 at La Timone Hospital, Marseille, France. We classified patients based on preoperative images and pathological results (single-gland or multiglandular disease). We then compared the demographical, laboratory and imaging results. We also asked a senior nuclear medicine practitioner who was blind to the ultrasound and pathological results to perform a second reading. Results: Of the total number of patients, 15.4% had negative, 54.4% discordant and 30.2% concordant imaging. After reviewing the scintigraphy results, 8% of the cases with discordant imaging would have been classified as concordant with ultrasound. Subtraction scintigraphy obtained better results than dual-phase scintigraphy (concordance with ultrasound in 50 vs 31% with classical scintigraphy). For the cases of discordant imaging, no predictive factors of single-gland disease could be identified. Ultrasound and scintigraphy were similarly effective in determining the correct location of the abnormal gland. Conclusion: Discordant results of preoperative imaging modalities do not discriminate between uniglandular and multiglandular diseases in hyperparathyroidism. Diagnostic differentiation between the different causes of hyperparathyroidism requires improvements in imaging techniques and might benefit from subtraction scintigraphy.

Primary hyperparathyroidism: review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus

“…A parathyroid adenoma may appear as an area of increased uptake or as a new upcoming configuration change on the 99m Tc-sestamibi scintigraphy. Subtraction scintigraphy is superior to dual-phase scintigraphy for identification of single- or multiple-gland disease [81]. …”

Scan-directed mini-incision focused parathyroidectomy: how accurate is accurate enough?

“…Our grading system was similar but not identical to that used by Philippon et al in an analysis of discordant scans of primary hyperparathyroidism patients in Marseille, France. 20 They also described a three-group approach where group 1 (positive concordant imaging) and group 3 (negative imaging) corresponded to our excellent and poor grades, respectively. However, the criteria for Philippon et al's second group were slightly more relaxed, whereby patients with 'only one positive image or both positive but with different results' was considered acceptable.…”

“…However, the criteria for Philippon et al's second group were slightly more relaxed, whereby patients with 'only one positive image or both positive but with different results' was considered acceptable. 20 However, this was supplemented by their use of intraoperative parathyroid hormone (IOPTH) measurement. In our study, we adopted a more stringent classification criteria (where no contradictory findings were considered acceptable) in order to robustly defend our validation in the absence of routine IOPTH measurement.…”

Frozen Tissue Examination: Is It really no Longer of Use in Parathyroid Surgery? Single-center Retrospective Study on 97 Patients treated by minimally Invasive Approach

“…As a result, not all scintigraphic examinations have been performed according to the same protocols and the information retained was, therefore, based in some cases on the account of the nuclear medicine physician. The sensitivity of these examinations, to be carried out by trained radiologists and nuclear medicine physicians, 15 varies in the literature ranging from 60 to 90% for the scintigraphy and from 60 to 85% for the ultrasound and reaches 96% in case of concordance in some studies. 16 It is, therefore, necessary to strive to obtain concordant imaging examinations by repeating the examinations if necessary or by completing the assessment by a cervical mediastinal thin-slice computed tomography (CT)-scan with contrast agents, using the MIBI SPECT, with three dimensional reconstruction 17 in order to detect a greater number of patients with multiglandular involvement and, thus, to immediately turn to an exploratory cervicotomy as first-line treatment.…”

“…The preoperative imaging examinations are, first of all, a cervical ultrasound combined with sestaMIBI, or better, 123I/sestaMIBI dual isotope scintigraphy. 15 The CT-scan appears to be a second-line examination reserved for inconsistencies of first-line examinations and for the investigation of mediastinal locations with a sensitivity of 88%. For this, millimeter cuts are recommended without injection and then with injection of contrast agent with acquisitions at 45 and 70 seconds.…”