Combined ultrasound and Sestamibi scintigraphy provides accurate preoperative localisation for patients with primary hyperparathyroidism

Abstract

Introduction Minimally invasive parathyroidectomy has advantages over the traditional bilateral neck exploration for the surgical treatment of primary hyperparathyroidism. It requires accurate localisation of the parathyroid pathology prior to surgery. The best method of preoperative localisation in a district general hospital setting is not well understood. Methods All patients who underwent parathyroidectomy for primary hyperparathyroidism from 2008 to 2016 were identified from a prospectively maintained database. Operative findings were correlated with radiological and histological results. Sensitivity and specificity of ultrasound, sestamibi scintigraphy and the two together were calculated for diagnostic precision and compared. Results One hundred and eighty-four patients met the inclusion criteria, of whom 81.5% had a histological diagnosis of a parathyroid adenoma. Ultrasound had higher sensitivity than sestamibi scintigraphy. Used together, ultrasound and sestamibi scintigraphy performed better than either ultrasound or sestamibi scintigraphy alone (P< 0.001). Twenty-two of 184 cases had no lesion located by either ultrasound or sestamibi scintigraphy preoperatively. Where neither ultrasound nor sestamibi scintigraphy located the lesion, additional computed tomography led to the excision of parathyroid pathology in one in ten patients. Conclusion The combination of ultrasound and sestamibi scintigraphy provides the highest sensitivity of preoperative localisation. This approach led to a high success rate of minimally invasive parathyroidectomy. Where preoperative localisation is not achieved with ultrasound or sestamibi scintigraphy, computed tomography adds little additional benefit. In this setting other modalities of localisation such a selective venous sampling, intraoperative methylene blue or intraoperative parathyroid hormone levels could be considered.

The Utility of Ultrasound in the Preoperative Localization of Primary Hyperparathyroidism: Insights from Pakistan

“…Similar results were seen in a recent study from China, which showed US sensitivity ranging from 90.70% for parathyroid adenoma to 93.5% for parathyroid hyperplasia [15]. Scattergood et al reported that US had higher sensitivity than 99m-Tc sestamibi scintigraphy [16]. Interestingly, a recent study regarding parathyroid carcinoma localization reported the sensitivity and accuracy of US to be 80% and 73% respectively, of 4-D CT to be 79% and 82%, and of 99m-Tc sestamibi to be 81% and 78% [17].…”

VEGFR‐2 is downregulated in sestamibi‐negative parathyroid adenomas

“…4 In cases with concordance, both imaging tools provide a sensitivity of approximately 88%. Currently, preoperative key imaging tools for localizing parathyroid adenomas include ultrasound and sestamibi scanning.…”

“…Currently, preoperative key imaging tools for localizing parathyroid adenomas include ultrasound and sestamibi scanning. 4 In cases with concordance, both imaging tools provide a sensitivity of approximately 88%. 4 Nonlocalizing parathyroid adenomas on imaging studies can represent a clinical challenge.…”

“…4 In cases with concordance, both imaging tools provide a sensitivity of approximately 88%. 4 Nonlocalizing parathyroid adenomas on imaging studies can represent a clinical challenge. In particular, sestamibi-negative parathyroid adenomas often require 4-gland exploration that may result in prolonged surgical time.…”

“…1 There is an ongoing debate regarding the potential underlying mechanisms by which Tc99m-sestamibi highlights the abnormal parathyroid gland(s). Cell metabolism, 2 increased vascularization, 3 and multidrug resistance 4,5 have been linked to an increased deposit of the tracer.…”