Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery

Abstract

Purpose Repeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse. Methods A retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated. Results Neck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24–48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%. Conclusion These findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.

Diagnostic utility of 11C‐methionine PET/CT in primary hyperparathyroidism in a UK cohort: A single‐centre experience and literature review

“…A total of 18 studies were identified that met our search criteria. 14,[18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34] Our cohort of patients is one of the largest cohorts investigating the role of 11 C-methionine PET/CT for the localisation of a parathyroid adenoma.…”

“…The study populations of 13 of the 18 studies identified in the literature review (Table 3) were not comprised exclusively of PHPT patients with parathyroid adenomas. 14,[18][19][20][21][22]24,26,28,30,[32][33][34] Patients with multiglandular hyperplasia, parathyroid carcinoma, tertiary hyperparathyroidism and MEN1 were also included in these studies, which may have impacted the reported sensitivities and PPVs of 11 C-methionine PET/CT in these studies.…”

“…25,27 However, the methods and results of our study were generally comparable to six of the included studies. 21,22,25,27,29,33 All studies included in the literature review conclude that 11 C-methionine PET/CT is a sensitive modality for the preoperative localisation of a parathyroid adenoma, particularly in patients with failed prior surgical intervention, inconclusive or negative prior imaging and/or ectopically located parathyroid adenomas. A majority of studies recommended that patients undergo 11 C-methionine PET/CT after failed US and/ or 99m Tc-MIBI.…”

“…A majority of studies recommended that patients undergo 11 C-methionine PET/CT after failed US and/ or 99m Tc-MIBI. 18,21,22,24,27,[29][30][31][32][33][34] Some even suggested that 11 C-methionine PET/CT is the preferable imaging modality over 99m Tc-MIBI. 18,24,27 It is reported that concomitant thyroid disease may contribute to discordant US and 99m Tc-MIBI results, and be a risk factor for surgical failure.…”

Questionable value of [99mTc]-sestamibi scintigraphy in patients with pHPT and negative ultrasound

“…Although there is a large body of literature on sensitivity and specificity of different imaging modalities to detect PAs prior surgery for pHPT, there are only few studies that started to create an algorithm for a sequential and rational preoperative diagnostic imaging sequence [ 14 , 15 ]. Furthermore, it is not even clear whether more preoperative localization diagnostics necessarily increase the reliability to detect the PA.…”