Imaging for primary hyperparathyroidism—an evidence-based analysis

Abstract

We found evidence at level III leading to recommendations at grade B, that sestamibi scintigraphy is a recommended first test, but that US by an experienced investigator may be an alternative. MIP may be performed when both tests are concordant, and in case of only one test being positive, unilateral exploration and use of intraoperative PTH measurements are recommended. Bilateral neck exploration is used when both tests are negative. For reoperative procedures, repeat investigations are recommended, but also to use US-guided fine needle aspiration and PTH measurements as well as venous sampling. However, for reoperative procedures, the level of evidence is weaker-level IV, but recommendations still at grade B.

The Accuracy of Ultrasound in the Pre-Operative Localisation of Parathyroid Lesions in Primary Hyperparathyroidism: A Review of the Literature

“…This is an important consideration for surgical planning. The sensitivities rates were similar to what was reported in a similar review (Mihai et al 2009) which reported ultrasound sensitivity rates of 51 to 96 per cent, and NM sensitivity rates from 34 to 100 per cent. The wider variation reported by Mihai et al (2009) is likely due to their inclusion of retrospective studies, short case series and older studies which were excluded from our review.…”

“…Prospective studies are more easily controlled, and allow more rigorous methodologies including the use of blinding (Euser et al 2009). The exclusion of retrospective studies significantly reduced the number of studies included in this review, as retrospective studies are more widely reported (Mihai, Simon & Hellman 2009) and prospective studies are less frequently reported due to long data collection periods when this study design is used. Articles prior to 2003 were excluded to capture the most advanced imaging technologies.…”

“…All studies, except two, (Mihai et al 2009, Prasannan et al 2007) stated that the US was interpreted without knowledge of the results of the NM scan. While, this approach limits risk of contamination between the two localization studies and provides an independent assessment of the localization study's performance, it does not mirror usual clinical practice.…”

“…A dual phased technique is used, where a gamma camera detects the radiation emitted from within the Parathyroid ultrasound (US) has emerged as an alternative or complementary localization procedure to NM techniques because it does not use ionizing radiation or an injection to the patient (Levy et al 2011), and has greater tolerance for patient movement. US is considered to be one of the most cost-effective, quick and easy imaging modalities, but it has demonstrated variable performance over time and between varying clinical environments (Whiting et al 2003;Mihai et al 2009) when localizing parathyroid lesions. Older studies, such as those by Liou et al (1996) have shown US to have sensitivities and specificities up to 75 per cent and 95 per cent respectively, compared to Tc 99m sestamibi which showed 87.5 per cent sensitivity and 100 per cent specificity.…”

“…The US equipment and sonographer expertise and protocols also have the potential to influence the accuracy of the ultrasound examination (Mihai et al 2009). US requires comprehensive and reproducible protocols as it is very operator-dependent, and localization accuracy may vary according to the level of experience of the sonographer (Yeh et al 2006).…”