Localization procedures in patients requiring reoperation for hyperparathyroidism

Abstract

Numerous techniques have been described for the preoperative localization of hyperfunctioning parathyroid glands. During the past 2 years, 18 patients have had operations for persistent (14) or recurrent (4) hyperparathyroidism. One or more hyperfunctioning parathyroid glands were identified at operation in all but 1 patient and all but 2 patients became normocalcemic. Eighteen patients had ultrasonography, 17 patients had computed tomography (CT) scanning, and 13 patients had selective venous sampling (SVS) for parathyroid hormone (PTH) assay. These studies correctly identified the lesion(s) in 9 (50%), 8 (47%), and 9 (69%) of the patients, respectively. In 3 patients, probable parathyroid tumors were identified by ultrasonography and confirmed by aspiration biopsy cytology under ultrasonic guidance. All had parathyroid tumors confirmed at operation. The smallest tumor localized by ultrasonography was 0.6×0.6×0.6 cm and by CT scanning was 0.9×0.9×0.8 cm. There was 1 false‐positive CT scan and 1 false‐positive SVS. In the 2 patients who failed to become normocalcemic no localization study was positive. One of these patients subsequently had a 0.6×0.6×0.5 cm mediastinal adenoma localized by CT scan, nuclear magnetic resonance, and SVS. The tumor was removed via median sternotomy and the patient is now normocalcemic. Digital angiography has recently been helpful for “mapping out” the venous pattern for venous sampling for PTH. Ultrasonography and CT scanning complemented each other, since one or the other of these studies was positive in 15 patients, yet only 2 patients had both a positive ultrasound and CT scan. When any 2 localizing tests suggested the same site for the parathyroid lesion, the tumor was found in all cases. One patient developed post‐pericardotomy syndrome after a medium sternotomy, but there were no other complications. Localization procedures expedite surgical treatment, decrease morbidity, and are strongly recommended in patients requiring reoperation for hyperparathyroidism.

The role of selective venous sampling in the management of persistent hyperparathyroidism revisited

“…The diagnostic value of SVS is based on the assumption that the regional drainage of each one of the four parathyroid glands is into the adjacent superior, middle, and inferior thyroid veins respectively (20). Despite potential anatomical variations, SVS is successful in predicting the side of a pathological parathyroid gland in 39-93% of patients with PHPT (20)(21)(22)(24)(25)(26)(27)(28)(29)(30)(31) and, more importantly, in 66-75% of patients with negative noninvasive studies (21,27,32). The major limitation of SVS, however, is that it pinpoints the area of venous drainage of a hyperactive gland rather than its exact anatomical location.…”

Reoperative parathyroidectomy in the era of localization technology

“…1,5 Failure to identify an adenoma at the time of initial surgery, however, suggests that the lesion may not be an obvious one or may be in an ectopic site, and most endocrine surgeons therefore perform preoperative localizing studies prior to reoperation. Most large reports of reoperative parathyroid surgery are either from the older literature 4,6 or have been collected over a prolonged period of time. 7 They, therefore, do not represent the many recent technical advances that have occurred in parathyroid gland localization, such as high-resolution spiral CT scanning 8 and magnetic resonance imagery MR. 9,10 Digital angiography and venography for selective venous sampling, 11 iodine 123 /sestamibi 12 scanning, and the availability of high-resolution small-part ultrasonography.…”

Operative strategie bei persistenz und rezidiv in der chirurgie des prim�ren hyperparathyreoidismus

“…Die Sonographie stellt als nichtinvasive und konstengfinstige Methode sowohl beim Ersteingriff als auch beim Rezidiveingriff das Verfahren der ersten Wahl dar, wenngleich die Erfolgsrate mit 12-60% sehr gering ist [2,3,6,10,21]. Eine Erfolgsrate von 87% [16] ist als auBergew6hnlich anzusehen.…”

“…Trotz ingesamt schlechterer Ergebnisse als bei der Kernspintomographie [10,21] ist die Computertomographie das beste Verfahren in der Darstellung von mediastinalen Nebenschilddrfisen. Dubost et al [13] verzeichneten eine Erfolgsrate von 63%.…”

“…Die Erfolgsrate dieses Verfahrens ist abh/ingig von GrSBe und Gewicht des Nebenschilddrfisenadenoms, insgesamt liegt die Erfolgsrate abet nur bei ca. 40% [10,21].…”