Long‐term Cure of Primary Hyperparathyroidism After Scan‐Directed Parathyroidectomy: Outcomes From A UK Endocrine Surgery Unit

Abstract

Background Two‐decades ago, the advent of sestamibi scintigraphy led to an enthusiastic acceptance of minimally invasive parathyroidectomy (MIP) in most surgical centres. More recently, concerns have been raised about the efficacy of limited neck exploration and some surgeons proposed bilateral neck exploration to be (once again) the gold standard operation for primary hyperparathyroidism in 2020s. Methods A departmental database was used to identify patients who had MIP after concordant dual localisation with sestamibi scintigraphy and ultrasound scans. Long‐term follow‐up data were obtained from electronic patient records to ascertain any further treatment for recurrent disease and confirm most recent biochemical status. Patients with negative localisation scans and those with familial disease were excluded from analysis. Results Between June 2001 and August 2014 a total of 404 patients (108 M:296F, median age 63 years, range 17–90 years) underwent MIP and had normalisation of calcium in first 6 weeks after the operation. Information on electronic patient records were missing in 14 patients; therefore, data on 390 patients were analysed. During median follow‐up of 78 months (IQR: 21.25–111.75 months), 375 patients had normocalcaemia (2.36 mmol/L, IQR: 2.29–2.44 mmol/L) at a median 75 months, (IQR: 20–118 months) after their operation. Overall, 15 (3.85%) patients had biochemical evidence of recurrent disease (2.70 mmol/L IQR: 2.63–2.75 mmol/L) at 92 months (Range: 6–196) after initial operation. Of these, 5 (1.28%) patients underwent a second parathyroid procedure. Conclusion Recurrence after scan‐directed unilateral neck exploration occurred in 4% of patients after a long disease‐free interval. Only one patient had recurrent disease within 1‐year of primary surgery. The data suggest that bilateral neck exploration at the time of initial operation, in this selected cohort, is unlikely to have uncovered multi‐gland disease and prevent disease recurrence. Focused parathyroidectomy in patients with convincing localisation studies should continue.

Single-Center Experience of Parathyroidectomy Using Intraoperative Parathyroid Hormone Monitoring

“…Considering the low incidence of HPT, our sample of 47 patients was meaningful to evaluate the outcome of parathyroid surgery using IOPTH. Although there are studies suggesting that preoperative localization imaging is a powerful tool for the successful resection of pathologic parathyroid glands in experienced centers, the addition of the IOPTH assay should be considered to prevent surgical failure for novice endocrine surgeons or inexperienced hospitals [ 50 ].…”

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

“…[ 60 ] In the long-term (mean: 78 months (21–112 months) follow-up of patients with positive scintigraphy and USG and underwent minimally invasive parathyroidectomy, the recurrence rate was reported as 3.85%. [ 61 ] However, data on long-term follow-up and recurrence after the initial successful parathyroidectomy are limited. In recent studies, it is noteworthy that the recurrence rate increases with long-term follow-up.…”

“…[ 11 , 59 ] Median recurrence times in long-term follow-up were determined as 77 months in a study, 92 months in other study and 12.2 years in another study. [ 11 , 61 , 62 ]…”

“…In the light of a better understanding of asymmetric hyperplasia and the information obtained from more sensitive third and fourth generation PTH tests and ioPTH monitoring; dormant disease needs to be better understood. [ 7 , 23 , 61 , 63 ]…”

Long‐Term Cure of Primary Hyperparathyroidism After Scan‐Directed Parathyroidectomy: Outcomes from a UK Endocrine Surgery Unit

“…In this issue, Patel and Mihai describe their long-term outcomes in a large cohort of patients undergoing minimally invasive parathyroidectomy (MIP) for a single parathyroid adenoma, after concordant dual localisation with Sestamibi scintigraphy and ultrasound scan [1]. They have demonstrated durable long-term outcomes utilising this approach in expert hands, without the use of intraoperative PTH measurement (IOPTH), reporting a very low recurrence rate of 3.85% in a cohort of 390 patients, with a median follow-up time of 78 months.…”