Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

Abstract

Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2–22%, and the rate of recHPT is 1–15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.

Persistent and Recurrent Primary Hyperparathyroidism: Intraoperative Supplemental Methods, Basic Principles of Surgery, and Other Treatment Options

“…Before reoperative parathyroid surgery, the diagnosis of primary HPT should be confirmed, and the indication for surgery should be established according to the patient’s symptoms and target organ involvement. [ 32 ]…”

“…It should be aimed to obtain at least 2 positive and concordant localization studies. [ 1 , 25 , 32 ] Reoperation should be applied to patients with positive localization studies. Approximately 95% of abnormal glands can be localized, especially when imaging modalities are combined.…”

“…The previous surgical complications and current health status of the patient should be evaluated. [ 32 ] . Before the reoperation, it should be tried to predict whether there is a single or multiple gland disease, the locations of the abnormal gland or glands, the number of normal parathyroid glands removed, whether the pathological gland is the only gland remaining, and a surgical strategy should be determined accordingly.…”

“…[26] Before reoperative parathyroid surgery, the diagnosis of primary HPT should be confirmed, and the indication for surgery should be established according to the patient's symptoms and target organ involvement. [32] Although the rate of multi-gland disease is higher in persistent and recurrent patients than in primary surgery, the major cause is adenoma. Pre-operative imaging is mandatory in patients with surgical indications.…”

Clinical adaptation of auxiliary methods and multidisciplinary approach to changing trends in parathyroid surgery

“…However, it is an invasive method and generally used for recurrent or persistent disease. [11,12] In addition to preoperative imaging studies, there are also some auxiliary methods used as a guide during surgery. While the use of an intraoperative gamma probe (IO-GP) is a helpful guide in finding the pathological gland, intraoperative parathormon (IO-PTH) allows us to make sure that the pathological gland is removed and to safely terminate the operation.…”