Primary Hyperparathyroidism: Is Image Localization Alone Sufficient to Ensure Long-Term Cure in Unifocal Disease?

Abstract

Introduction: Advances in imaging have facilitated precise preoperative localization and focused resection of hyperfunctional parathyroids in primary hyperparathyroidism (PHPT). Combining imaging techniques or a "dual" approach, when concordant, improves adenoma-localizing accuracy above individual modalities. This study sought to assess biochemical cure and failure rates (persistence or recurrence) of surgery directed by dual imaging alone in PHPT.Methodology: This observational, single-center analysis comprised 31 patients diagnosed with PHPT and imaged with both ultrasound (USG) of the neck and sestamibi scintigraphy. The extent of surgery was based solely on inter-modality concurrence for adenoma localization; imaging-concordant patients underwent focused parathyroidectomy, whereas discordant patients necessitated neck exploration (with extent altered according to scintigraphic lesion lateralization). No intraoperative localizing adjuncts were used.Results: Twenty-three patients had concordant imaging, of which 19 underwent focused exploration, with sensitivity and positive predictive value (PPV) for dual imaging of 100% and 95.7%, respectively. The overall sensitivity and PPV were 92.9% and 89.7% for USG alone and 100% and 93.6% for scintigraphy, respectively. The mean age and prevalence of thyroid disease were significantly higher in the discordant group. All patients achieved postoperative normocalcemia. There were no cases of persistent or recurrent hyperparathyroidism on follow-up.Conclusions: In the imaging-concordant setting, focused surgery may be safely performed with the omission of other adjuncts for localization. Older age and concomitant thyroid pathology predispose to discordant imaging and are risk factors for surgical failure when attempting an image-directed approach. Neck exploration is an alternative in these patients with excellent cure rates and acceptable morbidity.

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

“…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 39 . Eleven patients in our cohort had coexisting thyroid pathology and in seven patients (63.6%) 11 C‐methionine PET/CT correctly identified the adenoma.…”

“…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. 39 Eleven patients in our cohort had coexisting thyroid pathology and in seven patients (63.6%) 11 C-methionine PET/CT correctly identified the adenoma. No difference in prevalence of coexisting thyroid disease was observed between the patients that did and that did not localise on 11 Cmethionine PET/CT.…”