Use of Preoperative Imaging in Primary Hyperparathyroidism

Abstract

Context Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. Objective Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. Design, Setting, and Patients This is a retrospective cohort review of 1,485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. Main Outcome Measures Surgical cure rate, concordance of imaging with operative findings, and imaging performance. Results The overall cure rate was 94.1% (95% CI 0.93-0.95). Cure rate was significantly improved if sestamibi/SPECT was concordant with operative findings (95.9% vs. 92.5%, p = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, p = 0.59). Despite having a low number of cases (n=28), 4-D CT scan outperformed (higher sensitivity, specificity, PPV, NPV) all imaging modalities in multi-glandular disease and double adenomas, and sestamibi/SPECT in single adenomas. Conclusions Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4-D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism

“…A total of 23 studies investigated PHPT patient populations before initial parathyroid surgery. 8,[10][11][12][13][14][15][16][17][19][20][21][22][23][24][26][27][28][29][30][31][32][33] However, 3 studies reported specifically on patients with PHPT with recurrent/reoperative disease. 9,25,28 Characteristics of parathyroid disease are summarized in eTable 2 in the Supplement.…”

“…In subsets of patients with single-gland parathyroid disease (SGD), sensitivity of 4D-CT localization ranged from 58% to 92%, contrasted with 43% to 67% in patients with multigland parathyroid disease (MGD). 10,12,17,23,32,33 DECT & PET/CT Only 5 studies investigated the relatively novel application of DECT and PET/CT for PHPT patients. The mean values for DECT localization were 77.5% accuracy, 87.0% sensitivity, and 88.5% PPV.…”

“…10,14,19,26,33 In patients with SGD, sensitivity ranged from 53% to 80%, contrasted with 4% to 41% in patients with MGD. 10,12,17,23,32,33,35,36 Ultrasonography Of all imaging modalities included in this review, ultrasonography had the lowest and most variable sensitivity values as a first-line tool for identifying PHPT, ranging from 19% to 84%. Average values for ultrasound localization were: 57.4% accuracy, 55.3% sensitivity, 85.0% specificity, 85.2% PPV, and 61.1% NPV.…”

“…Meta-analyses included 23 studies in this review. [8][9][10][11][12][13][16][17][18][19][20][21][22][23][25][26][27][28][29][30][31][32][33] As seen in Figure 2, the pooled sensitivity for 4D-CT in the localization of PHPT in 4695 patients was 81% (95% CI, 77%-84%; I 2 , 88%). In contrast, the pooled sensitivity for sestamibi-SPECT/ CT in 4791 patients was 65% (95% CI, 59%-70%; I 2 , 93%).…”

Parathyroid Imaging: Past, Present, and Future

“…They encouraged the main utility of 4DCT is in the setting of negative 99m Tc-sestamibi SPECT/CT. In 28 patients where 4DCT was performed out of 1485 total adult patients in their retrospective cohort study, Broome et al suggested 4DCT performed better than 99Tc-sestamibi SPECT in single adenomas and better than other modalities investigated for MGD and double parathyroid adenoma (163). These findings were however underpowered and compared 4DCT to SPECT rather than SPECT/CT.…”