Elsevier

Surgery

Volume 144, Issue 1, July 2008, Pages 74-79
Surgery

Original Communication
Factors Contributing to Negative Parathyroid Localization: An Analysis of 1000 patients

https://doi.org/10.1016/j.surg.2008.03.019Get rights and content

Background

Localizing studies are the key for determining the optimal surgical strategy in patients with primary hyperparathyroidism (HP). Most of the data in the literature are retrospective in nature and from analysis on a per patient basis. This is a prospective study looking at the characteristics of the patient and the gland that determine the likelihood of an abnormal parathyroid to be detected by ultrasonography (US) and sestamibi scan (MIBI).

Methods

This is a prospective analysis of 1000 consecutive patients with HP who underwent parathyroidectomy at a tertiary care center. The study group included HP with single gland disease (63%), double adenoma (15%), as well as hyperplasia (15%), familial HP (2%), and secondary/tertiary HP (6%). All patients underwent surgeon-performed neck US followed by MIBI scan. Univariate logistic regression and multivariate analyses were performed on pre- and intraoperative variables.

Results

A total of 1845 abnormal glands were analyzed. Overall, US was superior to MIBI for the detection of abnormal glands in all subgroups. On multivariate analysis, body mass index (BMI), gland size, and gland volume were the statistically significant independent factors predicting detection by both US and MIBI in primary HP. The sensitivity of US was better for single gland disease than for multigland disease in primary HP, but the sensitivity of MIBI was similar in both groups. For a given size, hyperplastic glands in primary HP imaged less well with US and MIBI than in familial or secondary/tertiary HP.

Conclusion

This prospective study demonstrates that BMI and gland size independently predict accurate detection of abnormal parathyroid glands by US and MIBI in sporadic primary HP. Understanding the factors that affect the accuracy of parathyroid localization tests will allow the surgeon to develop a successful surgical strategy in a given patient.

Section snippets

Material and methods

A total of 1,089 consecutive patients underwent PTX between November 1999 to August 2006 for HP at the Cleveland Clinic, Ohio. Excluding patients with prior neck operations, 1,000 consecutive patients with first-time HP who underwent PTX were analyzed and were categorized as follows: SPHP with single gland disease (63%), double adenoma (15%), hyperplasia (15%), secondary/tertiary HP (6%) and familial HP (2%). All subjects in the secondary and tertiary group had chronic renal disease. Neck US

Demographic data

Of the total of 1845 abnormal glands analyzed, 630 involved single adenomas in SPHP, 291 double adenomas in SPHP, 586 hyperplasia in SPHP, 265 hyperplasia in secondary/tertiary HP, and 73 hyperplasia in familial HP. The Table summarizes the demographic data. With respect to etiology, patients with SPHP were older (mean, 60 years) when operated on, while patients with secondary/tertiary HP were the youngest group (mean, 46 years). There were no differences in BMI between subgroups.

Univariate logistic regression analysis, preoperative variables

Greater BMI

Discussion

This is the largest prospective study analyzing the factors affecting the sensitivity of preoperative localization studies for HP. A successful preoperative localization of parathyroid pathology is essential for a focal neck exploration; nevertheless, most of the relevant data are retrospective in nature. In this study, we looked systematically at parameters that might predict an accurate preoperative MIBI scan or US for first-time SPHP in a prospective manner by performing a bilateral neck

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  • Cited by (0)

    Presented as a poster at the Twenty-Eighth Annual Meeting of the American Association of Endocrine Surgeons, Tucson, Arizona, April 28–May 1, 2007.

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