Abstract
44 consecutive patients with confirmed primary hyperparathyroidism (HPT) undergoing surgery were prospectively enrolled in the study. There were 13 (29.5%) men and 31 (70.5%) women with an overall median age of 59 years (range 23–78 years). Prior to successful parathyroidectomy both 99Tcm-sestamibi/99Tcm-pertechnetate subtraction scintigraphy (SS) and helical CT were performed, and the results of imaging studies were compared against intraoperative findings. Final histopathology showed 40 (90.9%) solitary parathyroid (PT) adenomata (median size 18 mm, range 8–40 mm), that were in an ectopic location in 13 (32.5%) patients. Moreover, 3 (6.8%) patients had multiglandular disease (one patient with two PT adenomata, two patients with PT hyperplasia), while one (2.3%) patient had a PT carcinoma. The sensitivity and positive predictive value were 86.0% and 97.4% for SS, 88.1% and 94.9% for CT, and 100% and 97.4% for the combination of SS and CT, respectively. Calcium and parathyroid hormone (PTH) serum levels, and the mean size of the removed PT glands of patients with false negative results were lower than that of those with true positive results, but the difference was not significant. Among patients with solitary PT tumours (N=41) the sensitivity was 88.1% and 90.3% for SS and CT-scan, respectively. In conclusion, our study confirms the usefulness of SS, which should be the initial test for patients undergoing parathyroidectomy. However, the strategy of performing two tests in each patient with primary HPT could be of limited utility when the initial SS is positive.
References
1 Clark OH. Diagnosis of primary hyperparathyroidism. In: Clark OH, Duh Q-Y, editors. Textbook of endocrine surgery. Philadelphia: WB Saunders, 1997:297–301.
2 Borley NR, Collins REC, O'Doherty M, Coakley A. Technetium-99m-sestamibi parathyroid localization is accurate enough for scan-directed unilateral neck exploration. Br J Surg 1996;83:989–99.
3 Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122:998–1003.
4 Bonjer HJ, Bruining HA, Pols HAP, de Herden WW, van Hijck CHJ, Breeman WAP, et al. Intraoperative nuclear guidance in benign hyperparathyroidism and parathyroid cancer. Eur J Nucl Med 1997;24:246–51.
5 Naitoh T, Gagner M, Garcia-Ruiz A, Heniford BT. Endoscopic endocrine surgery in the neck. An initial report of endoscopic subtotal parathyroidectomy. Surg Endosc 1998;12:202–5.
6 Inabnet WB, Fulla Y, Richard B, Bonnichou P, Icard P, Chapuis Y. Unilateral neck exploration under local anesthesia: the approach of choice for asymptomatic primary hyperparathyroidism. Surgery 1999;126:1004–10.
7 Miccoli P, Bendinelli C, Berti P, Vignali E, Pinchera A, Marcocci C. Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery 1999;126:1117–22.
8 Van Dalen A, Smit CP, van Vroonhoven TJMV, Burger H, de Lange EE. Minimally invasive surgery for solitary parathyroid adenomata in patients with primary hyperparathyroidism: role of US with supplemental CT. Radiology 2001;220:631–9.
9 Lumachi F, Zucchetta P, Marzola MC, Boccagni P, Angelini F, Bui F, et al. Advantages of combined technetium-99m-sestamibi scintigraphy and high-resolution ultrasonography in parathyroid localization: comparative study in 91 patients with primary hyperparathyroidism. Eur J Endocrinol 2000;143:755–60.
10 Lumachi F, Zucchetta P, Varotto S, Polistina F, Favia G, D'Amico DF. Noninvasive localization procedures in ectopic hyperfunctioning parathyroid tumors. Endocr Relat Cancer 1999;6:123–5.
11 Weber AL, Randolph G, Aksoy FG. The thyroid and parathyroid glands. CT and MRI imaging and correlation with pathology and clinical findings. Radiol Clin North Am 2000;38:1105–29.
12 Gotway MB, Leung JWT, Gretchen AG, Litt HI, Reddy GP, Morita ET, et al. Hyperfunctioning parathyroid tissue: spectrum of appearances on noninvasive imaging. AJR Am J Roentgenol 2002;179:495–502.
13 Geatti O, Shapiro B, Orsolon PG, Proto G, Guerra UP, Antonucci F, et al. Localization of parathyroid enlargement: experience with technetium-99m-methoxyisobutylisonitrile and tallium-201 scintigraphy, ultrasonography and computed tomography. Eur J Nucl Med 1994;21:17–22.
14 Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, et al. Values of ultrasonography sestamibi scintigraphy and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism. World J Surg 1996;20:835–40.
15 Staudenherz A, Abela C, Niederle B, Steiner E, Helbich T, Puig S, et al. Comparison and histopathological correlation of three parathyroid imaging methods in a population with a high prevalence of concomitant thyroid diseases. Eur J Nucl Med 1997;24:143–9.
16 Apostolopoulos DJ, Houstoulaki E, Giannakenas C, Alexandrides T, Spiliotis J, Nikiforidis G, et al. Technetium-99m-tetrofosmin for parathyroid scintigraphy: comparison to thallium-technetium scanning. J Nucl Med 1998;39:1433–41.
17 Song AU, Phillips TE, Edmond CV, Moore DW, Clark SK. Success of preoperative imaging and unilateral neck exploration for primary hyperparathyroidism. Otolaryngol Head Neck Surg 1999;121:393–7.
18 Haber RS, Kim CK, Inabnet WB. Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with 99mtechnetium sestamibi scintigraphy. Clin Endocrinol 2002;57:214–49.
19 Civelek AC, Ozalp E, Donovan P, Udelsman R. Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. Surgery 2002;131:149–57.
20 Tziakouri C, Eracleous E, Skannavis S, Pierdies A, Symeonides P, Gourtsoyiannis N. Value of ultrasonography, CT and MRI imaging in the diagnosis of primary hyperparathyroidism. Acta Radiol 1996;37:720–6.
21 Okada Y, Mizutani Y, Tekouchi H, Shigeno C, Konishi J, Yoshida O. Preoperative imaging for parathyroid localization in primary hyperparathyroidism. Int J Urol 1997;4:38–42.
22 Lumachi F, Ermani M, Basso S, Zucchetta P, Borsato N, Favia G. Localization of parathyroid tumours in the minimally invasive era: which technique should be chosen? Population based analysis of 253 patients undergoing parathyroidectomy and factors affecting parathyroid glands detection. Endocr Relat Cancer 2001;8:63–9.
