Ann Surg Treat Res.  2015 Dec;89(6):300-305. 10.4174/astr.2015.89.6.300.

The role of preoperative ultrasonography, computed tomography, and sestamibi scintigraphy localization in secondary hyperparathyroidism

• Lee JB
• Kim WY
• Lee YM

• KMID: 2148304
• DOI: http://doi.org/10.4174/astr.2015.89.6.300

Abstract

PURPOSE
The role of preoperative localization studies is controversial in surgery of secondary hyperparathyroidism (sHPT). The aim of study was to evaluate the accuracy of preoperative ultrasonography (USG), CT, and 99mTc sestamibi scintigraphy (MIBI) in localizing enlarged parathyroid glands and to find the impact of correct localization in successful parathyroidectomy.
METHODS
We compared operative findings with the preoperative localization of ultrasonography, computerized tomography and sestamibi scintigraphy in 109 patients with sHPT and identified well-visualized locations of abnormal parathyroid glands by evaluating the sensitivity of each imaging study with regard to typical locations of glands. We investigated the effect of preoperative imaging localization on the surgical outcomes by measuring the intraoperative parathyroid hormone (ioPTH) decrement for positive or negative imaging localization.
RESULTS
USG (91.5%) had the highest sensitivity and MIBI (56.1%) had the lowest among 3 modalities. The sensitivity of combined USG and CT (95.0%) was the highest among combined 2 modalities. The combination of all 3 modalities (95.4%) had the highest sensitivity among the combinations of modalities. The reduction of ioPTH in patients with positive imaging localization (86.6%) was greater than negative imaging localization (84.2%), with no significant difference (P = 0.586). The recurrence or persistence of sHPT was not correlated with preoperative imaging localization (19 patients in negative, 16 in positive; P = 0.14).
CONCLUSION
Preoperative imaging localization contributed to surgical success but not to surgical outcomes. The combination of ioPTH measurement with imaging localization might be valuable for better surgical results in sHPT.

Keyword

Hyperparathyroidism; Ultrasonography; X-ray computed tomography; Technetium Tc 99m Sestamibi

MeSH Terms

Humans
Hyperparathyroidism
Hyperparathyroidism, Secondary*
Parathyroid Glands
Parathyroid Hormone
Parathyroidectomy
Radionuclide Imaging*
Recurrence
Technetium Tc 99m Sestamibi
Tomography, X-Ray Computed
Ultrasonography*
Parathyroid Hormone
Technetium Tc 99m Sestamibi

Figure

• 

  Fig. 1 Preoperative PTH and serum PTH levels after parathyroidectomy of negative and positive localization in secondary hyperparathyroidism. PTH, parathyroid hormone; ioPTH, intraoperative parathyroid hormone.

Reference

1. Tominaga Y, Tanaka Y, Sato K, Nagasaka T, Takagi H. Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism. Semin Surg Oncol. 1997; 13:78–86.

2. Martin KJ, Olgaard K, Coburn JW, Coen GM, Fukagawa M, Langman C, et al. Diagnosis, assessment, and treatment of bone turnover abnormalities in renal osteodystrophy. Am J Kidney Dis. 2004; 43:558–565.

3. Akerstrom G, Malmaeus J, Bergstrom R. Surgical anatomy of human parathyroid glands. Surgery. 1984; 95:14–21.

4. Roy M, Mazeh H, Chen H, Sippel RS. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg. 2013; 37:102–106.

5. Loftus KA, Anderson S, Mulloy AL, Terris DJ. Value of sestamibi scans in tertiary hyperparathyroidism. Laryngoscope. 2007; 117:2135–2138.

6. Alkhalili E, Tasci Y, Aksoy E, Aliyev S, Soundararajan S, Taskin E, et al. The utility of neck ultrasound and sestamibi scans in patients with secondary and tertiary hyperparathyroidism. World J Surg. 2015; 39:701–705.

7. Vulpio C, Bossola M, De Gaetano A, Maresca G, Bruno I, Fadda G, et al. Usefulness of the combination of ultrasonography and 99mTc-sestamibi scintigraphy in the preoperative evaluation of uremic secondary hyperparathyroidism. Head Neck. 2010; 32:1226–1235.

8. Lai EC, Ching AS, Leong HT. Secondary and tertiary hyperparathyroidism: role of preoperative localization. ANZ J Surg. 2007; 77:880–882.

9. Perie S, Fessi H, Tassart M, Younsi N, Poli I, St Guily JL, et al. Usefulness of combination of high-resolution ultrasonography and dual-phase dual-isotope iodine 123/technetium Tc 99m sestamibi scintigraphy for the preoperative localization of hyperplastic parathyroid glands in renal hyperparathyroidism. Am J Kidney Dis. 2005; 45:344–352.

10. Kawata R, Kotetsu L, Takamaki A, Yoshimura K, Takenaka H. Ultrasonography for preoperative localization of enlarged parathyroid glands in secondary hyperparathyroidism. Auris Nasus Larynx. 2009; 36:461–465.

11. Echenique Elizondo M, Diaz-Aguirregoitia FJ, Amondarain JA, Vidaur F. Intraoperative monitoring of intact PTH in surgery for renal hyperparathyroidism as an indicator of complete parathyroid removal. World J Surg. 2005; 29:1504–1509.

12. Seehofer D, Rayes N, Klupp J, Steinmuller T, Ulrich F, Muller C, et al. Predictive value of intact parathyroid hormone measurement during surgery for renal hyperparathyroidism. Langenbecks Arch Surg. 2005; 390:222–229.

13. Lokey J, Pattou F, Mondragon-Sanchez A, Minuto M, Mullineris B, Wambergue F, et al. Intraoperative decay profile of intact (1-84) parathyroid hormone in surgery for renal hyperparathyroidism: a consecutive series of 80 patients. Surgery. 2000; 128:1029–1034.

14. Barczynski M, Cichon S, Konturek A, Cichon W. A randomised study on a new cost-effective algorithm of quick intraoperative intact parathyroid hormone assay in secondary hyperparathyroidism. Langenbecks Arch Surg. 2005; 390:121–127.

15. National Kidney Foundation. K/DOQI clinical practice guidelines for bone metabolism and disease in chronic kidney disease. Am J Kidney Dis. 2003; 42:4 Suppl 3. S1–S201.

16. Trombetti A, Stoermann C, Robert JH, Herrmann FR, Pennisi P, Martin PY, et al. Survival after parathyroidectomy in patients with end-stage renal disease and severe hyperparathyroidism. World J Surg. 2007; 31:1014–1021.

17. Madorin C, Owen RP, Fraser WD, Pellitteri PK, Radbill B, Rinaldo A, et al. The surgical management of renal hyperparathyroidism. Eur Arch Otorhinolaryngol. 2012; 269:1565–1576.

18. Saengsuda Y. The accuracy of 99m Tc-MIBI scintigraphy for preoperative parathyroid localization in primary and secondary-tertiary hyperparathyroidism. J Med Assoc Thai. 2012; 95:Suppl 3. S81–S91.

19. Hindie E, Urena P, Jeanguillaume C, Melliere D, Berthelot JM, Menoyo-Calonge V, et al. Preoperative imaging of parathyroid glands with technetium-99m-labelled sestamibi and iodine-123 subtraction scanning in secondary hyperparathyroidism. Lancet. 1999; 353:2200–2204.

20. Takagi H, Tominaga Y, Uchida K, Yamada N, Morimoto T, Yasue M. Image diagnosis of parathyroid glands in chronic renal failure. Ann Surg. 1983; 198:74–79.

21. Kohri K, Ishikawa Y, Kodama M, Katayama Y, Iguchi M, Yachiku S, et al. Comparison of imaging methods for localization of parathyroid tumors. Am J Surg. 1992; 164:140–145.

22. Adalet I, Hawkins T, Clark F, Wilkinson R. Thallium-technetium-subtraction scintigraphy in secondary hyperparathyroidism. Eur J Nucl Med. 1994; 21:509–513.

23. Mohammadi A, Moloudi F, Ghasemi-Rad M. Preoperative localization of parathyroid lesion: diagnostic usefulness of color doppler ultrasonography. Int J Clin Exp Med. 2012; 5:80–86.

24. Caldarella C, Treglia G, Pontecorvi A, Giordano A. Diagnostic performance of planar scintigraphy using ⁹⁹mTc-MIBI in patients with secondary hyperparathyroidism: a meta-analysis. Ann Nucl Med. 2012; 26:794–803.

25. Harari A, Mitmaker E, Grogan RH, Lee J, Shen W, Gosnell J, et al. Primary hyperparathyroidism patients with positive preoperative sestamibi scan and negative ultrasound are more likely to have posteriorly located upper gland adenomas (PLUGs). Ann Surg Oncol. 2011; 18:1717–1722.

26. Inabnet WB. Intraoperative parathyroid hormone monitoring. World J Surg. 2004; 28:1212–1215.

27. Weber T, Zeier M, Hinz U, Schilling T, Buchler MW. Impact of intraoperative parathyroid hormone levels on surgical results in patients with renal hyperparathyroidism. World J Surg. 2005; 29:1176–1179.

28. Yamashita H, Cantor T, Uchino S, Watanabe S, Ogawa T, Moriyama T, et al. Sequential changes in plasma intact and whole parathyroid hormone levels during parathyroidectomy for secondary hyperparathyroidism. World J Surg. 2005; 29:169–173.