Preoperative localization for parathyroid surgery in patients with primary hyperparathyroidism
- Linwah Yip, MD
Linwah Yip, MD
- Associate Professor of Surgery
- University of Pittsburgh School of Medicine
- Shonni J Silverberg, MD
Shonni J Silverberg, MD
- Professor of Medicine
- Columbia University College of Physicians and Surgeons
- Ghada El-Hajj Fuleihan, MD, MPH
Ghada El-Hajj Fuleihan, MD, MPH
- Professor of Medicine
- American University of Beirut Medical Center, Lebanon
- Section Editors
- Sally E Carty, MD, FACS
Sally E Carty, MD, FACS
- Section Editor — Endocrine Surgery
- Professor, Chief, Division of Endocrine Surgery
- University of Pittsburgh School of Medicine
- Clifford J Rosen, MD
Clifford J Rosen, MD
- Section Editor — Bone Disease
- Professor of Nutrition
- University of Maine
- Professor of Medicine
- Tufts University School of Medicine
Primary hyperparathyroidism is usually caused by a solitary benign adenoma (80 to 85 percent) but can also be due to double adenomata (2 to 5 percent), diffuse or nodular hyperplasia (10 to 15 percent), or parathyroid carcinoma (<1 percent) . An open four-gland parathyroid exploration has traditionally been considered the gold standard for patients undergoing surgery for primary hyperparathyroidism. However, a more focused, minimally invasive approach to parathyroid surgery has been adopted at many centers [2,3].
Localization techniques are primarily used in patients who have biochemically confirmed sporadic primary hyperparathyroidism to identify patients who are candidates for a minimally invasive approach. They are also important in patients who have persistent or recurrent disease, or who have had prior cervical exploration and require remedial surgery. Patients with hereditary primary hyperparathyroidism generally undergo bilateral parathyroid exploration, even in the event of a positive localizing study, because of the potential for asymmetric hyperplasia. Localization studies, in conjunction with intraoperative parathyroid hormone testing, can help minimize the extent of surgical dissection, identify concurrent thyroid pathology, and detect ectopic parathyroid tissue, the latter being a particular advantage for patients who had prior failed parathyroid exploration. However, localization studies should not be used to diagnose or confirm the diagnosis of hyperparathyroidism or determine the need for surgery. Use of localization studies does not override the recommendation that parathyroid surgery should only be performed by highly experienced surgeons [2,4].
The techniques and role of preoperative localization in patients with primary hyperparathyroidism will be reviewed here. Decision making regarding the role of surgical therapy, the details of surgical management in these patients, and the role of surgery for secondary hyperparathyroidism in patients with end-stage renal disease is discussed elsewhere. (See "Indications for parathyroidectomy in end-stage renal disease" and "Parathyroid exploration for primary hyperparathyroidism", section on 'Focused parathyroid exploration' and "Primary hyperparathyroidism: Management", section on 'Candidates for surgery'.)
ROLE OF PREOPERATIVE LOCALIZATION
The diagnosis of primary hyperparathyroidism should be made based upon biochemical findings. Imaging studies are not used as a diagnostic tool because of high false-positive rates, which can range from 5 to 25 percent (table 1). In addition, a single-focus positive imaging result does not reliably exclude the presence of multiglandular parathyroid disease . Rather, preoperative localization studies help plan the operative approach in patients who have a biochemically confirmed diagnosis of primary hyperparathyroidism, and in whom other pathologies have been appropriately ruled out (eg, familial benign hypercalcemic hypocalciuria). For patients undergoing initial surgery, these studies are predominantly used to determine whether or not a patient is a candidate for a minimally invasive approach [6-8]. (See "Parathyroid hormone assays and their clinical use".)
Available radiologic expertise is an important factor in choosing the type of localization testing to be performed. Localization images should be displayed and available intraoperatively, since review during exploration often usefully guides successful surgery. (See 'Imaging modalities' below.)
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- ROLE OF PREOPERATIVE LOCALIZATION
- Minimally invasive and unilateral parathyroidectomy
- Reoperation for recurrent or persistent hyperparathyroidism
- Bilateral neck exploration
- IMAGING MODALITIES
- Sestamibi scintigraphy
- - SPECT
- - SPECT and CT fusion
- - Subtraction thyroid scan
- Four-dimensional computed tomography
- Magnetic resonance imaging
- Positron emission tomography and CT
- Invasive localization
- - Selective venous sampling
- - Selective arteriography
- NEGATIVE IMAGING
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS