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Preoperative localization for parathyroid surgery in patients with primary hyperparathyroidism

Linwah Yip, MD
Shonni J Silverberg, MD
Ghada El-Hajj Fuleihan, MD, MPH
Section Editors
Sally E Carty, MD, FACS
Clifford J Rosen, MD
Deputy Editor
Wenliang Chen, MD, PhD


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) [1]. 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'.)


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 [5]. 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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Literature review current through: Nov 2017. | This topic last updated: Aug 29, 2017.
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