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. 2021 Aug;406(5):1615-1624.
doi: 10.1007/s00423-021-02191-z. Epub 2021 May 16.

Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery

Anne Hendricks  1 , Christina Lenschow  1 , Matthias Kroiss  2 , Andreas Buck  3 , Ralph Kickuth  4 , Christoph-Thomas Germer  1 , Nicolas Schlegel  5
Affiliations

Evaluation of diagnostic efficacy for localization of parathyroid adenoma in patients with primary hyperparathyroidism undergoing repeat surgery

Anne Hendricks et al. Langenbecks Arch Surg. 2021 Aug.

Abstract

Purpose: Repeat surgery in patients with primary hyperparathyroidism (pHPT) is associated with an increased risk of complications and failure. This stresses the need for optimized strategies to accurately localize a parathyroid adenoma before repeat surgery is performed. However, evidence on the extent of required diagnostics for a structured approach is sparse.

Methods: A retrospective single-center evaluation of 28 patients with an indication for surgery due to pHPT and previous thyroid or parathyroid surgery was performed. Diagnostic workup, surgical approach, and outcome in terms of complications and successful removement of parathyroid adenoma with biochemical cure were evaluated.

Results: Neck ultrasound, sestamibi scintigraphy, C11-methionine PET-CT, and selective parathyroid hormone venous sampling, but not MRI imaging, effectively detected the presence of a parathyroid adenoma with high positive predictive values. Biochemical cure was revealed by normalization of calcium and parathormone levels 24-48h after surgery and was achieved in 26/28 patients (92.9%) with an overall low rate of complications. Concordant localization by at least two diagnostic modalities enabled focused surgery with success rates of 100%, whereas inconclusive localization significantly increased the rate of bilateral explorations and significantly reduced the rate of biochemical cure to 80%.

Conclusion: These findings suggest that two concordant diagnostic modalities are sufficient to accurately localize parathyroid adenoma before repeat surgery for pHPT. In cases of poor localization, extended diagnostic procedures are warranted to enhance surgical success rates. We suggest an algorithm for better orientation when repeat surgery is intended in patients with pHPT.

Keywords: Diagnostics; Imaging; Preoperative localization; Primary hyperparathyroidism (pHPT); Repeat surgery.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Cure rate and operative aspects with regard to concordant preoperative diagnostics. A The number of patients with biochemical cure is shown for the group with <2 or ≥2 concordant imaging. B The number of patients that required bilateral exploration is shown for the group with <2 or ≥2 concordant imaging
Fig. 2
Fig. 2
Algorithm for preoperative imaging before repeat surgery. For details see text
See this image and copyright information in PMC

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