Original Communication| Volume 144, ISSUE 1, P74-79, July 2008

Factors Contributing to Negative Parathyroid Localization: An Analysis of 1000 patients


      Localizing studies are the key for determining the optimal surgical strategy in patients with primary hyperparathyroidism (HP). Most of the data in the literature are retrospective in nature and from analysis on a per patient basis. This is a prospective study looking at the characteristics of the patient and the gland that determine the likelihood of an abnormal parathyroid to be detected by ultrasonography (US) and sestamibi scan (MIBI).


      This is a prospective analysis of 1000 consecutive patients with HP who underwent parathyroidectomy at a tertiary care center. The study group included HP with single gland disease (63%), double adenoma (15%), as well as hyperplasia (15%), familial HP (2%), and secondary/tertiary HP (6%). All patients underwent surgeon-performed neck US followed by MIBI scan. Univariate logistic regression and multivariate analyses were performed on pre- and intraoperative variables.


      A total of 1845 abnormal glands were analyzed. Overall, US was superior to MIBI for the detection of abnormal glands in all subgroups. On multivariate analysis, body mass index (BMI), gland size, and gland volume were the statistically significant independent factors predicting detection by both US and MIBI in primary HP. The sensitivity of US was better for single gland disease than for multigland disease in primary HP, but the sensitivity of MIBI was similar in both groups. For a given size, hyperplastic glands in primary HP imaged less well with US and MIBI than in familial or secondary/tertiary HP.


      This prospective study demonstrates that BMI and gland size independently predict accurate detection of abnormal parathyroid glands by US and MIBI in sporadic primary HP. Understanding the factors that affect the accuracy of parathyroid localization tests will allow the surgeon to develop a successful surgical strategy in a given patient.
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        • Clark O.H.
        Surgical treatment of primary hyperparathyroidism.
        Adv Endocrinol Metab. 1995; 6: 1-16
        • Chen H.
        • Sokoll L.J.
        • Udelsman R.
        Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay.
        Surgery. 1999; 126 (discussion 1021-2): 1016-1021
        • Ryan Jr., J.A.
        • Eisenberg B.
        • Pado K.M.
        • Lee F.
        Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests.
        Arch Surg. 1997; 132 (discussion 890–1): 886-890
        • Fahy B.N.
        • Bold R.J.
        • Beckett L.
        • Schneider P.D.
        Modern parathyroid surgery: a cost-benefit analysis of localizing strategies.
        Arch Surg. 2002; 137 (discussion 922-3): 917-922
        • Prasannan S.
        • Davies G.
        • Bochner M.
        • Kollias J.
        • Malycha P.
        Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi.
        Aust N Z J Surg. 2007; 77: 774-777
        • 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 (discussion 839-40): 835-839
        • Casas A.T.
        • Burke G.J.
        • Mansberger A.R.
        • Sathyanarayana Jr.,
        • Wei J.P.
        Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism.
        Am J Surg. 1993; 166: 369-373
        • Arici C.
        • Cheah W.K.
        • Ituarte P.H.
        • Morita E.
        • Lynch T.C.
        • Siperstein A.E.
        • et al.
        Can localization studies be used to direct focused parathyroid operations?.
        Surgery. 2001; 129: 720-729
        • Irvin 3rd, G.L.
        • Sfakianakis G.
        • Yeung L.
        • Deriso G.T.
        • Fishman L.M.
        • Molinari A.S.
        • Foss J.N.
        Ambulatory parathyroidectomy for primary hyperparathyroidism.
        Arch Surg. 1996; 131: 1074-1078
        • Martin 2nd, R.C.
        • Greenwell D.
        • Flynn M.B.
        Initial neck exploration for untreated hyperparathyroidism.
        Am Surg. 2000; 66: 269-272
        • Mihai R.
        • Gleeson F.
        • Buley I.D.
        • Roskell D.E.
        • Sadler G.P.
        Negative imaging studies for primary hyperparathyroidism are unavoidable: correlation of sestamibi and high-resolution ultrasound scanning with histological analysis in 150 patients.
        World J Surg. 2006; 30: 697-704
        • Mehta N.Y.
        • Ruda J.M.
        • Kapadia S.
        • Boyer P.J.
        • Hollenbeak C.S.
        • Stack Jr., B.C.
        Relationship of technetium Tc 99m sestamibi scans to histopathological features of hyperfunctioning parathyroid tissue.
        Arch Otolaryngol Head Neck Surg. 2005; 131: 493-498
        • Bleier B.S.
        • LiVolsi V.A.
        • Chalian A.A.
        • Gimotty P.A.
        • Botbyl J.D.
        • Weber R.S.
        Technetium Tc 99m sestamibi sensitivity in oxyphil cell-dominant parathyroid adenomas.
        Arch Otolaryngol Head Neck Surg. 2006; 132: 779-782
        • Bhatnagar A.
        • Vezza P.R.
        • Bryan J.A.
        • Atkins F.B.
        • Ziessman H.A.
        Technetium-99m-sestamibi parathyroid scintigraphy: effect of P-glycoprotein, histology and tumor size on detectability.
        J Nucl Med. 1998; 39: 1617-1620
        • Stephen A.E.
        • Roth S.I.
        • Fardo D.W.
        • Finkelstein D.M.
        • Randolph G.W.
        • Gaz R.D.
        • et al.
        Predictors of an accurate preoperative sestamibi scan for single-gland parathyroid adenomas.
        Arch Surg. 2007; 142: 381-386
        • Siegel A.
        • Alvarado M.
        • Barth Jr., R.J.
        • Brady M.
        • Lewis J.
        Parameters in the prediction of the sensitivity of parathyroid scanning.
        Clin Nucl Med. 2006; 31: 679-682
        • Kebebew E.
        • Hwang J.
        • Reiff E.
        • Duh Q.Y.
        • Clark O.H.
        Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model.
        Arch Surg. 2006; 141 (discussion 782): 777-782
        • Lo C.Y.
        • Lang B.H.
        • Chan W.F.
        • Kung A.W.
        • Lam K.S.
        A prospective evaluation of preoperative localization by technetium-99m sestamibi scintigraphy and ultrasonography in primary hyperparathyroidism.
        Am J Surg. 2007; 193: 155-159
        • Erbil Y.
        • Barbaros U.
        • Yanik B.T.
        • Salmaslioglu A.
        • Tunaci M.
        • Adalet I.
        • et al.
        Impact of gland morphology and concomitant thyroid nodules on preoperative localization of parathyroid adenomas.
        Laryngoscope. 2006; 116: 580-585
        • Pons F.
        • Torregrosa J.V.
        • Fuster D.
        Biological factors influencing parathyroid localization.
        Nucl Med Commun. 2003; 24: 121-124
        • Milas M.
        • Mensah A.
        • Alghoul M.
        • Berber E.
        • Stephen A.
        • Siperstein A.
        • et al.
        The impact of office neck ultrasonography on reducing unnecessary thyroid surgery in patients undergoing parathyroidectomy.
        Thyroid. 2005; 15: 1055-1059
        • Pham T.H.
        • Sterioff S.
        • Mullan B.P.
        • Wiseman G.A.
        • Sebo T.J.
        • Grant C.S.
        Sensitivity and utility of parathyroid scintigraphy in patients with primary versus secondary and tertiary hyperparathyroidism.
        World J Surg. 2006; 30: 327-332
        • Perie S.
        • Fessi H.
        • Tassart M.
        • Younsi N.
        • Poli I.
        • St Guily J.L.
        • 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
        • Muros M.A.
        • Bravo Soto J.
        • Lopez Ruiz J.M.
        • Rodriguez-Portillo M.
        • Ramirez Navarro A.
        • Bellon Guardia M.
        • et al.
        Two-phase scintigraphy with technetium 99m-sestamibi in patients with hyperparathyroidism due to chronic renal failure.
        Am J Surg. 2007; 193: 438-442