Various non-invasive and invasive tests are used for the localization of parathyroid adenomas in the reoperative setting. To help determine the most efficient algorithm for the evaluation of these patients, use of a combination of ultrasonography and sestamibi as the only preoperative imaging tests was explored.
This was an analysis of outcomes of 62 consecutive patients (21 men; mean age 55 years) treated between January 1995 and May 1999, and referred for persistent hyperparathyroidism after one (n = 47) or more (n = 15) previous explorations at which no abnormal parathyroid glands were found. While all patients underwent ultrasonography (all interpreted by one radiologist), computed tomography (CT), magnetic resonance imaging and sestamibi, the success of localization and reoperation was analysed using only the results of ultrasonography and sestamibi. Intraoperative ultrasonography (IOUS) was available in all cases.
Sixty-one patients (98 per cent) had curative reoperations with solitary adenomas confirmed pathologically. One adenoma was not found at operation. Forty-six adenomas (74 per cent) were ectopic including 14 in the tracheo-oesophageal groove and 12 in the anterior mediastinum. The sensitivity, positive predictive value and accuracy for ultrasonography were 91, 87 and 84 per cent respectively; the corresponding values for sestamibi were 75, 94 and 71 per cent. In 58 (94 per cent) of 62 patients preoperative ultrasonography and/or sestamibi accurately identified the adenoma. In three patients cured by operation, in whom combined ultrasonography and sestamibi was inaccurate, one gland was found by IOUS in strap muscle, one by blind cervical thymectomy and one by sternotomy based on CT findings. Thirty-seven patients (60 per cent) underwent IOUS. In nine of these patients IOUS was essential in guiding resection of the adenomas.
This study supports an algorithm of obtaining ultrasonography and sestamibi as the initial and perhaps only preoperative localization tests for patients with persistent hyperparathyroidism after failed operation at which no abnormal glands were found. Using this algorithm, reoperation should be successful in almost 95 per cent of cases. © 2000 British Journal of Surgery Society Ltd