Results of surgery for sporadic primary hyperparathyroidism in patients with preoperatively negative sestamibi scintigraphy and ultrasound.

PURPOSE: The purpose of this study is to investigate the results of first-time surgery for sporadic primary hyperparathyroidism (pHPT) in patients with preoperatively negative sestamibi scintigraphy and ultrasound. METHODS: Data were gathered prospectively in a multicenter database for quality control in parathyroid surgery. Between 2004 and 2008, 3,158 patients underwent first-time surgery for sporadic pHPT. A total of 984 patients were subjected to preoperative localization with ultrasound and sestamibi scintigraphy, and in 173 patients, both investigations were negative. Intraoperative findings and early outcome are reported. RESULTS: One hundred and fifty-five of 173 patients underwent bilateral neck exploration. The median weight of excised parathyroid tissue was 350 mg. In 23 patients (13.3%), the exploration was negative. A total of 112 patients (64.7%) had a histological diagnosis of parathyroid adenoma and 38 patients (22%) had multiglandular disease. Six weeks after operation, 164 patients were available for analysis, and 30 patients (18%) had persistent pHPT. The risk for persistent pHPT increased for patients with few intraoperatively identified (p = 0.001) and excised (p = 0.024) parathyroid glands. Patients operated with intraoperative parathyroid hormone (iOPTH) had lower risk for persistent pHPT 7/79 (9%) compared with 23/85 patients (27%) operated without iOPTH (p = 0.003). CONCLUSIONS: Negative localization with sestamibi and ultrasound in pHPT infers a highly selected patient population with small parathyroid adenomas, an alarmingly high rate of negative exploration, and an increased risk for persistent disease. The use of iOPTH influences cure rate favorably.

Changing biochemical presentation of primary hyperparathyroidism.

PURPOSE: Patients with primary hyperparathyroidism, pHPT, present with milder symptoms than previously. Some, but not all studies, suggest that this change in clinical pattern also implies lower preoperative parathyroid hormone (PTH) and/or calcium levels and smaller adenomas. This is important since reports indicate that smaller adenomas are more difficult to detect on preoperative imaging, possibly increasing the risk of surgical failure. METHODS: There were 640 patients with histologically confirmed single-gland pHPT identified in a prospectively collected database. Median values of preoperative calcium, PTH, as well as adenoma weight were compared in three different time periods: 1990-1995, 1996-2000, and 2000-2007. Correlation between the preoperative levels of calcium and PTH and adenoma weight was calculated. RESULTS: Preoperative ionized calcium decreased significantly over time (p < 0.001). There was a positive correlation between preoperative PTH and adenoma weight (r = 0.32, p < 0.001). The magnitude of this correlation decreased over time. In women, adenoma weight decreased significantly over time (p = 0.03). Median (25th-75th percentile) adenoma weight in women was 750 (400-1,380) mg, 650 (350-1,205) mg, and 520 (305-1,065) mg in the first, second, and third period, respectively. CONCLUSION: From 1990 to 2007, there was a significant trend to operate pHPT patients with lower preoperative serum ionized calcium levels. In women, the adenoma weight decreased. This trend could potentially lead to decreased sensitivity in preoperative localization procedures.

Impact of modern techniques on short-term outcome after surgery for primary hyperparathyroidism: a multicenter study comprising 2,708 patients.

PURPOSE: Preoperative localization procedures and the use of intraoperative parathyroidism (iOPTH) have led to a shift of paradigm from bilateral neck exploration to focused parathyroidectomy in primary hyperparathyroidism (pHPT). However, only a small number of randomized trials from specialized centers have been published. The main purpose of the study was to analyze the impact of localization procedures and iOPTH on short-term outcome after pHPT surgery in a multi-institutional setting. METHODS: An audit for quality assurance in pHPT surgery was performed in 23 Scandinavian departments in 2004-2008. Data were gathered prospectively in a database. Two thousand seven hundred and eight patients were registered and 78% were females. The median serum calcium level was 2.79 mmol/l. RESULTS: Localization procedures were performed in 1,831 patients (68%), (sestamibi in 54% and ultrasound in 41%) and iOPTH in 792 operations (29%). Bilateral exploration was performed in 61%, focused parathyroidectomy in 17%, and unilateral exploration in 22%. Histology showed parathyroid adenoma in 82%, with the median weight of 0.6 g. The alleviation of hypercalcemia at the first follow-up was 93% (94% for primary operation). In the multivariate logistic regression analysis, iOPTH increased cure rate (OR 1.70, 95% CI 1.14-2.53, p = 0.0092). The risk for postoperative medically treated hypocalcemia decreased with the use of localization procedures (OR 0.56, 95% CI 0.43-0.78, p = 0.0004) and iOPTH (OR 0.56, 95% CI 0.39-0.90, p = 0.0015). CONCLUSIONS: Localization procedures and iOPTH decreased the risk for hypocalcemia after pHPT surgery. Additionally, iOPTH influenced short-term cure rate favorably.

Scandinavian Quality Register for Thyroid and Parathyroid Surgery: audit of surgery for primary hyperparathyroidism.

BACKGROUND AND AIM: Scandinavian Quality Register for Thyroid and Parathyroid Surgery is an on-line web-based database with the aim to improve the quality of thyroid and parathyroid surgery. Preliminary data from surgery for primary hyperparathyroidism are reported here. MATERIALS AND METHODS: Fifteen departments registered 806 operations, with 639 women (79.7%) and 167 men. The median age of the patients was 62 years. RESULTS: Approximately 95.4% of the patients had sporadic disease and first time operation was performed in 93.8% of the patients. Localization examinations were performed in 524 patients (65%); sestamibi scintigraphy in 413 patients, with a true positive adenoma localization in 64.4% and ultrasound in 293 patients with adenoma localization in 61.1%. Bilateral neck exploration was performed in 66.8%, unilateral exploration in 16.1%, and focused minimal invasive surgery in 17.1%. In 301 patients planned for limited parathyroid exploration, conversion to bilateral neck surgery occurred in 11%. The cure rate, based on short follow-up, was 91.9%. Postoperative hypocalcemia occurred in 11.4% of the patients, and was associated with reoperation, concomitant thyroid operation, and the weight of excised parathyroid tissue. CONCLUSION: Localization examinations are performed in 2/3 of the patients, but limited neck exploration was performed in only approximately 1/3 of the operations. The cure rate was lower and postoperative hypocalcemia was more frequent than expected.