LOCALIZATION PROCEDURES IN PATIENTS WITH PERSISTENT OR RECURRENT HYPERPARATHYROIDISM

Objective: To determine the accuracy of noninvasive and invasive local ization studies in patients with persistent or recurrent hyperparathyr oidism (HPT). Design and Setting: Reoperations based on patients who w ere treated surgically for recurrent or persistent HPT at the Universi ty of California-San Francisco Hospitals from 1982 to 1993. Patients: This study evaluated 174 localization studies performed in 152 patient s before reoperation (110 women and 42 men). Main Outcome Measures: Th e accuracy of localization studies, including ultrasonography, thallou s chloride Tl 201-technetium Tc 99m pertechnetate scanning, technetium Tc 99m sestamibi scanning, magnetic resonance imaging, computed tomog raphy, and selective venous catheterization, were evaluated, as were t he results of parathyroid reoperations. Results: A total of 174 consec utive reoperations were performed in 152 patients with HPT (persistent , 113; recurrent, 39; mean age, 54 years; range, 21 to 88 years). One hundred thirty-three patients had primary HPT, 15 had secondary HPT, a nd four had tertiary HPT. Overall, 141 (93%) became normocalcemic, two (1%) became hypocalcemic, and nine (6%) remained hypercalcemic. Abnor mal parathyroid glands at reoperation were situated in a normal locati on in 77 cases (44%), in the mediastinum in 37 cases (22%), in a deep cervical location in 34 cases (19%), or in an intrathyroidal location in 14 cases (8%), or were undescended in four cases (2%); supernumerar y glands were found in 26 cases (15%). Some patients had more than one remaining abnormal gland. Selective venous catheterization with a par athyroid hormone assay was done in cases in which the results of nonin vasive localization studies were equivocal or negative, and it frequen tly converted an equivocal result of a localization study to a definit ely positive result. There were no complications from the localization studies. At reoperation, permanent hypoparathyroidism that required p arathyroid autotransplantation of cryopreserved tissue developed in tw o patients and two patients had recurrent laryngeal nerve palsies. Con clusion: We currently recommend using ultrasonography and technetium T c 99m sestamibi scanning and magnetic resonance imaging for patients w ith recurrent or persistent HPT. Selective venous catheterization with a parathyroid hormone assay is done selectively. Localization tests d ecrease morbidity and improve overall results in these patients.