Localization of parathyroid tumours in the minimally invasive era: which technique should be chosen? Population-based analysis of 253 patients undergoing parathyroidectomy and factors affecting parathyroid gland detection

A series of 253 consecutive patients with proved primary hyperparathyroidis m due to parathyroid tumours was reviewed. There were 68 (26.9%) men and 18 5 (73.1%) women, with a median age of 57 years (range 13-82 years). All pat ients, prior to successful parathyroidectomy, underwent one or more preoper ative localization procedures such as: neck ultrasonography (US) in 191 (75 .5%), Tl-201/Tc-99m-pertechnetate subtraction scintigraphy (TPS) in 144 (56 .9%), CT scan in 92 (36.4%), Tc-99m-sestamibi/Tc-99m-pertechnetate subtract ion scintigraphy (M PS) in 90 (35.6%), selective venous sampling (SVS) with parathyroid hormone (PTH) assay in 30 (11.9%), and magnetic resonance imag ing (MRI) in 6 (2.4%) patients. The results were compared with operative an d histological findings that showed 235 (92.9%) solitary parathyroid adenom as, 13 (5.1%) carcinomas and 5 (2.0%) double adenomas. Sensitivity and posi tive predictive value were 82.9% and 93.8% for US, 83.6% and 91.8% for TPS, 81.3% and 98.7% for CT scan, 85.1% and 96.1% for MPS, 65.4% and 80.9% for SVS, and 80.0% and 80.0% for MRI respectively, No different results (P = NS ) were found using US, TPS, MPS or CT scan, whereas SVS and MRI sensitivity was lower (P < 0.05). The combination of MPS and US was 94.0% sensitive (P < 0.05) but when TPS, CT scan or MRI were also used overall sensitivity di d not improve significantly (P = NS). In conclusion, MPS should be used as the starting preoperative localization procedure, while US and MPS together represent the most reliable noninvasive localization tool, If MPS and US a re negative or not in agreement, further studies are not cost-effective and the patient should undergo bilateral neck exploration.