Skip to main content
SpringerLink
Log in

Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

Preoperative imaging in patients undergoing surgery for primary hyperparathyroidism (PHPT) is used primarily to facilitate targeted parathyroidectomy. Failure of preoperative localisation mandates a bilateral exploration. It is thought that the results of imaging may also predict the success of surgery. The aims of this study were to assess whether the findings on preoperative localisation influenced outcomes following parathyroidectomy for PHPT and to explore factors underlying failure to cure at surgery.

Methods

We analysed outcomes of all patients who underwent first-time surgery for PHPT in two centres over a 5-year period to determine an association with demographic characteristics and findings on preoperative imaging. Records of patients not cured by initial surgery were reviewed to explore factors underlying failure to cure.

Results

The failure rate (persistent disease) in the entire cohort was 5 % (25/541) (bilateral neck explorations, 5 %; unilateral exploration, 7 %; targeted approach, 4 %), while two patients developed recurrent disease. In patients who had undergone dual imaging with an ultrasound scan and 99mTc-sestamibi scintigraphy, failure rates with “lateralised and concordant” imaging, “nonconcordant” imaging, and “dual-negative” imaging were 2, 9, and 11 %, respectively (p = 0.01). Of the 25 patients with persistent disease, multigland disease (MGD) was present in 52 % (13/25) and ectopic adenoma in 24 % (6/12).

Conclusions

Patients with PHPT who do not have lateralised and concordant dual imaging are at higher risk of persistent disease. A significant proportion of failures are due to the inability to recognise the presence and/or extent of MGD.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Fraser WD (2009) Hyperparathyroidism. Lancet 374(9684):145–158

    Article  CAS  PubMed  Google Scholar 

  2. Adler JT, Sippel RS, Chen H (2010) New trends in parathyroid surgery. Curr Probl Surg 47(12):958–1017

    Article  PubMed  Google Scholar 

  3. Wells SS, Leight GS, Ross AJ (1980) Primary hyperparathyroidism. Curr Probl Surg 17:398–484

    Article  PubMed  Google Scholar 

  4. Coker LH, Rorie K, Cantley L et al (2005) Primary hyperparathyroidism, cognition, and health-related quality of life. Ann Surg 242(5):642–650

    Article  PubMed  Google Scholar 

  5. Body JJ (2012) Primary hyperparathyroidism: diagnosis and management. Rev Med Brux 33(4):263–267

    CAS  PubMed  Google Scholar 

  6. Moalem J, Guerrero M, Kebebew E (2009) Bilateral neck exploration in primary hyperparathyroidism-when is it selected and how is it performed? World J Surg 33(11):2282–2291. doi:10.1007/s00268-009-9941-5

    Article  PubMed  Google Scholar 

  7. Ruda JM, Hollenbeak CS, Stack BC Jr (2005) A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003. Otolaryngol Head Neck Surg 132(3):359–372

    Article  PubMed  Google Scholar 

  8. Chen H (2002) Surgery for primary hyperparathyroidism: what is the best approach? Ann Surg 236(5):552–553

    Article  PubMed  Google Scholar 

  9. Mandl F (1926) Therapeutisher versuch bein falls von ostitis fibrosa generalisatamittles. Extirpation eines epithelkorperchen tumors. Wien Klin Woecheshr Zentral 143:245–284

    Google Scholar 

  10. Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235(5):665–672

    Article  PubMed  Google Scholar 

  11. Katz AD, Hopp D (1982) Parathyroidectomy. Review of 338 consecutive cases for histology, location, and reoperation. Am J Surg 144(4):411–415

    Article  CAS  PubMed  Google Scholar 

  12. Bergenfelz A, Lindblom P, Tibblin S et al (2002) Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg 236(5):543–551

    Article  PubMed  Google Scholar 

  13. Westerdahl J, Bergenfelz A (2007) Unilateral versus bilateral neck exploration for primary hyperparathyroidism: five-year follow-up of a randomized controlled trial. Ann Surg 246(6):976–980 discussion 980–981

    Article  PubMed  Google Scholar 

  14. Wang CA (1985) Surgical management of primary hyperparathyroidism. Curr Probl Surg 22:1–50

    Article  CAS  PubMed  Google Scholar 

  15. Tibblin S, Bondesson AG, Ljungberg O (1982) Unilateral parathyroidectomy in hyperparathyroidism due to single adenoma. Ann Surg 195:245–252

    Article  CAS  PubMed  Google Scholar 

  16. Bergenfelz AO, Wallin G, Jansson S et al (2011) Results of surgery for sporadic primary hyperparathyroidism in patients with preoperatively negative sestamibi scintigraphy and ultrasound. Langenbecks Arch Surg 396(1):83–90

    Article  PubMed  Google Scholar 

  17. Kebebew E, Clark OH (1998) Parathyroid adenoma, hyperplasia, and carcinoma: localization, technical details of primary neck exploration, and treatment of hypercalcemic crisis. Surg Oncol Clin N Am 7(4):48–72

    Google Scholar 

  18. Sackett WR, Barraclough B, Reeve TS et al (2002) Worldwide trends in the surgical treatment of primary hyperparathyroidismin the era of minimally invasive parathyroidectomy. Arch Surg 137(9):1055–1059

    Article  PubMed  Google Scholar 

  19. Prescott JD, Udelsman R (2009) Remedial operation for primary hyperparathyroidism. World J Surg 33:2324–2334. doi:10.1007/s00268-009-9962-0

    Article  PubMed  Google Scholar 

  20. Mack LA, Pasieka JL (2004) Asymptomatic primary hyperparathyroidism: a surgical perspective. Surg Clin N Am 84(3):803–816

    Article  PubMed  Google Scholar 

  21. Lo Gerfo P (1999) Bilateral neck exploration for parathyroidectomy under local anesthesia: a viable technique for patients with coexisting thyroid disease with or without sestamibi scanning. Surgery 126(6):1011–1015

    Article  CAS  PubMed  Google Scholar 

  22. Lo CY, Lang BH, Chan WF et al (2007) A prospective evaluation of preoperative localization by technetium-99m sestamibi scintigraphy and ultrasonography in primary hyperparathyroidism. Am J Surg 193(2):155–159

    Article  CAS  PubMed  Google Scholar 

  23. Kavanagh DO, Fitzpatrick P, Myers E et al (2012) A predictive model of suitability for minimally invasive parathyroid surgery in the treatment of primary hyperparathyroidism [corrected]. World J Surg 36(5):1175–1181. doi:10.1007/s00268-011-1377-z

    Article  PubMed  Google Scholar 

  24. Sukan A, Reyhan M, Aydin M (2008) Preoperative evaluation of hyperparathyroidism: the role of dual-phase parathyroid scintigraphy and ultrasound imaging. Ann Nucl Med 22(2):123–131

    Article  PubMed  Google Scholar 

  25. Mihai R, Simon D, Hellman P (2009) Imaging for primary hyperparathyroidism-an evidence-based analysis. Langenbecks Arch Surg 394(5):765–784

    Article  PubMed  Google Scholar 

  26. Arici C, Cheah WK, Ituarte PH et al (2001) Can localization studies be used to direct targeted parathyroid operations? Surgery 129(6):720–729

    Article  CAS  PubMed  Google Scholar 

  27. Scheiner JD, Dupuy DE, Monchik JM et al (2001) Pre-operative localization of parathyroid adenomas: a comparison of power and colour Doppler ultrasonography with nuclear medicine scintigraphy. Clin Radiol 56(120):984–988

    Article  CAS  PubMed  Google Scholar 

  28. Miura D, Wada N, Arici C et al (2002) Does intraoperative quick parathyroid hormone assay improve the results of parathyroidectomy? World J Surg 26(8):926–930. doi:10.1007/s00268-002-6620-1

    Article  PubMed  Google Scholar 

  29. Gawande AA, Monchik JM, Abbruzzese TA et al (2006) Reassessment of parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism after 2 preoperative localization studies. Arch Surg 141(4):381–384

    Article  CAS  PubMed  Google Scholar 

  30. Kebebew E, Hwang J, Reiff E et al (2006) Predictors of single gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model. Arch Surg 141(8):777–782

    Article  PubMed  Google Scholar 

  31. Merlino JI, Ko K, Minotti A et al (2003) The false negative technetium-99m-sestamibi scan in patients with primary hyperparathyroidism: correlation with clinical factors and operative findings. Am Surg 69(3):225–230

    PubMed  Google Scholar 

  32. Bergenfelz A, Tennvall J, Valdermarsson S et al (1997) Sestamibi versus thallium subtraction scintigraphy in parathyroid localization: a prospective comparative study in patients with predominantly mild primary hyperparathyroidism. Surgery 121(6):601–605

    Article  CAS  PubMed  Google Scholar 

  33. Siperstein A, Berber E, Mackey R et al (2004) Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism. Surgery 136(4):872–880

    Article  PubMed  Google Scholar 

  34. Gauger PG, Agarwal G, England BG et al (2001) Intraoperative parathyroid hormone monitoring fails to detect double parathyroid adenomas: a 2-institution experience. Surgery 130(6):1005–1010

    Article  CAS  PubMed  Google Scholar 

  35. Gordon LL, Snyder WH, Wians F Jr et al (1999) The validity of quick intraoperative parathyroid hormone assay: an evaluation in seventy-two patients based on gross morphologic criteria. Surgery 126(6):1030–1035

    Article  CAS  PubMed  Google Scholar 

  36. Politz D, Livingston CD, Victor B et al (2006) Minimally invasive radio-guided parathyroidectomy in 152 consecutive patients with primary hyperparathyroidism. Endocr Pract 12(6):630–634

    Article  PubMed  Google Scholar 

  37. Chen H, Sokoll LJ, Udelsman R (1999) Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery 126(6):1016–1022

    Article  CAS  PubMed  Google Scholar 

  38. Lew JI, Irvin GL 3rd (2009) Targeted parathyroidectomy guided by intra-operative parathormone monitoring does not miss multiglandular disease in patients with sporadic primary hyperparathyroidism: a 10-year outcome. Surgery 146(6):1021–1027

    Article  PubMed  Google Scholar 

  39. Lew JI, Rivera M, Irvin GL 3rd et al (2010) Operative failure in the era of targeted parathyroidectomy: a contemporary series of 845 patients. Arch Surg 145(7):628–633

    Article  CAS  PubMed  Google Scholar 

  40. Barczynski M, Konturek A, Hubalewska-Dydejczyk A et al (2009) Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy. Langenbecks Arch Surg 394(5):843–849

    Article  PubMed  Google Scholar 

  41. Prommegger R, Wimmer G, Profanter C et al (2009) Virtual neck exploration: a new method for localizing abnormal parathyroid glands. Ann Surg 250(5):761–765

    Article  PubMed  Google Scholar 

  42. Richards ML, Thompson GB, Farley DR (2008) Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 196(6):937–943

    Article  PubMed  Google Scholar 

  43. Wakamatsu H, Noguchi S, Yamashita H et al (2001) Technetium-99m tetrofosmin for parathyroid scintigraphy: a direct comparison with (99m)Tc-MIBI, (201)Tl, MRI and US. Eur J Nucl Med 28(12):1817–1827

    Article  CAS  PubMed  Google Scholar 

  44. Hunter GJ, Schellingerhout D, Vu TH et al (2012) Accuracy of four-dimensional CT for the localization of abnormal parathyroid glands in patients with primary hyperparathyroidism. Radiology 264(3):789–795

    Article  PubMed  Google Scholar 

  45. Rodgers SE, Hunter GJ, Hamberg LM et al (2006) Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 140(6):932–940

    Article  PubMed  Google Scholar 

Download references

Conflict of interest

None

Author information

Authors and Affiliations

  1. University of Sheffield, Sheffield, UK

    H. P. Patel & S. P. Balasubramanian

  2. Chesterfield Royal Hospital, Chesterfield, UK

    D. Chadwick

  3. Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK

    A. Bagul & B. J. Harrison

  4. Academic Unit of Surgical Oncology, University of Sheffield, Beech Hill Road, Sheffield, S10 2RX, UK

    A. Bagul

Authors
  1. A. Bagul
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. H. P. Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. D. Chadwick
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. B. J. Harrison
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. S. P. Balasubramanian
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to A. Bagul.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bagul, A., Patel, H.P., Chadwick, D. et al. Primary Hyperparathyroidism: An Analysis of Failure of Parathyroidectomy. World J Surg 38, 534–541 (2014). https://doi.org/10.1007/s00268-013-2434-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-013-2434-6

Keywords

Search

Navigation