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Success of Minimally Invasive Parathyroidectomy Despite Negative Sestamibi Scan

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Success of Minimally Invasive Parathyroidectomy Despite Negative Sestamibi Scan Open Access Austin Journal of Otolaryngology Research Article Success of Minimally Invasive Parathyroidectomy Despite Negative Sestamibi Scan Taylor CB, Krysinski MR and Miller FR* Department of Otolaryngology-Head and Neck Surgery, Abstract University of Texas Health Science Center San Antonio Objective: Evaluate minimally invasive parathyroidectomy in patients with School of Medicine, USA primary hyperparathyroidism and negative Sestamibi scan results. *Corresponding author: Miller FR, Department of Methods: A retrospective review was performed from July 2003 to July Otolaryngology-HNS, University of Texas Health Science 2010 of patients with primary hyperparathyroidism and negative Sestamibi scan Center San Antonio, USA results. All patients were treated at a tertiary academic center and the senior Received: March 24, 2016; Accepted: April 11, 2016; author performed all parathyroidectomy. 38 patients were included. No patients Published: April 13, 2016 were excluded. Results of preoperative Sestamibi scans and ultrasound were reviewed. Operative reports, pathologic diagnoses, and postoperative reports were reviewed. Results: Of the 38 patients with negative Sestamibi scans, 33 (86%) had positive ultrasound findings, which focused the area of surgery. Of the 33 patients with positive ultrasound findings, 28 patients (85%) underwent minimally invasive parathyroidectomy for a single adenoma with successful surgical cure. The 5 remaining patients had double adenomas or parathyroid hyperplasia. Of the 5 patients with negative Sestamibi scans and negative ultrasounds, 3 were found to have single gland disease, which was surgically cured. Conclusion: A negative Sestamibi scan does not preclude a minimally invasive neck exploration to cure primary hyperparathyroidism. With adjunctive ultrasound, a majority of patients may undergo minimally invasive parathyroidectomy with surgical success. Keywords: Parathyroidectomy; Sestamibi; Hyperparathyroidism; Parathyroid Introduction localization has been the 99mTc-Sestamibi scan and when results clearly demonstrate localization to a single quadrant, the study is Parathyroidectomy is first line therapy for patients with highly useful to the surgeon [3]. In these cases, minimally invasive primary hyperparathyroidism. In the majority of cases of primary parathyroidectomy has a high success rate [4]. hyperparathyroidism, disease is due to single gland disease, or parathyroid adenoma. In these patients, the treatment of choice is However, difficulty arises when the Sestamibi scan fails to localize excision of the single involved parathyroid gland [1-13]. a pathologic parathyroid gland. Negative Sestamibi scan results have been associated with higher rates of multiglandular disease5 as well There is an overall trend toward minimally invasive parathyroid as lower rates of biochemical cure (as defined by postoperative lab surgery by those who routinely operate on parathyroid glands [2]. studies of calcium and parathyroid hormone levels) [3]. Historically, patients with primary hyperparathyroidism underwent bilateral neck exploration for identification and removal of the The objective of this study was to evaluate whether minimally affected gland(s) [1]; however with the incorporation of specialized invasive parathyroidectomy can be successful in patients with imaging for localizing the pathologic gland to a specific quadrant primary hyperparathyroidism who have nonlocalizing (or negative) of the neck, the surgeon is able to plan and execute a more precise Sestamibi scans by using cervical ultrasound to localize the involved operation. Minimally invasive parathyroid surgery indicates a focused parathyroid glands. neck exploration that is limited to a unilateral neck exploration that Materials and Methods is guided by pre-operative imaging and the success of the procedure is determined by intra-operative biochemical testing (rapid PTH). Approval for this study was obtained from the Institutional The majority of endocrine surgeons who perform these minimally Review Board at the University of Texas Health Science Center at invasive parathyroid surgeries utilize focused small (central or lateral) San Antonio. This study employed a retrospective review of medical incisions as well as intraoperative rapid PTH assays for biochemical records of patients treated by the senior author at our tertiary confirmation [2]. The ability to use a focused incision and limit academic referral center from July 2003 to July 2010. The study dissection depends on reliable localization imaging to provide population included patients referred to our institution for surgical accurate representation of the adenoma relative to its surrounding evaluation of primary hyperparathyroidism that also had negative anatomy. The standard for preoperative parathyroid adenoma Sestamibi scans. Austin J Otolaryngol - Volume 3 Issue 1 - 2016 Citation: Taylor CB, Krysinski MR and Miller FR. Success of Minimally Invasive Parathyroidectomy Despite ISSN : 2473-0645 | www.austinpublishinggroup.com Negative Sestamibi Scan. Austin J Otolaryngol. 2016; 3(1): 1070. Miller et al. © All rights are reserved Miller FR Austin Publishing Group All patients with a negative Sestamibi scan subsequently found that over half of these surgeons who perform parathyroidectomy underwent cervical ultrasound imaging as part of preoperative do so using a minimally invasive technique [2]. Minimally invasive planning. Patients were then taken to the operating room, parathyroidectomy has decreased morbidity due to decrease operative where successful parathyroidectomy was confirmed with use of times, limited dissection, and decreased hospital stay [2]. The ability intraoperative rapid Parathyroid Hormone (PTH) assay. Our criteria to perform focused surgeries depends heavily on localizing imaging for biochemical cure of the hyperparathyroidism at the time of surgery studies, like Sestamibi scans, which have been used with success since included intact PTH levels that decrease by more than 50% and fall the concept of minimally invasive parathyroidectomy was introduced into the normal range from the highest pre-incision or pre-excisional [6]. Additional imaging studies have also been examined and have hormone levels in a peripheral blood sample obtained 10-15 minutes been found to be especially useful in cases where a Sestamibi scan after the removal of abnormal parathyroid tissue [14]. The inclusion does not provide localizing information. The negative Sestamibi criteria for these patients required that patients have 1) diagnosis of parathyroid scan is felt to be more likely in patients with smaller primary hyperparathyroidism, and 2) negative Sestamibi scan results. volume parathyroid pathology, in patients with multi-nodular goiters, No patients were excluded from this study. and in patients with potential ectopic parathyroid glands. In our study, as in other similar studies, ultrasonography is a useful adjunct A retrospective review of these patients’ records was conducted, for correctly identifying single gland disease in patients with negative including review of preoperative imaging studies, operative reports, Sestamibi scans [3]. Ultrasound is a very useful tool when used in the and final pathology reports. setting of a negative Sestamibi, as illustrated by the high percentage of Results positive ultrasounds in our population [4]. In our study, ultrasound imaging was performed by our institution’s radiology department; Thirty-eight patients with primary hyperparathyroidism and a however use of in-office ultrasound performed by the clinician at the negative Sestamibi scan underwent additional imaging with cervical time of evaluation adds an additional component for consideration. thyroid ultrasound. Of the 38 patients with negative Sestamibi scans, A study by Adler et al. found that surgeon-performed ultrasound 33 (86%) had ultrasound findings that allowed localization for focused was more successful in localizing additional pathologic glands when surgery. Of these 33 patients with localizing ultrasound findings, 28 compared to radiology-performed ultrasound [4]. (85%) underwent minimally invasive parathyroidectomy for a single adenoma with a successful surgical cure. The remaining 5 patients This study demonstrated the utility of ultrasound imaging in cases had either double adenomas (3 patients), or multigland disease (2 of negative Sestamibi scans for patients undergoing preoperative with parathyroid hyperplasia). planning for parathyroidectomy. Ultrasonography in the setting of negative Sestamibi scan has a high sensitivity for localizing single- There were 5 patients (14%) in this study who were found to have gland disease and good positive predictive value for obtaining both negative Sestamibi and negative ultrasound results. Ultimately, surgical cure. In fact, a large majority of our patients in this study 3 were found to have single adenoma and 2 patients demonstrated had a positive ultrasound, which allowed for successful execution of multi-gland disease at the time of surgery. All 38 patients in this minimally invasive parathyroidectomy. In those patients who did population underwent successful parathyroidectomy with surgical not have localizing ultrasound imaging studies, successful surgical cure, as confirmed by intra-operative PTH levels after removal cure was achieved with standard bilateral neck exploration and of the pathologic gland(s). Long term follow-up (> 6 months) was parathyroidectomy. This number is small (26%) in comparison to the available
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