title: Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography.
abstract: BACKGROUND
  Reoperation for hyperparathyroidism (HPT) carries an increased risk for morbidity and failure to cure. Accurate preoperative localization minimizes operative risk but is often difficult to achieve in the reoperative setting. Four-dimensional computed tomography (4D-CT) is an emerging technique that uses functional parathyroid anatomy for precise preoperative localization. We evaluated 4D-CT as a tool for localization of hyperfunctioning parathyroid tissue in the reoperative setting.
  
  
  METHODS
  A prospective endocrine database was queried to identify 45 patients who underwent reoperative parathyroidectomy after preoperative localization using 4D-CT. The patients were categorized into 1 of 3 groups: group 1 included those who had previous neck surgery for non-HPT conditions; group 2 included those who had undergone a previously unsuccessful neck exploration for HPT; and group 3 included patients with HPT who had a previous neck exploration with resection of at least 1 hypercellular parathyroid.
  
  
  RESULTS
  The sensitivity of 4D-CT for localization was 88% compared with 54% for sestamibi imaging. Four-dimensional CT more often correctly localized (p=0.0003) and lateralized (p=0.005) hyperfunctional parathyroid tissue than sestamibi did. Four-dimensional CT successfully localized hyperfunctional parathyroid tissue in 18 (82%) of 22 group 1 patients, 10 (91%) of 11 group 2 patients, and 8 (67%) of 12 group 3 patients. Three patients were lost to followup. At a mean followup of 9.8 months, 39 (93%) of 42 patients were surgically cured and 3 patients (7%; 2 in group 3) had persistent HPT.
  
  
  CONCLUSIONS
  Four-dimensional-CT is an ideal tool for preoperative localization of hyperfunctioning parathyroid tissue in the reoperative setting. Localization and successful reoperation are most difficult in patients who have undergone an earlier operation that included resection of at least one hypercellular parathyroid suggesting multigland disease.
authors.affiliation: Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
authors.forename: Melinda M
authors.initials: MM
authors.lastname: Mortenson
authors.forename: Douglas B
authors.initials: DB
authors.lastname: Evans
authors.forename: Jeffrey E
authors.initials: JE
authors.lastname: Lee
authors.forename: George J
authors.initials: GJ
authors.lastname: Hunter
authors.forename: Dawid
authors.initials: D
authors.lastname: Shellingerhout
authors.forename: Thinh
authors.initials: T
authors.lastname: Vu
authors.forename: Beth S
authors.initials: BS
authors.lastname: Edeiken
authors.forename: Lei
authors.initials: L
authors.lastname: Feng
authors.forename: Nancy D
authors.initials: ND
authors.lastname: Perrier
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D006961:Hyperparathyroidism / Q000000981:diagnostic imaging* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000601:surgery; D010280:Parathyroid Glands / Q000601:surgery*; D016105:Parathyroidectomy; D011300:Preoperative Care; D012086:Reoperation; D014057:Tomography, X-Ray Computed