title: Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases.
abstract: OBJECTIVE
  The aim of this study was to determine the success of limited neck exploration (LE) for primary hyperparathyroidism (1 degrees HPT).
  
  
  METHODS
  Between 1999 and 2007, 1407 patients with hyperparathyroidism underwent bilateral neck exploration (BE). Of these, 1158 patients with first-time sporadic 1 degrees HPT were analyzed prospectively. Based on surgeon-performed ultrasound (US) and sestamibi scan (MIBI), LE was initially performed. Regardless of results, BE followed to identify the presence of additional parathyroid pathology.
  
  
  RESULTS
  Of 1158 patients, 242 (21%) were found to require concomitant thyroid surgery thus excluding LE. Of the remaining 916 patients, a single abnormal gland was identified on MIBI in 682 (74%), US in 731 (80%), and concordance of both in 588 (64%). Unsuspected multiglandular disease (MGD) was identified at BE in 22%, 22%, and 20% of patients, respectively. Adding intraoperative parathyroid hormone sampling (IOPTH) further reduced the rate of unsuspected MGD to 16%, 17%, and 16%. Overall, IOPTH correctly predicted MGD in only 22%. Neither concomitant nonsurgical thyroid disease nor more stringent selection criteria (preop Ca>11 mg/dL and PTH>120 pg/dL) altered success rates. In patients with MGD, a subsequent gland identified was larger than the index gland in 23%. Ninety-eight percent of BE patients were cured of 1 degrees HPT.
  
  
  CONCLUSIONS
  This is the largest study to evaluate the prevalence of additional parathyroid pathology in patients who are candidates for LE. Limitations in localizing studies and IOPTH fail to identify MGD in at least 16% of patients, risking future recurrence.
authors.affiliation: Endocrine and Metabolism Institute, Section of Endocrine Surgery, The Cleveland Clinic, Cleveland, Ohio 44195, USA. sipersa@ccf.org
authors.forename: Allan
authors.initials: A
authors.lastname: Siperstein
authors.forename: Eren
authors.initials: E
authors.lastname: Berber
authors.forename: German F
authors.initials: GF
authors.lastname: Barbosa
authors.forename: Michael
authors.initials: M
authors.lastname: Tsinberg
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Greene
authors.forename: Jamie
authors.initials: J
authors.lastname: Mitchell
authors.forename: Mira
authors.initials: M
authors.lastname: Milas
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000097:blood / Q000175:diagnosis* / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D011446:Prospective Studies; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D013961:Thyroid Gland / Q000000981:diagnostic imaging / Q000601:surgery; D014463:Ultrasonography
chemical_list: C470125:PTH protein, human; D010281:Parathyroid Hormone; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi