title: Minimally invasive parathyroid surgery, the Norman 20% rule: is it valid?
abstract: The 20 per cent rule proposed by Norman established a guideline using radioactivity in the minimally invasive radioguided parathyroidectomy (MIRP) technique to localize and confirm removal of an abnormal parathyroid gland in patients with primary hyperparathyroidism. If radioactivity in the resected gland was at least 20 per cent of excision site/background radioactivity, the 20 per cent rule was satisfied. Patients meeting these criteria underwent unilateral MIRP without intraoperative parathyroid hormone assay or intraoperative frozen section. The study aim was to independently evaluate the 20 per cent rule in MIRP patients with primary hyperparathyroidism. Using the University of Louisville Parathyroid Database from January 1, 1999 to December 31, 2007, 216 MIRP patients with complete radioguided and postoperative management data were identified. The average percentage of ex vivo parathyroid gland radioactivity compared with excision site/background radioactivity was 107 per cent with a range from 14 to 388 per cent. For 99 per cent (196/198) radioactivity recorded from the excised gland was at least 20 per cent of radioactivity recorded from the excision site. Normocalcemia was documented in 98.5 per cent (195/198) at 12 month follow-up. Our data supports the 20 per cent rule in that in 99 per cent of MIRP patients the resected gland radioactivity was at least 20 per cent of excision site radioactivity allowing localization and confirmation of an overactive gland without intraoperative parathyroid hormone monitoring or tissue analysis.
authors.affiliation: Division of Otolaryngology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA. amyquillo@gmail.com
authors.forename: Amy R
authors.initials: AR
authors.lastname: Quillo
authors.forename: Jeffery M
authors.initials: JM
authors.lastname: Bumpous
authors.forename: Richard E
authors.initials: RE
authors.lastname: Goldstein
authors.forename: Muffin M
authors.initials: MM
authors.lastname: Fleming
authors.forename: Michael B
authors.initials: MB
authors.lastname: Flynn
mesh_terms: D002118:Calcium / Q000097:blood; D003661:Decision Support Techniques; D006801:Humans; D006961:Hyperparathyroidism / Q000000981:diagnostic imaging* / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures; D016105:Parathyroidectomy / Q000379:methods*; D018579:Patient Selection; D011183:Postoperative Complications; D011874:Radiometry; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D015203:Reproducibility of Results; D012189:Retrospective Studies; D017256:Technetium Tc 99m Sestamibi; D016896:Treatment Outcome
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D002118:Calcium