title: An analysis of whether surgeon-performed neck ultrasound can be used as the main localizing study in primary hyperparathyroidism.
abstract: BACKGROUND
  Tc-99 sestamibi (MIBI) scan is the imaging study most frequently used in primary hyperparathyroidism (PHP). Transcutaneous cervical ultrasonography (US) is the other modality used for preoperative localization. The aim of this study was to determine whether surgeon-performed neck US can be used as the primary localizing study in PHP.
  
  
  METHODS
  This was a prospective study of 1,000 consecutive patients with first-time, sporadic PHP who underwent parathyroidectomy at a tertiary academic center. All patients had surgeon-performed neck US and MIBI before bilateral neck exploration.
  
  
  RESULTS
  The findings at exploration were 72% single adenoma, 15% double adenoma, and 13% hyperplasia. When US suggested single-gland disease (n = 842), MIBI was concordant in 82.5%, discordant and false in 8%, negative in 7%, and discordant but correct in 2.5%. When US suggested multigland disease (n = 68), MIBI was concordant in 47%, discordant and false in 41%, and negative in 12%. When US was negative (n = 90), MIBI was positive and correct in 43%, negative in 31%, and positive but false in 26%. Surgeon-performed neck US identified unrecognized thyroid nodules in 326 patients (33%), which led to fine-needle aspiration biopsy in 161 (49%) patients and thyroid surgery in 103 (32%) patients, with a final diagnosis of thyroid cancer in 24 (7%) patients.
  
  
  CONCLUSIONS
  Our results show that MIBI provides additional useful information in only a minority of patients with a positive US in PHP. Nevertheless, MIBI benefits about half of patients with a negative US. Because one-third of this patient population has unrecognized thyroid nodules as well, we propose that the most cost-effective algorithm would be to do US first and reserve MIBI for US-negative cases.
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Shamil
authors.initials: S
authors.lastname: Aliyev
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Orhan
authors.initials: O
authors.lastname: Agcaoglu
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Erol
authors.initials: E
authors.lastname: Aksoy
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Onur
authors.initials: O
authors.lastname: Birsen
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Mira
authors.initials: M
authors.lastname: Milas
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Jamie
authors.initials: J
authors.lastname: Mitchell
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH.
authors.forename: Allan
authors.initials: A
authors.lastname: Siperstein
authors.affiliation: Department of Endocrine Surgery, Cleveland Clinic, Cleveland, OH. Electronic address: berbere@ccf.org.
authors.forename: Eren
authors.initials: E
authors.lastname: Berber
mesh_terms: D000236:Adenoma / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D005260:Female; D006801:Humans; D006980:Hyperthyroidism / Q000000981:diagnostic imaging* / Q000209:etiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000000981:diagnostic imaging; D011446:Prospective Studies; D011877:Radionuclide Imaging; D017256:Technetium Tc 99m Sestamibi; D013964:Thyroid Neoplasms / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery; D014463:Ultrasonography
chemical_list: D017256:Technetium Tc 99m Sestamibi