title: Preoperative imaging for focused parathyroidectomy: making a good strategy even better.
abstract: OBJECTIVE
  Surgical treatment for primary hyperparathyroidism (pHPT) has undergone a major paradigm shift during the last decades from bilateral cervicotomy with four-gland neck exploration to image-guided focused approaches. The primary objective of the present study was to compare the performances of parathyroid scintigraphy (PS), parathyroid ultrasonography (US), and the combination of both procedures for guiding a focused approach on the basis of modified interpretation criteria.
  
  
  METHODS
  Data from 199 patients operated for apparent sporadic pHPT and evaluated with US and PS using dual-isotope (123)I/(99m)Tc-sestamibi planar pinhole and single-photon emission computed tomography (SPECT) acqusitions were evaluated.
  
  
  RESULTS
  A total of 127 patients underwent a focused approach and the remainder had bilateral cervicotomy. In 42 cases, a focused approach was not performed due to the absence of concordant results between US and PS for a single-gland abnormality. Four patients had persistent disease and three had recurrent disease. A localizing preoperative PS had a sensitivity of 93.3%, positive predictive value of 85.8%, negative predictive value of 73.0%, and accuracy of 83.4% for predicting uniglandular disease. Additional SPECT images accurately localize posterior adenomas that are often missed by US. Compared with PS, US had a lower sensitivity (P<0.01). Our imaging protocol also enabled diagnosis of multiglandular disease in 60.6%.
  
  
  CONCLUSIONS
  PS using a highly sensitive dual-tracer subtraction method is the most accurate technique for directing a focused approach. PS could be sufficient for directing a focused approach in the presence of a negative US in two major circumstances: posterior locations due to acquired ectopia that could be missed by US, and previous history of thyroidectomy due to interpretation difficulties.
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Carole
authors: C
authors: Guerin
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Aoife
authors: A
authors: Lowery
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Sophie
authors: S
authors: Gabriel
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Frédéric
authors: F
authors: Castinetti
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Mélanie
authors: M
authors: Philippon
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Josiane
authors: J
authors: Vaillant-Lombard
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Anderson
authors: A
authors: Loundou
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Jean-François
authors: JF
authors: Henry
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France.
authors: Frédéric
authors: F
authors: Sebag
authors: Departments of Endocrine SurgeryNuclear MedicineEuropean Center for Research in Medical ImagingEndocrinologyRadiologyLa Timone University Hospital, Aix-Marseille University, 264 Rue Saint-Pierre, 13385 Marseille Cedex 5, FranceDepartment of Public HealthAix-Marseille University, Marseille, France david.taieb@ap-hm.fr.
authors: David
authors: D
authors: Taïeb
mesh_terms: D000236:Adenoma / Q000000981:diagnostic imaging / Q000601:surgery*; D000368:Aged; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D007457:Iodine Radioisotopes; D008297:Male; D008875:Middle Aged; D009333:Neck / Q000000981:diagnostic imaging; D010280:Parathyroid Glands / Q000000981:diagnostic imaging*; D010282:Parathyroid Neoplasms / Q000000981:diagnostic imaging / Q000601:surgery*; D016105:Parathyroidectomy / Q000379:methods*; D011300:Preoperative Care / Q000379:methods*; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D016896:Treatment Outcome; D014463:Ultrasonography
chemical_list: D007457:Iodine Radioisotopes; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi