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Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation
Mehmet Uludag1, Mehmet Taner Unlu1, Mehmet Kostek1
1Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye.
Sisli Etfal Hastanesi Tip Bulteni
|April 17, 2023
Summary
Persistent or recurrent hyperparathyroidism after surgery requires careful re-evaluation. Advanced imaging techniques aid in localizing remaining or new hyperfunctioning parathyroid tissue for successful re-treatment.
Area of Science:
- Endocrinology
- Surgical Oncology
- Nuclear Medicine
Background:
- Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia, with surgery being the definitive treatment.
- Surgical failure, leading to persistent or recurrent hyperparathyroidism (perHPT/recHPT), remains a significant complication despite high success rates.
- perHPT is defined as persistent hypercalcemia post-surgery or recurrence within 6 months, while recHPT is recurrence after a normocalcemic period.
Purpose of the Study:
- To review the diagnostic and localization strategies for persistent or recurrent hyperparathyroidism (perHPT/recHPT).
- To emphasize the importance of pre-operative evaluation and appropriate imaging in managing these challenging cases.
- To guide clinicians on selecting optimal imaging modalities for re-operative parathyroid surgery.
Main Methods:
- Review of pre-operative evaluation including surgical history and biochemical data.
- Discussion of non-invasive imaging modalities: ultrasonography (USG), Tc99m sestamibi scintigraphy (SPECT/CT), 4D-CT, 4D-MRI, and PET/CT (11C-choline or 18F-fluorocholine).
- Brief mention of invasive methods like selective venous sampling and imaging-guided biopsy when non-invasive methods fail.
Main Results:
- Accurate diagnosis and confirmation of perHPT/recHPT are crucial before re-intervention.
- Combination of USG and sestamibi scintigraphy improves localization of abnormal parathyroid glands.
- Advanced imaging like 4D-CT, 4D-MRI, and PET/CT are valuable for detecting lesions missed by conventional methods.
Conclusions:
- Surgical re-intervention is recommended for confirmed perHPT/recHPT based on established guidelines.
- A multi-modal imaging approach, starting with conventional methods and progressing to advanced techniques, is essential for successful localization.
- Invasive procedures are reserved for complex cases where non-invasive imaging is inconclusive.
Keywords:
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