Determinants and clinical significance of negative scintigraphic findings in primary hyperparathyroidism: a retrospective observational study

Abstract

Aim In patients with recurrent primary hyperparathyroidism (pHPT) or preceding thyroid operation, scintigraphic localization of the pathological parathyroid gland is sometimes unsuccessful. Reason for diagnostic failure, and its clinical relevance is poorly understood.

Methods This retrospective observational study in patients suffering from a pHPT evaluated independent predictors of a negative preoperative scintigraphy (SC) result, and its relevance for intraoperative outcome using logistic regression analysis.

Results Among 86 pHPT patients scheduled for parathyroid operation, 63 (73%) had a history of a preceding thyroid or parathyroid operation. Preoperative SC could not identify an adenoma in 30 patients (34.9%), and in 12 patients (14.0%), the surgeon was subsequently unable to localize abnormal parathyroid tissue. Preoperative parathyroid hormone concentration was the only significant independent predictor of a negative SC finding (non-linear and indirect association). Independent from surgical history, an unsuccessful intraoperative focus localization was exclusively predicted by preoperative ultrasonographic (US) and SC findings (OR per diagnostic category 2.98; 95%-CI 1.03–8.58, p=0.043, and OR 2.26; 95%-CI: 1.10–4.63, p=0.027, respectively). Compared to exclusive US, however, the combination of SC and US significantly increased the sensitivity and predictive power to identify patients at a high risk for a complicated surgical procedure.

Conclusion In patients before parathyroidectomy, a low preoperative parathyroid hormone concentration is significantly associated with a high likelihood for a negative SC finding. Combining US with SC before operation significantly increases the chance to identify patients prone to negative intraoperative findings.

Zusammenfassung

Ziel Bei Patienten mit rezidivierendem primärem Hyperparathyreoidismus (pHPT) oder vorangegangenen Schilddrüsenoperationen ist die szintigrafische (SZ) Lokalisierung der pathologischen Nebenschilddrüse manchmal erfolglos. Die Gründe dafür und die klinische Relevanz dieses Befundes sind nur unzureichend bekannt.

Methoden In dieser retrospektiven Beobachtungsstudie wurden unabhängige Prädiktoren für ein negatives präoperatives SZ Ergebnis und dessen Bedeutung für das intraoperative Ergebnis anhand von logistischen Regressionsanalysen untersucht.

Ergebnisse Bei 30 (34,9%) von 86 pHPT Patienten konnte präoperativ mittels SZ kein Adenom festgestellt werden, und bei 12 Patienten (14,0%) gelang es intraoperativ nicht, abnormales Nebenschilddrüsengewebe zu lokalisieren. Die präoperative Parathormonkonzentration war der einzige signifikante unabhängige Prädiktor für einen negativen SZ Befund (nicht-linearer indirekter Zusammenhang). Eine erfolglose intraoperative Fokuslokalisation wurde ausschließlich durch präoperativen Ultraschall (US)- und SZ-Befunde vorhergesagt (OR pro diagnostische Kategorie 2.98; 95%-CI 1.03–8.58, p=0.043 bzw. OR 2.26; 95%-CI: 1.10 4.63, p=0.027). Im Vergleich zum ausschließlichen US erhöhte der kombinierte Einsatz von SZ und US jedoch die Chance signifikant, Patienten mit hohem Risiko für einen negativen intraoperativen Befund zu identifizieren.

Schlussfolgerung Bei Patienten vor Parathyreoidektomie ist eine niedrige präoperative Parathormonkonzentration signifikant mit einer hohen Wahrscheinlichkeit für einen negativen SZ Befund assoziiert. Die präoperative Kombination von US und SZ erhöht die Wahrscheinlichkeit, Patienten zu identifizieren, bei denen ein negativer intraoperativer Befund zu erwarten ist, erheblich.

Schlüsselwörter

primärer Hyperparathyreoidismus - Nebenschilddrüsenszintigrafie - Parathyreoidektomie - Nebenschilddrüsenultraschall - Parathormon - Nebenschilddrüsenadenom

Keywords

primary hyperparathyroidism - parathyroid scintigraphy - parathyroidectomy - parathyroid ultrasonography - parathyroid hormone - parathyroid adenoma

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