The Role of Preoperative Ultrasound and Sestamibi Scintigraphy in the Surgical Management of Primary Hyperparathyroidism: A Review of Literature

Background: Primary hyperparathyroidism (pHPT) is one of the most common endocrine diseases and the most common cause of hypercalcemia. Since routine laboratory testing, the prevalence of the disease has increased from 0.1% to 0.4% worldwide. The only curative treatment is parathyroidectomy. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are cervical ultrasonography (US) and/or Sestamibi scintigraphy. Objectives: To describe the accuracy of US and Sestamibi for detection of hyperfunctioning parathyroid adenomas preoperatively in patients with confirmed pHPT from our medical institution. Results: This is a retrospective study from a prospectively kept database that included thirty-one patients with the confirmed diagnosis of pHPT clinically and biochemically. The average age was 57.8 years old. Preoperative US and surgery findings were compared with a sensitivity of 51%. Preoperative Sestamibi and surgery findings were compared resulting in a sensitivity of 71%. Both imaging methods combined, resulted in a sensitivity of 80%. Conclusion: In patients with pHPT, Sestamibi is an effective method for localizing parathyroid pathology preoperatively, but the false negative rate can be high. US tends to have a wider range explained by the operator-dependent factor. The combination of US and Sestamibi reduces the rate of false negatives, as reported in international literature. It is important to mention that these studies cannot be used as a confirmatory test for this disease. It should only be used as an adjunct to help plan the operation.

Para-tracheal neck dissection-is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma(PTC)has a high propensity for regional metastases,however,the impact of such metastases on the outcome of the patients is minimal.The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma.Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC.Ultrasonography is highly sensitive in evaluating lateral neck nodes,however,its value in evaluating the central compartment is limited,resulting in a relatively high rate of occult metastases in this compartment.The main potential complications of para-tracheal neck dissection(PTND)are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone.New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage.These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer.By doing that,the complications may be lower and identical to thyroidectomy alone,thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.