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Surgery for Hyperparathyroidism in Image-Negative Patients
Rodney K Chan, Daniel T Ruan, Atul Gawande, Francis D. Moore, Jr.
Brigham and Women's Hospital, Boston, MA
Objective: To define the outcomes of surgery in patients with primary hyperparathyroidism and preoperative studies that fail to image an adenoma.
Design: Prospective, single-surgeon case series
Setting: Referral Center
Patients: 41 consecutive patients in a 5 year period with primary hyperparathyroidism, indications for surgery, and both cervical ultrasound and MIBI nuclear scans that were non-localizing.
Outcome measures: Extent of surgery required to produce cure; operative findings
Results: Of 430 patients undergoing surgery for primary hyperparathyroidism, 290 received both an US and a MIBI scan. Of these 290, 41 did not image an adenoma and underwent cervical exploration. Of these 41, 40 were normocalcemic at 100 day follow-up. That one has been re-explored and cured by removal of a mediastinal adenoma. To achieve initial cure, 22% of the patients required partial thyroidectomy, 17% partial thymectomy, and 17% paratracheal dissection to access or devascularize an obscure adenoma. Pathology found was an obscure adenoma in 66%, double adenoma in 5%, and parathyroid hyperplasia in 29%.
Conclusion: Patients whose preoperative localization studies fail to localize a solitary adenoma commonly require extensive surgery to cure hyperparathyroidism. Lack of localization may be a reasonable criterion on which to base referral of the patient to a high volume center.
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