Pre-operative Parathyroid Gland Localization in Primary Hyperparathyroidism. A Systematic Literature Review.

Abstract

Introduction: Primary hyperparathyroidism is amongst the most common endocrine disorders. Parathyroidectomy is the only definitive cure. Traditionally, bilateral neck exploration was performed; however, now surgeons largely prefer minimally invasive parathyroidectomy. Pre-operative localization aids in selecting candidates for minimally invasive parathyroidectomy. Non-invasive imaging modalities commonly used include ultrasound, sestamibi scintigraphy, 4-D CT, MRI, PET and PET/CT.

Objective: The objective of this literature review is to evaluate technique, accuracy, advantages and disadvantages of the non-invasive imaging modalities in order to propose algorithm in de novo and re-operative cases.

Methods: This systematic review is written according to the PRISMA guidelines. A comprehensive literature search of PubMed/MEDLINE and Google Scholar was performed using search terms “primary hyperparathyroidism” OR “parathyroid adenoma” AND “pre-operative localization” OR “pre-surgical localization”. 195 papers were identified through literature search. Following removal of 19 duplicates, titles and abstracts of 176 papers were reviewed. After thorough analysis, 41 papers were included in this literature review.

Results: Minimally invasive parathyroidectomy (MIP) requires accurate pre-operative localization. Surgeons prefer two concordant imaging techniques prior to MIP. In de novo cases ultrasound and sestamibi scintigraphy are the commonly employed techniques. However, 4-D CT has shown superior performance. In re-operative cases ultrasound and 4-D CT are used as first line modalities. MRI, PET or PET/CT are preferred prior to invasive methods of localization in inconclusive first line imaging of re-operative cases.

Conclusion: Determination of accuracy of different imaging techniques can help select candidates for targeted tissue dissection with smaller incision and improved surgical outcome. However, devising a single algorithm for pre-operative localization using non-invasive imaging techniques remains undetermined.