S. Zaheer1, D. Graham1, L. Kuo1, H. Wachtel1, R. Roses1, G. Karakousis1, R. R. Kelz1, D. L. Fraker1 1Hospital Of The University Of Pennsylvania,Department Of Surgery,Philadelphia, PA, USA
INTRODUCTION
Reoperative parathyroid surgery (RPS) can be challenging, especially following bilateral neck dissection (BNE). Noninvasive imaging studies (NIIS) such as ultrasound, sestamibi scan, SPECT and magnetic resonance imaging are less sensitive in this setting. 4‐dimensional cat scan (4DCT), a relatively new imaging method, is superior to other NIIS in localizing parathyroid disease but is not widely available. In such scenarios, selective venous sampling (SVS) may be useful for operative planning. We present the results of SVS in a cohort of NIIS‐negative patients with persistent or recurrent disease.
Methods:
RPS patients enrolled in our institutional prospective endocrine surgery registry from 1997 to 2013 were identified for inclusion in the study. Patients with positive localization by NIIS were excluded from the study. Study patients underwent SVS followed by parathyroid exploration with intra-operative PTH monitoring. SVS results were classified as non-localized, lateralized (identification of the correct side of the abnormal gland) or localized (identification of the correct side and position of the abnormal gland) through an assessment of intra-operative findings and pathologic review. Descriptive statistics were performed. Test characteristics were calculated.
Results:
We identified 165 patients with recurrent/persistent disease necessitating surgical intervention. Of the surgical candidates, 19 patients had negative NIIS and were referred for SVS. The sensitivity of lateralization by SVS was 95% (18/19). The sensitivity of localization by SVS was 44.4% (8/18). The final diagnosis was adenoma in 15 patients, hyperplasia in 3 patients and parathyroid carcinoma in 1 patient. Immediate cure was achieved in 88.9% of patients. Long-term cure was achieved in 15/19 (78.9%) patients, among those who lateralized the cure rate was 14/18 (77.8%). Interestingly, cure was not achieved in 2/8 patients who were localized by SVS. One had parathyroid cancer metastatic to left lower neck and the other had multigland hyperplasia.
Conclusion:
SVS is a useful test for the preoperative localization of abnormal parathyroid glands when other NIIS fail. Despite SVS results, the long-term cure rate in this population remains substantially lower than that reported for initial surgical candidates. SVS is especially important in reoperative cases when 4‐ dimensional CT is not locally available.