Review of 41 patients operated on for primary hyperparathyroidism

We reviewed 41 cases of operation for primary hyperparathyroidism (PHPT) in our institution between 1987 and 1999. The objective of this study was 1) to evaluate the sensitivity and positive predictive value of several localization studies for an enlarged parathyroid gland: 2) to determine whether a selective, unilateral-exploration operation is safe; and 3) to investigate rates of coexisting malignancies of other organs. A total of 61 enlarged parathyroid glands (701 ± 131 mg wt) were removed, and the lesions consisted of 32 adenomas, two cancers, and seven hyperplasias. MIBI scintigraphy had both a high sensitivity (88.9%) and positive predictive value (88.9%) for localization of abnormal parathyroid glands and yielded better performance than the other techniques, including ultrasonography, CT scanning, and Tl-Tc scintigraphy. However, all of the localization techniques failed to detect enlarged glands (18/32 glands = 62.5%) in patients with multi-glandular parathyroid lesions. Initial operations with selective unilateral exploration of the neck were successful in 23 of 24 patients (95.8%). Operative failure was due to missing the second adenoma of a double adenoma. Malignant tumors were found in 11 patients (26.8%) previously treated or concurrently managed at the time of parathyroidectomy. There was a significant increase in serum-intact PTH level in patients with concurrent malignant tumors compared to patients who had no association of malignancies. In conclusion, 1) at least two preoperative localization tests, an MIBI scan and ultrasonography, are helpful in accurately localizing an abnormal parathyroid gland; 2) selective unilateral exploration is safe and desirable if the second ipsilateral gland is normal macroscopically; and 3) systematic examination for malignant tumors is necessary in PHPT patients before and after parathyroidectomy.