Factors Associated With Discordance Between Preoperative Parathyroid 4-Dimensional Computed Tomographic Scans and Intraoperative Findings During Parathyroidectomy | Endocrine Surgery | JAMA Surgery | JAMA Network
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1.
Carty  SE, Worsey  J, Virji  MA, Brown  ML, Watson  CG.  Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay.  Surgery. 1997;122(6):1107-1114.PubMedGoogle ScholarCrossref
2.
Siperstein  A, Berber  E, Mackey  R, Alghoul  M, Wagner  K, Milas  M.  Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism.  Surgery. 2004;136(4):872-880.PubMedGoogle ScholarCrossref
3.
Bergenfelz  AO, Jansson  SK, Wallin  GK,  et al.  Impact of modern techniques on short-term outcome after surgery for primary hyperparathyroidism: a multicenter study comprising 2,708 patients.  Langenbecks Arch Surg. 2009;394(5):851-860.PubMedGoogle ScholarCrossref
4.
Cheung  K, Wang  TS, Farrokhyar  F, Roman  SA, Sosa  JA.  A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism.  Ann Surg Oncol. 2012;19(2):577-583.PubMedGoogle ScholarCrossref
5.
Eichhorn-Wharry  LI, Carlin  AM, Talpos  GB.  Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas.  Am J Surg. 2011;201(3):334-338.PubMedGoogle ScholarCrossref
6.
Hunter  GJ, Schellingerhout  D, Vu  TH, Perrier  ND, Hamberg  LM.  Accuracy of four-dimensional CT for the localization of abnormal parathyroid glands in patients with primary hyperparathyroidism.  Radiology. 2012;264(3):789-795.PubMedGoogle ScholarCrossref
7.
Lubitz  CC, Stephen  AE, Hodin  RA, Pandharipande  P.  Preoperative localization strategies for primary hyperparathyroidism: an economic analysis.  Ann Surg Oncol. 2012;19(13):4202-4209.PubMedGoogle ScholarCrossref
8.
Starker  LF, Mahajan  A, Björklund  P, Sze  G, Udelsman  R, Carling  T.  4D parathyroid CT as the initial localization study for patients with de novo primary hyperparathyroidism.  Ann Surg Oncol. 2011;18(6):1723-1728.PubMedGoogle ScholarCrossref
9.
Galvin  L, Oldan  JD, Bahl  M, Eastwood  JD, Sosa  JA, Hoang  JK.  Parathyroid 4D CT and scintigraphy: what factors contribute to missed parathyroid lesions?  Otolaryngol Head Neck Surg. 2016;154(5):847-853.PubMedGoogle ScholarCrossref
10.
Rodgers  SE, Hunter  GJ, Hamberg  LM,  et al.  Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography.  Surgery. 2006;140(6):932-940.PubMedGoogle ScholarCrossref
11.
Kukar  M, Platz  TA, Schaffner  TJ,  et al.  The use of modified four-dimensional computed tomography in patients with primary hyperparathyroidism: an argument for the abandonment of routine sestamibi single-positron emission computed tomography (SPECT).  Ann Surg Oncol. 2015;22(1):139-145.PubMedGoogle ScholarCrossref
12.
Hoang  JK, Sung  WK, Bahl  M, Phillips  CD.  How to perform parathyroid 4D CT: tips and traps for technique and interpretation.  Radiology. 2014;270(1):15-24.PubMedGoogle ScholarCrossref
13.
Sepahdari  AR, Bahl  M, Harari  A, Kim  HJ, Yeh  MW, Hoang  JK.  Predictors of multigland disease in primary hyperparathyroidism: a scoring system with 4D-CT imaging and biochemical markers.  AJNR Am J Neuroradiol. 2015;36(5):987-992.PubMedGoogle ScholarCrossref
14.
Sho  S, Yilma  M, Yeh  MW,  et al.  Prospective validation of two 4D-CT–based scoring systems for prediction of multigland disease in primary hyperparathyroidism.  AJNR Am J Neuroradiol. 2016;37(12):2323-2327.PubMedGoogle ScholarCrossref
15.
Mazeh  H, Chen  H, Leverson  G, Sippel  RS.  Creation of a “Wisconsin Index” nomogram to predict the likelihood of additional hyperfunctioning parathyroid glands during parathyroidectomy.  Ann Surg. 2013;257(1):138-141.PubMedGoogle ScholarCrossref
16.
Kebebew  E, Hwang  J, Reiff  E, Duh  QY, Clark  OH.  Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model.  Arch Surg. 2006;141(8):777-782.PubMedGoogle ScholarCrossref
17.
Berber  E, Parikh  RT, Ballem  N, Garner  CN, Milas  M, Siperstein  AE.  Factors contributing to negative parathyroid localization: an analysis of 1000 patients.  Surgery. 2008;144(1):74-79.PubMedGoogle ScholarCrossref
18.
McCoy  KL, Chen  NH, Armstrong  MJ,  et al.  The small abnormal parathyroid gland is increasingly common and heralds operative complexity.  World J Surg. 2014;38(6):1274-1281.PubMedGoogle ScholarCrossref
19.
Mortenson  MM, Evans  DB, Lee  JE,  et al.  Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography.  J Am Coll Surg. 2008;206(5):888-895.PubMedGoogle ScholarCrossref
Original Investigation
December 2017

Factors Associated With Discordance Between Preoperative Parathyroid 4-Dimensional Computed Tomographic Scans and Intraoperative Findings During Parathyroidectomy

Author Affiliations
  • 1Section of Endocrine Surgery, David Geffen School of Medicine, University of California, Los Angeles
  • 2Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles
JAMA Surg. 2017;152(12):1141-1147. doi:10.1001/jamasurg.2017.2649
Key Points

Question  What factors contribute to discordance between preoperative parathyroid 4-dimensional computed tomographic scans and intraoperative findings?

Findings  In an analysis of a database that included 411 patients with primary hyperparathyroidism who underwent preoperative 4-dimensional computed tomographic scans followed by parathyroidectomy, we found that the presence of multigland disease, multinodular goiter or thyroid nodule, parathyroid lesion size of 10 mm or less, and parathyroid lesion in the inferior position were associated with discordance between preoperative parathyroid 4-dimensional computed tomographic scans and intraoperative findings.

Meaning  Understanding potential limitations and factors affecting the accuracy of preoperative 4-dimensional computed tomographic scans may enable surgeons to fully leverage this new localization technique in preoperative planning and intraoperative troubleshooting.

Abstract

Importance  Parathyroid 4-dimensional computed tomographic scans (4D-CTs) have emerged as an accurate and cost-effective initial localization study for patients with primary hyperparathyroidism. However, potential limitations and factors affecting the accuracy of preoperative 4D-CTs remain poorly defined.

Objectives  To characterize factors associated with missed parathyroid lesions on preoperative 4D-CTs and to investigate patterns of commonly observed errors.

Design, Setting, and Participants  A prospectively accrued patient database was analyzed from September 1, 2011, through October 31, 2016. The study was performed in a tertiary referral center. Consecutive patients with primary hyperparathyroidism undergoing preoperative 4D-CTs and subsequent parathyroidectomy were included in the study.

Main Outcomes and Measures  Discordance between preoperative 4D-CTs and intraoperative findings in the number and location of abnormal parathyroid lesions.

Results  Of 411 patients studied (mean [SD] age, 59 [14] years; 325 [79.1%] female), 123 (29.9%) had discordance between preoperative 4D-CTs and intraoperative findings. Among the 411 patients, 75 (18.2%) had major discordance, including incorrectly localized adenoma on the contralateral side of the neck, missed double adenoma, and absence of any abnormal lesion detected on 4D-CTs. Compared with concordant cases, discordant cases had higher frequencies of multigland disease (66.7% [82 of 123] vs 24.3% [70 of 288], P < .001) and multinodular goiter or thyroid nodule (40.7% [50 of 123] vs 29.2% [84 of 288], P = .02). Missed parathyroid lesions were smaller (mean [SD], 0.86 [0.29] vs 1.24 [0.50] cm; P < .001) and were more likely to be in the inferior position (65.4% [87 of 133] vs 38.1% [177 of 465], P < .001). Parathyroid lesion size of 10 mm or less (odds ratio [OR], 4.37; 95% CI, 2.24-8.54), multigland disease (OR, 7.63; 95% CI, 3.49-16.69), multinodular goiter or thyroid nodule (OR, 1.82; 95% CI, 1.01-3.28), and parathyroid lesion in the inferior position (OR, 6.82; 95% CI, 3.10-14.99) were independently associated with discordant 4D-CT results.

Conclusions and Relevance  Multigland disease was most strongly associated with discordance between preoperative 4D-CTs and intraoperative findings, followed by parathyroid lesion in the inferior position and parathyroid lesion size of 10 mm or less. Awareness of these potential pitfalls may allow surgeons to better leverage this new localization technique in preoperative planning and intraoperative troubleshooting.

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