Aygün Nurcihan, İşgör Adnan, Uludağ Mehmet
Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey.
Department of General Surgery, Bahcesehir University, Faculty of Medicine, Istanbul, Turkey.
Sisli Etfal Hastan Tip Bul. 2019 Dec 3;53(4):379-384. doi: 10.14744/SEMB.2019.37097. eCollection 2019.
Primary hyperparathyroidism (pHPT) is a common disease, and its curative treatment is surgical. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are ultrasonography and/or scintigraphy. With the contribution of these studies to the localization of the pathological gland, focused surgery has become the first standard of choice. In this study, we aimed to evaluate the efficacy of ultrasonography and scintigraphy in the preoperative localization of the pathologic gland or glands in patients who underwent surgical treatment and cure for pHPT.
In this study; the data of the biochemically diagnosed pHPT patients, who had Tc 99m-MIBI scintigraphy and/or ultrasonography for localisation preoperatively, were evaluated retrospectively. The lesion, which was positive in USG or scintigraphy for localization, was evaluated according to the neck side or neck quadrant, and the results were compared with intraoperative localization findings. The effectiveness of both methods and combinations was evaluated with the localization rates, sensitivity and positive predictive values (PPV). The three methods were compared with the Youden index (J).
The mean age of 380 patients included in this study was 54.8±12.8 years (20-83). Three hundred eight of them were female, and 72 were male. Scintigraphy was performed in 339 patients, USG was performed in 344 patients, and both USG and scintigraphy were performed in 306 patients. One hundred twenty patients (32%) underwent bilateral neck exploration (BNE), and 260 patients (68.4%) underwent minimally invasive parathyroidectomy (MIP) (unilateral exploration or focused surgery). Single adenoma was detected in 358 (94%), double adenoma in 10 (3%) and hyperplasia in 12 (3%) patients.Localization rates of USG, scintigraphy, USG and scintigraphy combinations were 53%, 74%, 75%; their sensitivity was 56%, 85%, 89%; PPDs were 90%, 86%, 83%. The efficiency of scintigraphy is higher than USG (J: 0.743 vs 0.527). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.743 vs 0.754).The localization rates of USG, scintigraphy, USG and scintigraphy combinations were 46%, 64%, 66%; their sensitivity was 51%, 83%, 88%; PPDs were 79%, 74%, 73%. The efficiency of scintigraphy is higher than that of USG (J: 0.64 vs 0.427). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.64 vs 0.66).
In patients with pHPT, scintigraphy is a more effective method for USG as the first step preoperative imaging and should be preferred as the first method if there is no contraindication. A combination of scintigraphy with USG may contribute minimally to the efficacy of scintigraphy. It may be advantageous for early detection of the pathologic gland in patients with incompatible two imaging and initiating surgery on the positive side of the first scintigraphy. Scintigraphy and USG methods may allow successful MRP surgery in the majority of patients with pHPT.
原发性甲状旁腺功能亢进症（pHPT）是一种常见疾病，其根治性治疗方法是手术。如今，术前定位检查已成为手术治疗前的标准操作，而第一阶段的成像方法是超声检查和/或闪烁扫描。随着这些检查对病理性腺体定位的帮助，聚焦手术已成为首选的第一标准。在本研究中，我们旨在评估超声检查和闪烁扫描在接受手术治疗并治愈的pHPT患者病理性腺体术前定位中的效果。
在本研究中，对生化诊断为pHPT且术前接受过锝99m-甲氧基异丁基异腈（Tc 99m-MIBI）闪烁扫描和/或超声检查以进行定位的患者数据进行回顾性评估。对超声检查或闪烁扫描中定位呈阳性的病变，根据颈部侧面或颈部象限进行评估，并将结果与术中定位结果进行比较。通过定位率、敏感性和阳性预测值（PPV）评估两种方法及其联合使用的有效性。用约登指数（J）对这三种方法进行比较。
本研究纳入的380例患者的平均年龄为54.8±12.8岁（20 - 83岁）。其中308例为女性，72例为男性。339例患者进行了闪烁扫描，344例患者进行了超声检查，306例患者同时进行了超声检查和闪烁扫描。120例患者（32%）接受了双侧颈部探查（BNE），260例患者（68.4%）接受了微创甲状旁腺切除术（MIP）（单侧探查或聚焦手术）。358例（94%）患者检测出单发腺瘤，10例（3%）患者检测出双发腺瘤，12例（3%）患者检测出增生。超声检查、闪烁扫描、超声检查与闪烁扫描联合使用的定位率分别为53%、74%、75%；敏感性分别为56%、85%、89%；PPV分别为90%、86%、83%。闪烁扫描的效率高于超声检查（J：0.743对0.527）。闪烁扫描与超声检查联合使用时，闪烁扫描对超声检查的贡献有限（J：0.743对0.754）。超声检查、闪烁扫描、超声检查与闪烁扫描联合使用的定位率分别为46%、64%、66%；敏感性分别为51%、83%、88%；PPV分别为79%、74%、73%。闪烁扫描的效率高于超声检查（J：0.64对0.427）。闪烁扫描与超声检查联合使用时，闪烁扫描对超声检查的贡献有限（J：0.64对0.66）。
在pHPT患者中，闪烁扫描作为术前第一步成像方法比超声检查更有效，如果没有禁忌证，应首选闪烁扫描作为第一种方法。闪烁扫描与超声检查联合使用对闪烁扫描效果的贡献可能最小。对于两种成像不相符的患者，闪烁扫描可能有利于早期发现病理性腺体，并在首次闪烁扫描阳性侧进行手术。闪烁扫描和超声检查方法可能使大多数pHPT患者成功进行微创甲状旁腺切除术（MRP）。
