Rotstein L, Irish J, Gullane P, Keller M A, Sniderman K
Division of General Surgery, Toronto Hospital, University of Toronto, Ontario, Canada.
Head Neck. 1998 Sep;20(6):535-9. doi: 10.1002/(sici)1097-0347(199809)20:6<535::aid-hed8>3.0.co;2-8.
Recurrent and/or persistent hyperparathyroidism (HPT) is an uncommon disease. Relatively few cases are seen by any one center or surgeon. Most of the prior reviews of this problem were done in the era prior to potentially accurate magnetic resonsance imaging (MRI) and sestimibi scan localization and do not reflect current preoperative localization technology.
All cases of recurrent or persistent parathyroidectomy seen in our institution between 1992 and 1996 were reviewed retrospectively to assess the predictive value of preoperative MRI, selective venous sampling, sestimibi scanning, ultrasound examination, and computerized tomography (CT) scanning. The preoperative localization studies were compared with the findings at operation, the pathology report, and the patient's long-term calcium status.
Twenty-eight patients were operated upon at our institution for recurrent or persistent HPT during this time interval. The final pathology turned out to be: adenoma, 24; hyperplasia, 2; carcinoma, 2. The site at which the reoperative pathology was found was in the neck in 22 patients and intrathoracic requiring sternotomy in 6. The long-term outcome, i.e., serum calcium level at > 6 months postoperatively, was normocalcemia in 22 of 28 (85%), persistent hypocalcemia in 2 of 28, and persistent hypercalcemia in 2 of 28. Some combination of MRI, sestimibi, selective venous sampling, ultrasound, and CT scan was performed on all patients preoperatively. Preoperative MRI scans were performed on 26 of 28 patients. They correctly localized the side and site of the pathology in only 12, yielding a sensitivity of 66%. There were, however, no false positives; therefore, the positive predictive value of this test was 100%. Selective venous sampling was carried out on 26 of 28 patients and correctly localized in only 8 (sensitivity, 50%). Again, there were no false positives, yielding a positive predictive value of 100%. Sestimibi scanning was performed in 16 of 28, localizing in 8 (sensitivity, 50%). The positive predictive value of this test was 80%. Ultrasound was performed in 26 of 28 patients and localized in only 3, yielding a sensitivity of 17%, with a positive predictive value of 75%. Computerized tomographic scan was performed preoperatively only when all other investigations turned out to have been nonlocalizing and was therefore done in only four patients, one of whom had a positive CT scan showing an intrathoracic, intrapericardial adenoma.
These data demonstrate that despite the availability of what are putatively accurate preoperative localizing tests for previously unoperated cases, no one localizing test is particularly sensitive in reoperative parathyroid surgery. Magnetic resonance imaging and selective venous sampling, however, are complementary and when positive do accurately predict the site of the persistent/recurrent parathyroid pathology. Use of these preoperative localizing studies resulted in a successful outcome, i.e., normocalcemia or hypocalcemia in 93% of patients operated on.
复发性和/或持续性甲状旁腺功能亢进症（HPT）是一种罕见疾病。任何一个中心或外科医生见到的病例相对较少。此前对该问题的大多数综述是在有可能进行精确的磁共振成像（MRI）和甲氧基异丁基异腈扫描定位之前的时代完成的，并未反映当前的术前定位技术。
回顾性分析1992年至1996年间在我们机构进行的所有复发性或持续性甲状旁腺切除术病例，以评估术前MRI、选择性静脉采血、甲氧基异丁基异腈扫描、超声检查和计算机断层扫描（CT）的预测价值。将术前定位研究结果与手术发现、病理报告以及患者的长期血钙状况进行比较。
在此期间，我们机构对28例复发性或持续性HPT患者进行了手术。最终病理结果为：腺瘤24例；增生2例；癌2例。再次手术发现病理的部位，22例在颈部，6例在胸腔内需要开胸手术。长期结果，即术后6个月以上的血清钙水平，28例中有22例（85%）为血钙正常，28例中有2例持续低钙血症，28例中有2例持续高钙血症。所有患者术前均进行了MRI、甲氧基异丁基异腈、选择性静脉采血、超声和CT扫描的某种组合检查。28例患者中有26例进行了术前MRI扫描。其中仅12例正确定位了病理的侧别和部位，敏感性为66%。然而，没有假阳性结果；因此，该检查的阳性预测值为100%。28例患者中有26例进行了选择性静脉采血，仅8例正确定位（敏感性为50%）。同样，没有假阳性结果，阳性预测值为100%。28例中有16例进行了甲氧基异丁基异腈扫描，8例定位正确（敏感性为50%）。该检查的阳性预测值为80%。28例患者中有26例进行了超声检查，仅3例定位正确，敏感性为17%，阳性预测值为75%。仅在所有其他检查均未能定位时才进行术前CT扫描，因此仅4例患者进行了该项检查，其中1例CT扫描阳性，显示为胸腔内、心包内腺瘤。
这些数据表明，尽管对于先前未手术的病例有公认的精确术前定位检查，但在再次甲状旁腺手术中，没有一种定位检查特别敏感。然而，磁共振成像和选择性静脉采血是互补的，当结果为阳性时，确实能准确预测持续性/复发性甲状旁腺病理的部位。使用这些术前定位研究可使93%接受手术的患者获得成功结果，即血钙正常或低钙血症。
