Radioguided surgery of primary hyperparathyroidism in a population with a high prevalence of thyroid pathology

  • Paloma García-TalaveraEmail author
  • Carmen González
  • José Ramón García-Talavera
  • Esther Martín
  • Mariano Martín
  • Alberto Gómez
Original Article



Patients with concomitant thyroid pathology are usually excluded from minimally invasive radioguided parathyroidectomy (MIRP). We assessed the value in these patients of the gamma probe, alone or in combination with other techniques, in MIRP and unilateral or bilateral approaches. We evaluated its performance in association with intraoperative determination of intact parathyroid hormone (ioPTHi) and preoperative 99mTc-MIBI dual phase scintigraphy.


Included in the study were 87 patients with a diagnosis of primary hyperparathyroidism who underwent radioguided surgery. They were divided into two groups depending on the presence of concomitant thyroid pathology (TP group, 33 patients) or absence of concomitant thyroid pathology (NTP group, 54 patients).


In the TP group, ioPTHi achieved the highest accuracy (90.9%), followed by the gamma probe (81.8%) and scintigraphy (69.7%). In the NTP group, the probe (94.4%) performed better than ioPTH and scintigraphy (both 85.2%). In the TP group, scintigraphy in combination with the gamma probe had a success rate of 90.9%, and 94% in combination with ioPTHi. The three techniques are applied together had a success rate of 97%. For all patients undergoing MIRP, the probe alone worked well, irrespective of the presence or absence of concomitant thyroid pathology.


Patients with concomitant thyroid pathology should not be a priori excluded from a MIRP, as long as other adjuvant techniques (scintigraphy or ioPTHi) are used in conjunction with the gamma probe. In these patients, the probe can also be helpful in unilateral or bilateral surgery.


Primary hyperparathryoidism Concomitant thyroid pathology ioPTHi 99mTc-Sestamibi Radioguided surgery 


  1. 1.
    Jacobson SR, van Heerden JA, Farley DR, Grant CS, Thompson GB, Mullan BP, et al. Focused cervical exploration for primary hyperparathyroidism without intraoperative parathyroid hormone monitoring or use of the gamma probe. World J Surg 2004;28:1127–31.CrossRefPubMedGoogle Scholar
  2. 2.
    Solórzano CC, Carneiro-Pla DM, Irvin GL. Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg 2006;202:18–24.CrossRefPubMedGoogle Scholar
  3. 3.
    Gross ND, Weissman JL, Veenker E, Cohen JI. The diagnostic utility of computed tomography for preoperative localization in surgery for hyperparathyroidism. Laryngoscope 2004;114:227–31.CrossRefPubMedGoogle Scholar
  4. 4.
    Farley DR. Technetium-99m-2-methoxyisobutylisonitrile scintigraphy: preoperative and intraoperative guidance for primary hyperparathyroidism. World J Surg 2004;28:1207–11.CrossRefPubMedGoogle Scholar
  5. 5.
    Goldstein RE, Billheimer D, Martin WH, Richards K. Sestamibi scanning and minimally invasive radioguided parathyroidectomy without intraoperative parathyroid hormone measurement. Ann Surg 2003;237:722–30.CrossRefPubMedGoogle Scholar
  6. 6.
    Adil E, Adil T, Fedok F, Kauffman G, Goldenberg D. Minimally invasive radioguided parathyroidectomy performed for primary hyperparathyroidism. Otolaryngol Head Neck Surg 2009;141:34–8.CrossRefPubMedGoogle Scholar
  7. 7.
    Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, et al. Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism. World J Surg 1996;20:835–40.CrossRefPubMedGoogle Scholar
  8. 8.
    Irvin GL, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg 2004;28:1287–92.CrossRefPubMedGoogle Scholar
  9. 9.
    Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA. Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. Surgery 1988;104:1121–7.PubMedGoogle Scholar
  10. 10.
    Siperstein A, Berber E, Barbosa GF, Tsinberg M, Greene AB, Mitchell J, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg 2008;248:420–8.PubMedGoogle Scholar
  11. 11.
    Mariani G, Gulec SA, Rubello D, Boni G, Puccini M, Pelizzo M, et al. Preoperative localization and radioguided parathyroid surgery. J Nucl Med 2003;44:1443–58.PubMedGoogle Scholar
  12. 12.
    Bergenfelz A, Lindblom P, Tibblin S, Westerdhal J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomised controlled trial. Ann Surg 2002;236:543–51.CrossRefPubMedGoogle Scholar
  13. 13.
    Irvin GL, Dembrow VD, Prudhomme DL. Clinical usefulness of an intraoperative “quick parathyroid hormone” assay. Surgery 1993;114:1019–22.PubMedGoogle Scholar
  14. 14.
    Chen H, Pruhs Z, Starling JR, Mack E. Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. Surgery 2005;138:583–7.CrossRefPubMedGoogle Scholar
  15. 15.
    McGreal G, Winter DC, Sookhai S, Evoy D, Ryan M, O’Sullivan GC, et al. Minimally invasive, radioguided surgery for primary hyperparathyroidism. Ann Surg Oncol 2001;8:856–60.CrossRefPubMedGoogle Scholar
  16. 16.
    Murphy C, Norman J. The 20% rule: a simple, instantaneous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery 1992;126:1023–9.CrossRefGoogle Scholar
  17. 17.
    Hindié E, Ugur Ö, Fuster D, O’Doherty M, Grassetto G, et al. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging 2009;36:1201–16.CrossRefPubMedGoogle Scholar
  18. 18.
    Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122:998–1003.CrossRefPubMedGoogle Scholar
  19. 19.
    Bonjer HJ, Bruining HA, Pols HA, de Herder WW, van Eijck CHJ, Breeman WAP, et al. Intraoperative nuclear guidance in benign hyperparathyroidism and parathyroid cancer. Eur J Nucl Med 1997;24:246–51.PubMedGoogle Scholar
  20. 20.
    Casara D, Rubello D, Cauzzo C, Pelizzo MR. 99mTc-MIBI radioguided minimally invasive parathyroidectomy: experience with patients with normal thyroids and nodular goiters. Thyroid 2002;12:53–61.CrossRefPubMedGoogle Scholar
  21. 21.
    Norman J, Politz D. 5,000 parathyroid operations without frozen section or PTH assays: measuring individual parathyroid gland hormone production in real time. Ann Surg Oncol 2009;16:656–66.CrossRefPubMedGoogle Scholar
  22. 22.
    Rubello D, Al-Nahhans A, Mariani G, Gross MD, Rampin L, Pelizzo MR. Feasibility and long-term results of focused radioguided parathyroidectomy using a low 37 MBq (1 mCi) 99mTc-sestamibi protocol. Int Semin Surg Oncol 2006;3:30.CrossRefPubMedGoogle Scholar
  23. 23.
    Rubello D, Casara D, Gianini S, Piotto A, De Carlo E, Muzzio PC, et al. Importance of radio-guided minimally invasive parathyroidectomy using hand-held gamma probe and low (99m)Tc-MIBI dose. Technical considerations and long-term clinical results. Q J Nucl Med 2003;47:129–38.PubMedGoogle Scholar
  24. 24.
    Friedman M, Gurpinar B, Schalch P, Joseph NJ. Guidelines for radioguided parathyroid surgery. Arch Otolaryngol Head Neck Surg 2007;133:1235–9.CrossRefPubMedGoogle Scholar
  25. 25.
    Rubello D, Mariani G, Al-Nahhas A, Pelizzo MR. Minimally invasive radio-guided parathyroidectomy: long-term results with the ‘low 99mTc-sestamibi protocol’. Nucl Med Commun 2006;27:709–13.CrossRefPubMedGoogle Scholar
  26. 26.
    Weigel TL, Murphy J, Kabbani L, Ibele A, Chen H. Radioguided thoracoscopic mediastinal parathyroidectomy with intraoperative parathyroid hormone testing. Ann Thorac Surg 2005;80:1262–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Berland T, Smith SL, Huguet KL. Occult fifth gland intrathyroid parathyroid adenoma identified by gamma probe. Am Surg 2005;71:264–6.PubMedGoogle Scholar
  28. 28.
    Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands. Am J Surg 2006;191:418–23.CrossRefPubMedGoogle Scholar
  29. 29.
    Clark OH. Mediastinal parathyroid tumors. Arch Surg 1988;123:1096–100.PubMedGoogle Scholar
  30. 30.
    Lumachi F, Zucchetta P, Varotto S, Polistina F, Favia G, D’Amico D. Noninvasive localization procedures in ectopic hyperfunctioning parathyroid tumors. Endocr Relat Cancer 1999;6:123–5CrossRefPubMedGoogle Scholar
  31. 31.
    Casara D, Rubello D, Pelizo MR, Shapiro B. Clinical role of 99mTcO4/MIBI scan, ultrasound and intraoperative gamma probe in the performance of unilateral and minimally invasive surgery in primary hyperparathyroidism. Eur J Nucl Med 2001;28:1351–9.CrossRefPubMedGoogle Scholar
  32. 32.
    Rubello D, Casara D, Pelizzo MR. Optimization of peroperative procedures. Nucl Med Commun 2003;24:133–40.CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Paloma García-Talavera
    • 1
    Email author
  • Carmen González
    • 2
  • José Ramón García-Talavera
    • 3
  • Esther Martín
    • 3
  • Mariano Martín
    • 3
  • Alberto Gómez
    • 2
  1. 1.Department of Nuclear MedicineUniversity Hospital of ValladolidValladolidSpain
  2. 2.Department of SurgeryUniversity Hospital of SalamancaSalamancaSpain
  3. 3.Department of Nuclear MedicineUniversity Hospital of SalamancaSalamancaSpain

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