Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism

BACKGROUND: With a secure diagnosis of hyperparathyroidism, preoperative localization of abnormal glands is the initial step toward limited parathyroidectomy. Nuclear scanning and ultrasonography done by third parties are costly. We investigated whether ultrasonography performed by the operating surgeon (SUS) could be the initial and only preoperative localization study in patients with sporadic primary hyperparathyroidism. STUDY DESIGN: Two hundred twenty-six patients underwent preoperative SUS and Sestamibi scans before limited parathyroidectomy guided by quick intraoperative parathyroid hormone assay. SUS findings were noted before the surgeon had access to the scan results. Charge for localization by nuclear scan was $1,315 and $204 for SUS. Successful localization was determined by operative findings, intraoperative hormone dynamics, and postoperative calcium levels. RESULTS: SUS correctly localized all the offending glands in 173 of 226 (77%) successfully treated patients. In 53 patients, SUS showed no parathyroid gland (n = 32), did not recognize multiglandular disease (n = 5), and showed an incorrect location of the abnormal gland (n = 16). In these patients, the technetium-99m-sestamibi scans successfully identified all abnormal tissue in 30 of 53 (57%). Localization using both methods was correct in 203 of 226 (90%) patients. Accuracy of SUS and scans used separately was equal. With use of quick intraoperative parathyroid hormone assay, successful parathyroidectomy was accomplished in 223 of 226 (99%), unilateral exploration in 88%, and overnight stay avoided in 78% of patients. CONCLUSIONS: With equal accuracy, SUS is more convenient, less expensive, and noninvasive when compared with scans. Sestamibi should be used when the SUS is negative or equivocal. SUS should be the initial localizing test in the treatment of sporadic primary hyperparathyroidism.