ASO Author Reflections: Utility of New 99m Tc-MIBI Scintigraphy Before Reoperating Patients with Persistent Sporadic Pri
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Utility of New 99mTc-MIBI Scintigraphy Before Reoperating Patients with Persistent Sporadic Primary Hyperparathyroidism: Results of a Retrospective Multicenter Study ´ ric Mirallie´, MD Samuel Frey, MD, and E Chirurgie Cance´rologique, Digestive et Endocrinienne, Institut des Maladies de l’Appareil Digestif, Centre Hospitalier Universitaire de Nantes, Nantes, France
PAST As parathyroidectomy is the only curative treatment for primary hyperparathyroidism (PHPT), focused surgical approaches are preferred, making preoperative localization imaging mandatory. The combined use of ultrasound scanning (US) and 99mTc methoxyisobutylisonitrile (MIBI) scintigraphy is the most frequently used strategy.1 Despite a high cure rate, PHPT persists in 2.5–15% of patients.2 Persistent PHPT is defined as failure of cure within 6 months after surgery. In case of persistent PHPT, redo surgery exposes patients to higher morbidity and failure rate, and preoperative imaging studies are strongly needed.3 Studying a cohort of 50 patients who we failed to cure with first surgery preceded by MIBI scintigraphy in three tertiary referral centers, we aimed to study the interest in repeating this exam before redo surgery in persistent sporadic PHPT. PRESENT In this retrospective multicenter study, a total of 42 patients (82%) were cured after redo surgery.4 Second MIBI scintigraphy led to a cure rate of 64% and permitted identification of pathologic glands, missed by the first scintigraphy, in 50% of the cases. Among them, 17 patients
had multiglandular disease and 8 patients had negative first preoperative imaging. In six patients, a pathologic gland was excised in second surgery after being identified by both first and second MIBI scintigraphy due to an initial surgical error. This second imaging exam showed high specificity (89%) and negative predictive value (80%). Sensitivity was 63%, and positive predictive value 78%. Adding a concordant US improved the sensitivity only slightly to 70%. FUTURE In our practice, we are convinced that repeating MIBI scintigraphy before redo surgery in persistent PHPT should be done in first intention. The use of imaging studies such as four-dimensional CT imaging or 18F choline remain limited in current practice by cost and availability, and should be performed in case of negative MIBI scintigraphy. Furthermore, as limited surgical experience is an important factor predicting failure of first parathyroidectomy,5 redo surgery should be performed at high-volume centers. The experience of nuclear physicians also plays an important role in the performance of MIBI scintigraphy, and high accuracy of the second scintigraphy could be obtained when performed at expert centers (72% cases in our study). DISCLOSURES disclose.
Ó Society of Surgical Oncology 2020 First Received: 21 March 2020 E´. Mirallie´, MD e-mail: [email protected]
The authors have no related conflicts of interest to
REFERENCES 1. Egan R, Scott-Coombes D. The surgical management of sporadic p
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