Single gland versus multigland disease in primary hyperparathyroidism at the Wits Donald Gordon Medical Centre in Johannesburg, South Africa

Abstract

Background: Primary hyperparathyroidism (PHPT) is caused by excessive parathyroid hormone production by autonomously functioning parathyroid gland(s). Most commonly this is by adenomatous change in a single parathyroid gland. This single pathological gland may then be removed in a focused or minimally invasive surgical approach rather than a traditional bilateral neck exploration. However, to do this, the abnormal gland needs to be localized preoperatively using imaging.

Objectives: To review patients with PHPT undergoing first parathyroidectomy at the Wits Donald Gordon Medical Centre, in Johannesburg South Africa, to determine the distribution of pathology between single and multigland disease, techniques used to localize disease preoperatively and outcome according to surgical approach.

Methods: A retrospective review was conducted on all eligible patients with biochemically confirmed PHPT undergoing first parathyroidectomy by a single surgeon for PHPT at the Wits Donald Gordon Medical Centre in Johannesburg, South Africa over a period from October 2008 to January 2018.

Results: Records of a total of 252 patients with PHPT who underwent first parathyroidectomy were reviewed. Single gland disease was the cause of PHPT in 83.3% (n = 210) of patients, multigland disease including double adenomas and hyperplastic change accounted for the remainder. A neck USS was done in 71.8% (n = 181) patients with a sensitivity of 77.1% (95% confidence interval of 68.5 to 84.4%) while 75.4% (n = 190) of patients had a Tc-99 Sestamibi SPECT scan with an comparable sensitivity of 72.9% in localizing SG disease (63.9 – 80.7%). Combined USS and Tc99 Sestamibi SPECT scan had a sensitivity in SG disease of 79.7% (71.3 – 86.5%). However, only 44.8% (n = 113) of patients had a minimally invasive parathyroidectomy.

Conclusion: A bilateral neck exploration remains the gold standard surgical approach in the management of PHPT. However, given the predominance of single gland disease, accurate preoperative localization techniques, and successful surgical outcomes, minimally invasive parathyroidectomy is of equal importance in the parathyroid surgeon’s armamentarium.