Journal of Postgraduate Medicine
 Open access journal indexed with Index Medicus & ISI's SCI  
Users online: 8567  
Home | Subscribe | Feedback | Login 
About Latest Articles Back-Issues Articlesmenu-bullet Search Instructions Online Submission Subscribe Etcetera Contact
 ::  Similar in PUBMED
 ::  Search Pubmed for
 ::  Search in Google Scholar for
 ::  Article in PDF (304 KB)
 ::  Citation Manager
 ::  Access Statistics
 ::  Reader Comments
 ::  Email Alert *
 ::  Add to My List *
* Registration required (free) 

  IN THIS Article
 ::  References

 Article Access Statistics
    PDF Downloaded20    
    Comments [Add]    
    Cited by others 4    

Recommend this journal


  Table of Contents     
Year : 2013  |  Volume : 59  |  Issue : 1  |  Page : 1-3

The increasing role of minimal invasive radioguided parathyroidectomy for treating single parathyroid adenoma

Department of Nuclear Medicine, Santa Maria della Misericordia Hospital, Rovigo, Italy

Date of Web Publication22-Mar-2013

Correspondence Address:
D Rubello
Department of Nuclear Medicine, Santa Maria della Misericordia Hospital, Rovigo
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0022-3859.109477

Rights and Permissions

How to cite this article:
Grassetto G, Rubello D. The increasing role of minimal invasive radioguided parathyroidectomy for treating single parathyroid adenoma. J Postgrad Med 2013;59:1-3

How to cite this URL:
Grassetto G, Rubello D. The increasing role of minimal invasive radioguided parathyroidectomy for treating single parathyroid adenoma. J Postgrad Med [serial online] 2013 [cited 2023 Jun 8];59:1-3. Available from:

As Karahan, et al., [1] have shown in their study published in the present issue of the journal entitled: "Minimally invasive parathyroidectomy under local anesthesia", the treatment of choice in case of primary hyperparathyroidism is surgery. The success of the surgical treatment (patient's calcium level returns to normal) depends on the success of localization, identification and removal of abnormal glands.

The first parathyroidectomy dates back to 1925, probably for parathyroid carcinoma that relapsed early, and the first successful treatment of primary hyperparathyroidism by conventional cervicotomy and bilateral neck exploration dates back to 1928. [2],[3],[4],[5],[6] From that day on, when the correlation between hyperparathyroidism symptoms and increased production of parathyroid hormone by an overactive parathyroid gland became clear, parathyroid surgery received a large development and radical changes.

Bilateral neck exploration remained the pivotal strategy of hyperparathyroidism treatment for a long time, until 1982 when Tibblin proposed unilateral neck exploration. [2],[6],[7] This approach seemed enough to study at least two parathyroid glands obtaining information sufficient for suspecting a multigland disease (hyperplasia). [2] Nevertheless, this selective approach, even though curative in many cases thanks to the large prevalence of hyperparathyroidism caused by single adenoma (85%), remained a hazard and unavoidable failures eclipsed it. [2],[8],[9],[10],[11],[12]

Conventional cervicotomy with bilateral neck exploration was considered imperative in the pre-imaging era because the discrimination between single (adenoma) and multigland (hyperplasia) disease was based only on the macroscopic appearance of the glands. So, in the absence of a reliable pre-operative or intra-operative imaging study to identify or localize abnormal parathyroid glands, conventional four-gland exploration is mandatory. So much as, in 1990, the National Institutes of Health (NIH) concluded that pre-operative localization in primary hyperparthyroidism patients without prior neck surgery was rarely indicated and not proven to be cost-effective. So NIH indicated the four-gland exploration as the operation of choice in hyperparathyroidism. [8],[13]

From the last decade of the 20 th century, the diffusion of imaging modalities enables to visualize and localize the parathyroid tissue, have allowed the surgeons to plan a more selective approach called minimally invasive parathyroidectomy (MIP). Also, the introduction of intraoperative quick PTH (parathyroid hormone) assay, that gives the opportunity to measure PTH blood levels during surgery, has permitted the wide spread of this surgery. In fact, the fast decrease of PTH level after gland removal greater than 50% respect on pre-operative value, allows to early evaluate the success of surgery during operation. [2],[14],[15],[16]

The introduction and successful implementation of MIP has revolutionized the surgical approach to hyperparathyroidism. [15] The cervicotomy access can be very short, especially for inferior parathyroid disease, and local anesthesia with or without sedation can be adopted. [1] MIP provides smaller neck incision and less tissue dissection with better cosmetic, lower morbidity, shorter operating time and earlier discharge. [8],[17],[18]

It is worth noting that not all the patients with primary hyperparathyroidism are good candidates for MIP. Accurate initial diagnosis and careful patient selection criteria must be considered: a successful surgery cannot rescind these steps. [2],[14]

As is well known, the diagnosis of primary hyperparathyroidism is biochemical: increment of PTH blood level, increase blood and urine calcium level, decrease in blood phosphate level and increase in urine phosphate level. [8] Only after the diagnosis can the imaging modalities be applied with the purpose to localize the parathyroid tissue and to discriminate between single and multigland disease. Parathyroid pathologic glands can be visualized by many imaging techniques: scintigraphy, high-resolution ultrasound, computed tomography and magnetic resonance. [8],[19] By now it appears to be clear that 99m Tc-Sestamibi parathyroid scintigraphy, together with neck ultrasonography, is the most sensitive and specific imaging technique to localize parathyroid glands. [14],[15] 99m Tc-Sestamibi parathyroid scintigraphy specificity and sensibility show further increase when the dual tracer-subtraction protocol is used and when SPECT (single photon emission computed tomography) acquisition of neck and thorax are gained other than planar imaging. [2],[15],[20],[21],[22] Tomographic sections allow to better localize deeper, posterior parathyroid glands and the ectopic ones, especially if an hibrid instrumentation is used: SPECT/CT technique permits to better localize foci of Sestamibi uptake by software fusion between coregistration of morphological CT imagines and functional sections. [23],[24] Dual-phase 99m Tc-Sestamibi protocol, that is a simplification of double tracer-subtraction scintigraphy, must be considered when dual-tracer subtraction protocol cannot be used, especially in the presence of iodine saturation of the thyroid or during thyroid drugs' assumption. [8]

Only when a single parathyroid disease (adenoma) diagnosis and localization are clear the MIP approach should be considered. In particular, MIP can be suggested if: a) there is high likelihood of solitary parathyroid adenoma at pre-operative 99m Tc-Sestamibi/US imaging; b) there is an unambiguous 99m Tc-Sestamibi uptake in the adenoma; c) 99m Tc-Sestamibi avid thyroid nodules are absent. [14] Many works reported in the literature state that, using these criteria, about two-thirds of all primary hyperparathyroidism patients can benefit from MIP. [14],[25],[26],[27],[28],[29],[30],[31],[32],[33] In cases of big adenomas, thyroid goiter or multiple glands' disease, bilateral neck exploration remains the recommended approach. In particular, when thyroid goiter is associated with parathyroid disease, the MIP can fail both due to the encumbrance caused by thyroid gland and for the low reliability of localizing imaging procedures. [2] Moreover, if during minimally invasive surgery the suspicion of malignant parathyroid disease arises, it is mandatory to convert the surgical approach from mini to open. [2] Also, when the location of the parathyroid adenoma is uncertain and intraoperative quick PTH assay is not available, bilateral neck exploration surgery is preferred. [2]

The minimally invasive approach, proposed in case of primary hyperparathyroidism supported by single parathyroid adenoma, is usually performed by video, endoscopic or radioactive assistance. The radio-guided procedure takes advantage of the detectability of 99m Tc-Sestamibi during surgical intervention by a gamma detecting intraoperative probe and of the different kinetics of this radioactive compound between thyroid and parathyroid tissue. [2],[8] The first protocol for radio-guided MIP was proposed by Norman in 1997 and consists of a single-day procedure: in the same day the patient is submitted to a dual-phase scintigraphy with 740-925 MBq of 99m Tc-Sestamibi and, 2-3 h p.i. (post injection), he undergoes radio-guided surgery. [8],[14],[31] This protocol has the advantages of being cost-effective and rapid because it takes only one day to perform both, imaging localization and surgical treatment. Nevertheless, it has the limitation of using dual-phase 99m Tc-Sestamibi scintigraphy, which, is characterized by a sub-optimal sensititivity and specificity in comparison to double-tracer scan, especially in the presence of thyroid nodules. Moreover, performing diagnostic imaging and surgery in the same day does not allow to correctly organize the operating schedule and approaches (MIP versus open surgery). [14]

A few years later, in 2000, Casara and Rubello proposed the low-dose multiple-day 99m Tc-Sestamibi protocol: the first day a double-tracer subtraction protocol 99m Tc-Sestamibi scintigraphy is performed in association with neck ultrasound; then, within one week of the scintigraphy, the radio-guided MIP is carried out upon 37 MBq 99m Tc-Sestamibi injection in the operating room 10 min before surgery. [8],[14] The low-dose protocol provides two advantages: a) less radiation exposure to the patient and operating personnel (approximately 20 times lower than Norman's protocol) b) more accurate scheduling and planning of surgical approach. [14],[34]

Both described protocols are safe and effective with reported intraoperative parathyroid adenoma detection close to 95%, without major intraoperative surgical complications. [14]

In conclusion, minimally invasive radio-guided parathyroidectomy has an important role in primary hyperparathyroidism treatment but it cannot be separate from an accurate diagnosis and localization of parathyroid glands, especially if a thyroid disease is associated. With this purpose double-tracer 99mTc-Sestamibi with subtraction protocol and neck/thorax SPECT/CT, together with neck ultrasound, constitute a better diagnostic imaging approach to primary hyperparathyroidism and allow to choose the most accurate surgical procedure.

 :: References Top

1.Karahan Ö, Okuþ A, Sevinç B, Eryýlmaz MA, Ay S, Çaycý M, et al. Minimally invasive parathyroidectomy under local anesthesia. J Postgrad Med 2013;59:21-4.  Back to cited text no. 1
  Medknow Journal  
2.Pelizzo MR, Pagetta C, Piotto A, Sorgato N, Merante Boschin I, Toniato A, et al. Surgical treatment of primary hyperparathyroidism: From bilateral neck exploration to minimally invasive surgery. Minerva Endocrinol 2008;33:85-93.  Back to cited text no. 2
3.Hackett DA, Kauffman GL Jr. Historical perspective of parathyroid disease. Otolaryngol Clin North Am 2004;37:689-700.  Back to cited text no. 3
4.Organ CH Jr. The history of parathyroid surgery, 1850-1996: The Excelsior Surgical Society 1998 Edward D Churchill Lecture. J Am Coll Surg 2000;191:284-99.  Back to cited text no. 4
5.Niederle BE, Schmidt G, Organ CH, Niederle B. Albert J and his surgeon: A historical reevaluation of the first parathyroidectomy. J Am Coll Surg 2006;202:181-90.  Back to cited text no. 5
6.Dubose J, Ragsdale T, Morvant J. "Bodies so tiny": The history of parathyroid surgery. Curr Surg 2005;62:91-5.  Back to cited text no. 6
7.Grant CS, Thompson G, Farley D, van Heerden J. Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy: Mayo Clinic experience. Arch Surg 2005;140:472-8.  Back to cited text no. 7
8.Hindié E, Ugur O, Fuster D, O'Doherty M, Grassetto G, Ureña P, et al. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging 2009;36:1201-16.  Back to cited text no. 8
9.Elgazzar A. Parathyroid gland. In: Elgazzar A, editor. The pathophysiologic basis of nuclear medicine. Berlin: Springer; 2001. p. 141-6.  Back to cited text no. 9
10.Giordano A, Rubello D. Le Paratiroidi - sez. Endocrinologia. In: Dondi M, Giubbini R, editors. Medicina Nucleare nella pratica clinica. Patron ed.; Bologna. 2003. p. 171-83.  Back to cited text no. 10
11.Grassetto G, Alavi A, Rubello D. PET and parathyroid. PET Clin 2008;2:385-93.  Back to cited text no. 11
12.DeLellis RA, Mazzaglia P, Mangray S. Primary hyperparathyroidism: A current perspective. Arch Pathol Lab Med 2008;13:1251-62.  Back to cited text no. 12
13.NIH conference, diagnosis and management of asymptomatic primary hyperparathyroidism: Consensus development conference statement. Ann Intern Med 1991;114:593-7.  Back to cited text no. 13
14.Rubello D, Al-Nahhas 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.  Back to cited text no. 14
15.Rubello D, Kapse N, Grassetto G, Massaro A, Al-Nahhas A. Minimally invasive radio-guided surgery for primary hyperparathyroidism: From preoperative to intraoperative localization imaging. Ann Endocrinol (Paris) 2010;71:511-8.  Back to cited text no. 15
16.Vittal SK, Sai Vishnupriya V, Sucharitha V, Vittal S. Surgery of parathyroid. Indian J Surg 2010;72:10-5.  Back to cited text no. 16
17.Perrier ND, Ituarte PH, Morita E, Hamill T, Gielow R, Duh QY, et al. Parathyroid surgery: Separating promise from reality. J Clin Endocrinol Metab 2002;87:1024-9.  Back to cited text no. 17
18.Fahy BN, Bold RJ, Beckett L, Schneider PD. Modern parathyroid surgery: A cost-benefit analysis of localizing strategies. Arch Surg 2002;137:917-22.  Back to cited text no. 18
19.Hopkins CR, Reading CC. Thyroid and parathyroid imaging. Semin Ultrasound CT MR 1995;16:279-95.  Back to cited text no. 19
20.Rubello D, Gross MD, Mariani G, AL-Nahhas A. Scintigraphic techniques in primary hyperparathyroidism: From pre-operative localisation to intra-operative imaging. Eur J Nucl Med Mol Imaging 2007;34:926-33.  Back to cited text no. 20
21.Rubello D, Massaro A, Cittadin S, Rampin L, Al-Nahhas A, Boni G, et al. Role of 99mTc-sestamibi SPECT in accurate selection of primary hyperparathyroid patients for minimally invasive radio-guided surgery. Eur J Nucl Med Mol Imaging 2006;33:1091-4.  Back to cited text no. 21
22.Turgut B, Elagoz S, Erselcan T, Koyuncu A, Dokmetas HS, Hasbek Z, et al. Preoperative localization of parathyroid adenomas with technetium-99m methoxyisobutylisonitrile imaging: Relationship with P-glycoprotein expression, oxyphilic cell content, and tumoral tissue volume. Cancer Biother Radiopharm 2006;21:579-90.  Back to cited text no. 22
23.Taieb D, Hindie E, Grassetto G, Colletti PM, Rubello D. Parathyroid scintigraphy: When, how, and why? A concise systematic review. Clin Nucl Med 2012;37:568-74.  Back to cited text no. 23
24.Kumar KV, Jha S, Shaikh A, Modi KD. Single photon emission computed tomography-CT in ectopic parathyroid adenoma. Indian J Endocrinol Metab 2011;15:334-6.  Back to cited text no. 24
25.Rubello D, Fig LM, Casara D, Piotto A, Boni G, Pelizzo MR, et al. Radioguided surgery of parathyroid adenomas and recurrent thyroid cancer using the "low sestamibi dose" protocol. Cancer Biother Radiopharm 2006;21:194-205.  Back to cited text no. 25
26.Rubello D, Casara D, Pelizzo MR. Optimization of peroperative procedures. Nucl Med Commun 2003;24:133-40.  Back to cited text no. 26
27.Casara D, Rubello D, Piotto A, Pelizzo MR. 99mTc-MIBI radio-guided minimally invasive parathyroid surgery planned on the basis of a preoperative combined 99mTc-pertechnetate/99mTc-MIBI and ultrasound imaging protocol. Eur J Nucl Med 2000;27:1300-4.  Back to cited text no. 27
28.Casara D, Rubello D, Pelizzo MR, Shapiro B. Clinical role of 99mTcO4/MIBI scan, ultrasound and intra-operative gamma probe in the performance of unilateral and minimally invasive surgery in primary hyperparathyroidism. Eur J Nucl Med 2001;28:1351-9.  Back to cited text no. 28
29.Rubello D, Casara D, Giannini 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.  Back to cited text no. 29
30.Rubello D, Piotto A, Casara D, Muzzio PC, Shapiro B, Pelizzo MR. Role of gamma probes in performing minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: Optimization of preoperative and intraoperative procedures. Eur J Endocrinol 2003;149:7-15.  Back to cited text no. 30
31.Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122:998-1003.  Back to cited text no. 31
32.Costello D, Norman J. Minimally invasive radioguided parathyroidectomy. Surg Oncol Clin N Am 1999;8:555-64.  Back to cited text no. 32
33.Mariani G, Gulec SA, Rubello D, Boni G, Puccini M, Pelizzo MR, et al. Preoperative localization and radioguided parathyroid surgery. J Nucl Med 2003;44:1443-58.  Back to cited text no. 33
34.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.  Back to cited text no. 34

This article has been cited by
1 Analysis of 61 SNPs from the CAD specific genomic loci reveals unique set of SNPs as significant markers in the Southern Indian population of Hyderabad
Manjula Gorre, Pranavchand Rayabarapu, Sriteja Reddy Battini, Kumuda Irgam, Mohan Reddy Battini
BMC Cardiovascular Disorders. 2022; 22(1)
[Pubmed] | [DOI]
2 Cirugía radioguiada en el hiperparatiroidismo primario: revisión de las diferentes técnicas disponibles
E. Goñi-Gironés, S. Fuertes-Cabero, I. Blanco-Sáiz, I. Casáns-Tormo, P. García-Talavera San Miguel, J. Martín-Gil, C. Sampol-Bas, P. Abreu-Sánchez, R. Díaz-Expósito, S. Vidal-Sicart
Revista Española de Medicina Nuclear e Imagen Molecular. 2021; 40(1): 57
[Pubmed] | [DOI]
3 Radioguided surgery in primary hyperparathyroidism: a review of the different techniques available
E. Goñi Gironés, S. Fuertes Cabero, I. Blanco Sáiz, I. Casáns-Tormo, P. García-Talavera San Miguel, J. Martín Gil, C. Sampol Bas, P. Abreu Sánchez, R. Díaz Expósito, S. Vidal-Sicart
Revista Española de Medicina Nuclear e Imagen Molecular (English Edition). 2021; 40(1): 57
[Pubmed] | [DOI]
4 Ultrasonography alone can reliably locate parathyroid tumours and facilitates minimally invasive parathyroidectomy
HZ Butt, MA Husainy, A Bolia, NJM London
The Annals of The Royal College of Surgeons of England. 2015; 97(6): 420
[Pubmed] | [DOI]


Print this article  Email this article
Online since 12th February '04
© 2004 - Journal of Postgraduate Medicine
Official Publication of the Staff Society of the Seth GS Medical College and KEM Hospital, Mumbai, India
Published by Wolters Kluwer - Medknow