Correlation of pre-operative imaging findings and parathyroidectomy outcomes support NICE 2019 guidance.

CONTEXT Pre-operative localisation studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalised disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. OBJECTIVE This study aims to correlate parathyroidectomy outcomes with pre-operative imaging in a single, high-volume institution. METHODS Data from a prospectively maintained departmental database of operations performed from 2017-2019 was analysed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, pre-operative imaging, surgical strategy, and post-operative outcomes. RESULTS A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localised patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalised group (those with negative US and sestamibi) (p=0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double positive imaging and 5.7% of patients with double negative imaging (otherwise, bilateral parathyroid visualisation was performed). There was no significant difference in post-operative complications between patients undergoing unilateral or bilateral neck exploration. CONCLUSIONS Patients with negative pre-operative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localised. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of pre-operative imaging findings.