Tricks of the trade: Techniques for preoperative localization in reoperative parathyroidectomy

Background: Reoperative parathyroidectomy for recurrent/persistent primary hyperparathyroidism (PHPT) has high rates of failure. The goal of this study was to analyze our experience with imaging and parathyroid vein sampling (PAVS) for recurrent/persistent PHPT. Methods: We performed a retrospective cohort study (2002-2018) of patients with recurrent/persistent PHPT undergoing reoperative parathyroidectomy. Results: Among 181 patients, the most common imaging study was sestamibi (89.5%), followed by ultrasound (75.7%). CT had the highest rate of localization (70.8%) compared to sestamibi (58.0%) and ultrasound (47.4%). PAVS was performed in 25 patients, and localized in 96%. Ultrasound and sestamibi both demonstrated 62% PPV for operative pathology, compared to 41% in CT. PAVS was 95% sensitive with 95% PPV for predicting the correct side of abnormal parathyroid tissue. Conclusions: We recommend a sequential imaging evaluation for reoperative parathyroidectomy, with sestamibi and/or ultrasound followed by CT. PAVS should be considered if non-invasive imaging fails to localize.