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Gerard M Doherty - One of the best experts on this subject based on the ideXlab platform.
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4d ct is superior to ultrasound and sestamibi for localizing recurrent Parathyroid Disease
Annals of Surgical Oncology, 2018Co-Authors: Moska Hamidi, Gerard M Doherty, Michael C Sullivan, George J Hunter, Leena Hamberg, Nancy L Cho, Atul A Gawande, Francis D Moore, Matthew A NehsAbstract:Recurrent primary hyperParathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing Parathyroid adenomas in recurrent or persistent PHPT. We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of Parathyroid lesions were collected for each patient. A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland Disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. 4D-CT localized Parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
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an international perspective on ultrasound training and use for thyroid and Parathyroid Disease
World Journal of Surgery, 2010Co-Authors: Barbra S Miller, Paul G Gauger, James T Broome, Richard E Burney, Gerard M DohertyAbstract:Use of ultrasound (USN) by endocrine surgeons has dramatically increased. Presently, optimal training and certification requirements have not been standardized at any level (resident/fellow/attending). We sought to define the types of USN training endocrine surgeons receive and how USN is employed in practice. We hypothesized that in more recent years fellowship-trained endocrine surgeons were more likely to receive formal training in the use of USN during their endocrine surgery fellowship. A survey link was sent via email to a large group of endocrine surgeons around the world asking about the settings in which they received USN training, the type of instruction received, current use of USN, and other various questions. χ2 analysis was performed and P < 0.05 was considered significant. One hundred twenty-one surveys were collected from respondents in 27 countries. Median time from completion of residency to the present was 17 years (range = 2–49). Fifty-nine percent of both fellowship- and nonfellowship-trained endocrine surgeons currently use USN in their practice. Of those currently performing USN, 38% reported no USN training of any kind (47% international vs. 23% United States). USN experience among international and U.S. residents was not different (P = 0.27). Fifty-nine percent of respondents reported completing an endocrine surgery fellowship; of those, 85% reported no formal USN training. Forty-one percent reported not being comfortable performing USN at the completion of their endocrine surgery fellowships, requiring the presence of someone else to assist with the exam. USN training among endocrine surgeons varies widely around the world. Despite an increase in the number of formal endocrine surgery fellowships offered, it does not appear that the number with formal USN training and certification has increased. Formal USN certification is achieved in only a minority of cases among practicing endocrine surgeons. It is currently unknown whether there is a difference in competency between endocrine surgeons with formal versus informal USN training.
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multiple endocrine neoplasia type 1 Parathyroid adenoma development over time
World Journal of Surgery, 2004Co-Authors: Gerard M Doherty, Terry C Lairmore, Mary K DebenedettiAbstract:Multiple gland Parathyroid Disease is one of the hallmarks of multiple endocrine neoplasia (MEN) type 1. Often mislabeled Parathyroid hyperplasia, the process is actually the development of multiple adenomas. Some clinicians have reported results of selective Parathyroidectomy in this group, removing only grossly enlarged glands. We argue that all the glands are at risk and should be addressed at any planned Parathyroid intervention. Our hypothesis is that, given sufficient time, patients would all develop adenomas in each of the Parathyroid glands. Our available data to address this issue are the Parathyroidectomy results from a single institution series. Patients who had initial Parathyroid exploration for hyperParathyroidism in the setting of MEN-1 were reviewed. This study includes those patients who had the weights of the resected glands documented; 23 men and 21 women met the criteria. The total weight of the Parathyroid glands did not vary with the age of the patient at operation. However, the number of normal glands identified did vary significantly with age (p < 0.02), with older patients being less likely to have any normal Parathyroid glands. Although total Parathyroid weight may correlate with development of hypercalcemia and indications for operation, the involvement of multiple Parathyroid glands in MEN-1 is a function of time, as independent events in each gland must occur. Given time, MEN-1 patients all develop multiple gland Disease, and this reality must be used in planning operative management for patients with this syndrome.
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impact of intraoperative Parathyroid hormone monitoring on the prediction of multiglandular Parathyroid Disease
World Journal of Surgery, 2004Co-Authors: Thomas Clerici, Michael Brandle, Jochen Lange, Gerard M Doherty, Paul G GaugerAbstract:Optimal interpretation of the results of intraoperative Parathyroid hormone (IOPTH) monitoring during neck exploration for primary hyperParathyroidism (pHPT) is still controversial. The reliability of the “50% rule” in multiglandular Disease (MGD) is often disputed, mostly because of competing pathophysiologic paradigms. The aim of this study was to ascertain and corroborate the ability of IOPTH monitoring to detect MGD in a practice, combining conventional and alternative Parathyroid-ectomy techniques. This is a retrospective single institution analysis of 69 consecutive patients undergoing cervical exploration for pHPT by various approaches. The IOPTH measurements were performed after induction of anesthesia but prior to skin incision and 10 minutes after excision of the first visualized enlarged Parathyroid gland. In this series, 55 patients (80%) had single adenomas, and 14 patients (20%) had MGD. In 8 of the 14 patients with MGD, IOPTH levels were obtained sequentially after removal of every enlarged gland. Of these 8 patients, 6 (75%) had a false-positive decrease (decrease below 50% of baseline value in presence of another enlarged gland) failing to predict the presence of a second enlarged gland. In 2 cases IOPTH monitoring provided a true-negative result, correctly predicting MGD. If MGD is defined by gross morphologic criteria, IOPTH monitoring fails to predict the presence of MGD reliably. However, if MGD is defined by functional criteria, the course of these patients does not seem significantly affected. The importance of these findings must be further investigated, especially with regard to the outcome of minimally invasive Parathyroid procedures.
Francis D Moore - One of the best experts on this subject based on the ideXlab platform.
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4d ct is superior to ultrasound and sestamibi for localizing recurrent Parathyroid Disease
Annals of Surgical Oncology, 2018Co-Authors: Moska Hamidi, Gerard M Doherty, Michael C Sullivan, George J Hunter, Leena Hamberg, Nancy L Cho, Atul A Gawande, Francis D Moore, Matthew A NehsAbstract:Recurrent primary hyperParathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing Parathyroid adenomas in recurrent or persistent PHPT. We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of Parathyroid lesions were collected for each patient. A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland Disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. 4D-CT localized Parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
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reassessment of Parathyroid hormone monitoring during Parathyroidectomy for primary hyperParathyroidism after 2 preoperative localization studies
Archives of Surgery, 2006Co-Authors: Atul A Gawande, Jack M Monchik, Thomas A Abbruzzese, Jason D Iannuccilli, Shahrul I Ibrahim, Francis D MooreAbstract:Hypothesis: For patients with primary hyperParathyroidism and patients with 2 localization studies showing the same single location of Parathyroid Disease, use of intraoperative Parathyroid hormone (IOPTH) measurement does not significantly increase the success of minimally invasive Parathyroidectomy. Design: Retrospective cohort study. Setting: Experience of 2 academic centers over 5 years (at Brigham and Women's Hospital, Boston, Mass) and almost 4 years (at Rhode Island Hospital, Providence). Patients: A total of 569 patients with primary hyperParathyroidism who underwent technetium Tc 99m sestamibi (MIBI) Parathyroid imaging and neck ultrasonography (US). Main Outcome Measures: Incidence of correct prediction of location and extent of Disease. Results: In 322 patients (57%), MIBI and US imaging identified the same single site of Disease. In 319 (99%) of these 322 patients, surgical exploration confirmed a Parathyroid adenoma at that site, and the IOPTH levels normalized on removal. In 3 (1%) of the 322 patients, IOPTH measurement identified unsuspected additional Disease. In 3 (1%) of the remaining 319 patients, IOPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in patients with positive MIBI and positive US imaging was 1% with IOPTH measurement and 2% without IOPTH measurement (P=.50). In 201 (35%) of the 569 patients, only 1 of the 2 studies recognized an abnormality or the studies disagreed on location. In these cases, either MIBI imaging or US imaging (if MIBI imaging was negative) failed to predict the correct site or extent of Disease in 76 (38%) of the 201 patients (P<.001 vs concordant studies). Conclusions: In primary hyperParathyroidism, concordant preoperative localization with MIBI and US imaging is highly accurate. Use of IOPTH measurement in these cases adds only marginal benefit. When only 1 of the 2 studies identifies Disease or the studies conflict, however, IOPTH measurement remains essential during minimally invasive Parathyroidectomy.
Robert Udelsman - One of the best experts on this subject based on the ideXlab platform.
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surgery for primary hyperParathyroidism
Cancer, 2014Co-Authors: Glenda G Callender, Robert UdelsmanAbstract:In the Western world, primary hyperParathyroidism is now a relatively common disorder that is diagnosed in 0.7% of the general population and in 2% of postmenopausal women. Although patients today typically present with less severe manifestations of Disease, the evaluation and management of patients with Parathyroid Disease remains challenging. Primary hyperParathyroidism is a complex Disease process that requires careful diagnosis and thoughtful medical and surgical management. The surgical management of patients with persistent or recurrent Disease, inherited primary hyperParathyroidism syndromes, and Parathyroid carcinoma is particularly challenging. High-quality imaging and reliable intraoperative adjuncts are critical to success.
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surveillance for early detection of aggressive Parathyroid Disease carcinoma and atypical adenoma in familial isolated hyperParathyroidism associated with a germline hrpt2 mutation
Journal of Bone and Mineral Research, 2006Co-Authors: Thomas G Kelly, Andrew Arnold, Robert Udelsman, Trisha M Shattuck, Miguel Reyesmugica, Andrew F Stewart, William F Simonds, Thomas O CarpenterAbstract:Familial hyperParathyroid syndromes involving mutations of HRPT2 (also CDC73), a tumor suppressor, are important to identify because the relatively high incidence of Parathyroid malignancy associated with such mutations warrants a specific surveillance strategy. However, there is a dearth of reports describing experience with surveillance and early detection informed by genetic insight into this disorder. Introduction: Familial isolated hyperParathyroidism (FIHP) is a rare cause of Parathyroid (PT) tumors without other neoplasms or endocrinopathies. Germline mutations in CASR, MEN1, and rarely, HRPT2 have been identified in kindreds with FIHP. HRPT2 mutations may be enriched in FIHP families with PT carcinoma, underscoring the importance of identifying causative mutations. Materials and Methods: A 13-year-old boy, whose father had died of PT carcinoma, developed primary hyperParathyroidism. A left superior PT mass was identified by ultrasonography and removed surgically. Aggressive histological features of the boy's tumor included fibrous trabeculae, mitoses, and microscopic capsular infiltration. Two years later, under close biochemical surveillance, primary hyperParathyroidism recurred 5 months after documentation of normocalcemia and normal Parathyroid status. Ultrasound and MRI identified a newly enlarged right superior PT gland but indicated no recurrent Disease in the left neck. Histologic features typical of a benign adenoma were evident after surgical extirpation of the gland. Results: Leukocyte DNA analysis revealed a frameshift mutation in exon 2 of HRPT2. The initial tumor manifested the expected germline HRPT2 mutation, plus a distinct somatic frameshift mutation, consistent with the Knudson “two hit” concept of biallelic inactivation of a classic tumor suppressor gene. Genetic screening of the patient's 7 asymptomatic and previously normocalcemic siblings revealed three with the same germline HRPT2 mutation. One of the siblings newly identified as mutation-positive was noted to be hypercalcemic at the time of the genetic screening. He was found to have a PT adenoma with aggressive features. Two of the five children of another mutation-positive sibling also carry the same HRPT2 mutation. Conclusions: Despite the reported rarity of HRPT2 mutations in FIHP, a personal or family history of PT carcinoma in FIHP mandates serious consideration of germline HRPT2 mutation status. This information can be used in diagnostic and management considerations, leading to early detection and removal of potentially malignant Parathyroid tumors.
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partial median sternotomy an attractive approach to mediastinal Parathyroid Disease
World Journal of Surgery, 2006Co-Authors: Jason S Gold, Patricia Donovan, Robert UdelsmanAbstract:Background Parathyroid exploration through a standard cervical approach is adequate for the resection of most mediastinal Parathyroid glands. A subset of mediastinal Parathyroid glands causing hyperParathyroidism, however, cannot be removed in this manner.
Atul A Gawande - One of the best experts on this subject based on the ideXlab platform.
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4d ct is superior to ultrasound and sestamibi for localizing recurrent Parathyroid Disease
Annals of Surgical Oncology, 2018Co-Authors: Moska Hamidi, Gerard M Doherty, Michael C Sullivan, George J Hunter, Leena Hamberg, Nancy L Cho, Atul A Gawande, Francis D Moore, Matthew A NehsAbstract:Recurrent primary hyperParathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing Parathyroid adenomas in recurrent or persistent PHPT. We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of Parathyroid lesions were collected for each patient. A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland Disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months. 4D-CT localized Parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.
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reassessment of Parathyroid hormone monitoring during Parathyroidectomy for primary hyperParathyroidism after 2 preoperative localization studies
Archives of Surgery, 2006Co-Authors: Atul A Gawande, Jack M Monchik, Thomas A Abbruzzese, Jason D Iannuccilli, Shahrul I Ibrahim, Francis D MooreAbstract:Hypothesis: For patients with primary hyperParathyroidism and patients with 2 localization studies showing the same single location of Parathyroid Disease, use of intraoperative Parathyroid hormone (IOPTH) measurement does not significantly increase the success of minimally invasive Parathyroidectomy. Design: Retrospective cohort study. Setting: Experience of 2 academic centers over 5 years (at Brigham and Women's Hospital, Boston, Mass) and almost 4 years (at Rhode Island Hospital, Providence). Patients: A total of 569 patients with primary hyperParathyroidism who underwent technetium Tc 99m sestamibi (MIBI) Parathyroid imaging and neck ultrasonography (US). Main Outcome Measures: Incidence of correct prediction of location and extent of Disease. Results: In 322 patients (57%), MIBI and US imaging identified the same single site of Disease. In 319 (99%) of these 322 patients, surgical exploration confirmed a Parathyroid adenoma at that site, and the IOPTH levels normalized on removal. In 3 (1%) of the 322 patients, IOPTH measurement identified unsuspected additional Disease. In 3 (1%) of the remaining 319 patients, IOPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in patients with positive MIBI and positive US imaging was 1% with IOPTH measurement and 2% without IOPTH measurement (P=.50). In 201 (35%) of the 569 patients, only 1 of the 2 studies recognized an abnormality or the studies disagreed on location. In these cases, either MIBI imaging or US imaging (if MIBI imaging was negative) failed to predict the correct site or extent of Disease in 76 (38%) of the 201 patients (P<.001 vs concordant studies). Conclusions: In primary hyperParathyroidism, concordant preoperative localization with MIBI and US imaging is highly accurate. Use of IOPTH measurement in these cases adds only marginal benefit. When only 1 of the 2 studies identifies Disease or the studies conflict, however, IOPTH measurement remains essential during minimally invasive Parathyroidectomy.
Ralph P Tufano - One of the best experts on this subject based on the ideXlab platform.
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are preoperative sestamibi scans useful for identifying ectopic Parathyroid glands in patients with expected multigland Parathyroid Disease
Surgery, 2018Co-Authors: Farah Karipineni, Zeyad T Sahli, Helina Somervell, Aarti Mathur, Jason D Prescott, Ralph P Tufano, Martha A ZeigerAbstract:Abstract Background The role of preoperative localization studies in patients with hyperParathyroidism and expected multigland Disease remains poorly defined. Our study investigates the usefulness of obtaining preoperative sestamibi scans and ultrasonography of the neck in identifying ectopic glands in this group of patients. Methods Under Institutional Review Board approval, we performed a retrospective review of patients who underwent operation for secondary hyperParathyroidism, tertiary hyperParathyroidism, lithium-induced hyperParathyroidism, and multiple endocrine neoplasia syndrome at a tertiary institution between 2004 and 2015. We reviewed patient demographics, laboratory, radiology, pathology, and operative reports. Results Of 2,975 Parathyroidectomies performed during this period, 154 operations were performed in 149 patients who met the criteria. Of the 149 patients, 82 (55.0%) had secondary, 31 (20.8%) had tertiary, 23 (15.4%) had lithium-induced HPT, and 13 (10.1%) had multiple endocrine neoplasia syndrome; 86 ectopic glands were identified in 64 patients (43.0%). Sensitivity for identification of ectopic glands was 29% for sestamibi scan and 7% for ultrasonography, while 89% of mediastinal glands were localized by sestamibi scans and thoracotomy, thoracoscopy, or sternotomy occurred in 4.7% of patients. Conclusion We found a greater rate of preoperative localization of ectopic glands than reported previously. Because the sensitivity of sestamibi for identification of ectopic glands is 23.0%, the implication of missing mediastinal glands warrants preoperative imaging.
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multiphase computed tomography for localization of Parathyroid Disease in patients with primary hyperParathyroidism how many phases do we really need
Surgery, 2014Co-Authors: Salem I Noureldine, Nafi Aygun, Michael J Walden, Ahmed Hassoon, Sachin K Gujar, Ralph P TufanoAbstract:Background Multiphase computed tomography (CT) involves multiple cervical CT acquisitions to accurately identify hyperfunctional Parathyroid glands, thus increasing radiation exposure to the patient. We hypothesized that only 2 cervical acquisitions, instead of the conventional 4, would provide equivalent localization information and halve the radiation exposure. Methods We identified 53 consecutive patients with primary hyperParathyroidism who underwent multiphase CT before Parathyroidectomy. All scans were reinterpreted first using 2 phases then using all 4 phases. The accuracies of interpretations were determined with surgical findings serving as the standard of reference. Results Sixty-four hyperfunctional Parathyroid glands were resected with a mean weight of 394.3 mg. Two-phase CT lateralized the hyperfunctional glands in 38 patients with a sensitivity, positive predictive value (PPV), and accuracy of 100%, 71.7%, and 71.7%, respectively. Four-phase CT lateralized the hyperfunctional glands in 39 patients with a sensitivity, PPV, and accuracy of 95.1%, 76.5%, and 73.6%, respectively. For quadrant localization, the accuracy of 2-phase and 4-phase CT was 50.9% and 52.8%, respectively. Conclusion Our results suggest that 2-phase and 4-phase CT provide an equivalent diagnostic accuracy in localizing hyperfunctional Parathyroid glands. The reduced radiation exposure to the patient may make 2-phase acquisitions a more acceptable alternative for preoperative localization.
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can ultrasound be used as the primary screening modality for the localization of Parathyroid Disease prior to surgery for primary hyperParathyroidism a review of 440 cases
Operations Research Letters, 2011Co-Authors: Joshua M Levy, Emad Kandil, Lillian Yau, Jonathan D Cuda, Sheila Sheth, Ralph P TufanoAbstract:Background/Aims: Sestamibi scintigraphy and neck ultrasonography have both been proposed as screening modalities for the detection of abnormal Parathyroid glands in patients with primary hyperParathyroidism. As a result, many surgeons use both techniques prior to surgery. The goal of this study was to independently evaluate both ultrasound and sestamibi as single-modality preoperative screening tools for primary hyperParathyroidism. Methods: A retrospective review of consecutive patients who underwent surgery for primary hyperParathyroidism from January 1999 to December 2009. Imaging results were compared to surgical findings. Results: 440 patients were found to meet inclusion criteria. Sensitivities for correct localization of a single Parathyroid adenoma for sestamibi versus ultrasound were: 83% (95% CI 78–86) versus 72% (95% CI 67–76). Ultrasound operator had no influence on sensitivity, and ultrasound identified nodular thyroid Disease in 31% of patients. Conclusion: Ultrasonography alone can be used as the primary screening modality in patients with primary hyperParathyroidism. Ultrasound sensitivity is conserved despite operator variability, and identifies concomitant thyroid pathology.
