Ultrasound and technetium-99m sestamibi scintigraphy diagnostic performance as preferred localization techniques in patients with primary hyperparathyroidism: A literature review

Introduction: Primary hyperparathyroidism (PHPT) is a medical problem whose definitive management is surgery. Preoperative imaging studies for identifying the solitary parathyroid adenoma are a requirement for focused parathyroidectomy in patients with PHPT. There are various imaging modalities for the localization study. Nevertheless, up until now, the gold standard for parathyroid imaging has still not been established. Accurate parathyroid imaging is needed in PHPT cases to support the success of focused parathyroidectomy and prevent increasing patient morbidity due to bilateral neck exploration. Aims and objectives: It is very important for this study to investigate the positive predictive value (PPV) and sensitivity of sestamibi and ultrasonography as preoperative localization techniques. Materials and methods: Literature search has been carried out on Cochrane, PubMed, and the ScienceDirect database site, using a combination of Medical Subject Headings (MeSH) search terms and keywords: “parathyroidectomy,”“primary hyperparathyroidism,”“parathyroid adenoma,” “ultrasound,”“ultrasonography,”“radionuclide imaging,”“sestamibi,”“sensitivity and specificity,” and “predictive values of tests.” A literature search was conducted to look for previous publications, about the sensitivity and positive predictive value of ultrasonography as a technique of localizing preoperative compared with sestamibi in localizing parathyroid adenomas in patients with PHPT. After research articles have been obtained, a selection and examination of journals according to the inclusion and exclusion criteria was conducted. Results: A total of 192 studies were obtained, which are Cochrane (0) study, PubMed (33) studies, and Science Direct (159) studies. After screening, 15 studies are selected for review. According to the studies, ultrasonography has a sensitivity of 55–100% and PPV 74–100%. Ultrasonography has a wide range of sensitivity because it is highly operator-dependent depending the expertise of the operator. Ultrasonography by radiologists has a sensitivity of 55–94.6% and PPV 74–97.2%, while ultrasonography by a surgical specialist has a sensitivity of 83–93.2% and PPV 80–85.1%. Sestamibi has a sensitivity of 64–93.3% and PPV 70.5–100%. Limitation of sestamibi includes poor spatial resolution causing low precision in anatomic localization, and there is the use of ionizing radiation. While SPECT/CT has similar sensitivity in localizing parathyroid adenomas located on the retrothyroid and ectopic sites (sensitivity 86.7% and 81.5%; PPV 98.1% and 100%). The study has found that adding ultrasonography to the SPECT/CT examination increased sensitivity, but decreased PPV. Conclusion: Ultrasound examination is very dependent on the operator so that sensitivity varies, influenced by the expertise and experience of the operator in each institution. Ultrasonography can be used as the main modality in localization studies in patients with PHPT in areas that do not have nuclear radiology facilities.