Recommendation ID
NG132/2
Question

What is the best and most cost-effective management strategy for people whose first surgery for primary hyperparathyroidism is not successful?

Any explanatory notes
(if applicable)
Preoperative imaging

There was limited evidence on preoperative imaging so the committee also used their clinical knowledge and experience to make the recommendations. They agreed that the purpose of preoperative imaging is to help guide the surgical approach. It is not essential in all circumstances (for example, if a decision has already been made to perform 4‑gland exploration).

Evidence suggested that ultrasound scanning is accurate in identifying abnormal parathyroid tissue. Ultrasound scanning is widely available, safe and does not involve any exposure to radiation. However, the committee noted that the accuracy of ultrasound depends on the expertise of the person performing it. They therefore recommended sestamibi as an alternative.

Although dual scanning using 2 different imaging modalities has the advantage of providing both anatomical and functional information, the committee agreed that a second imaging modality is only needed if it will further inform the surgical approach. Evidence suggests that sestamibi scanning is accurate in detecting single-gland disease. The committee did not make a recommendation on 4D CT scanning because there was no evidence available.

The committee agreed that if dual scanning fails to identify an adenoma or is discordant, further imaging will not add useful information and will expose the person to unnecessary radiation. They acknowledged that preoperative imaging does not detect all adenomas, so 4‑gland exploration should be offered if preoperative imaging does not identify an adenoma.

Type of surgery

The committee agreed that, based on their experience, people whose preoperative imaging does not identify a single adenoma will more frequently have multigland disease and will benefit from 4‑gland exploration. If the first-modality and second-modality scans are discordant, 4‑gland exploration can be considered because the specific anatomical location of the adenoma cannot be assured.

For people with a single adenoma, a small amount of evidence shows that both focused parathyroidectomy and 4‑gland exploration are safe and effective. The committee agreed that focused parathyroidectomy offers the potential advantages of lower temporary hypocalcaemia, a shorter surgery time and minor cosmetic benefit. However, it also carries a marginally (around 5%) higher chance of recurrence or persistent disease. They therefore agreed that people with a single adenoma should be offered a choice of focused parathyroidectomy or 4‑gland exploration, and that the possible benefits and risks of each type of surgery should be discussed with them.

Intraoperative PTH monitoring

There was limited evidence on intraoperative PTH (IOPTH) monitoring. The committee noted that in their experience, there is a marginal benefit with the use of IOPTH, but this could be partially attributed to surgical expertise.

IOPTH monitoring is costly and its effectiveness in improving surgical outcomes is uncertain. The committee agreed that their experience together with the limited evidence did not support IOPTH monitoring as part of standard practice.

Follow-up after surgery

Based on their knowledge and experience, the committee agreed that people who have had parathyroid surgery can be considered biochemically cured if their albumin-adjusted serum calcium and PTH levels are within the reference range before discharge after surgery and their albumin-adjusted serum calcium level is within the reference range 3 to 6 months after surgery.

The committee acknowledged the potential of bone turnover markers to check bone health after surgery for primary hyperparathyroidism but were unable to make a recommendation because of a lack of evidence. They therefore made a research recommendation on bone turnover markers.

Unsuccessful surgery

There was no evidence on further surgical management for people who have had unsuccessful first surgery, and very limited evidence on drug therapy with cinacalcet compared with placebo. The committee agreed that input from a multidisciplinary team at a specialist centre should be sought, noting that repeat parathyroid surgery is relatively uncommon, failure rates are higher than in first surgery and it carries a higher risk. They also made a research recommendation on management after unsuccessful first surgery.

How the recommendations might affect practice

The recommendations for preoperative imaging largely reflect current practice. However, there is variation in the number and type of preoperative tests carried out and the resulting course of action. The committee thought that the recommendations will necessitate changes in practice for some providers. They noted that using a maximum of 2 imaging modalities before surgery would change practice in centres that currently use more than 2 imaging modalities.

Although not widely used, IOPTH testing is most likely to be found in larger centres that are undertaking parathyroidectomies most frequently. The recommendation is expected to lead to changes in practice in these centres.

The recommendations on type of surgery are considered to generally reflect current practice. However, in some centres, current practice is not to offer surgery to people if no adenoma is identified on imaging. These recommendations will therefore necessitate changes in practice for some providers.

The recommendations on follow‑up after surgery reflect current practice in most NHS centres, so the committee thought that there would be little change in practice.

The recommendations on unsuccessful surgery are current practice in many areas.

Full details of the evidence and the committee's discussion are in:

Source guidance details

Comes from guidance
Hyperparathyroidism (primary): diagnosis, assessment and initial management
Number
NG132
Date issued
May 2019

Other details

Is this a recommendation for the use of a technology only in the context of research? No  
Is it a recommendation that suggests collection of data or the establishment of a register?   No  
Last Reviewed 23/05/2019