Surgery in practice and science · 2026
Cautious clinical interpretation of preoperative Tc-99m-Sestamibi localization scan among chronic kidney disease and transplanted patients.
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Elhadad Orel, Fisher Ran, Tzukert Keren, Weinberger Jeffrey, Mazeh Haggi, Hirshoren Nir
Аннотация
INTRODUCTION: Chronic kidney disease (CKD) patients and kidney transplant recipients are predisposed to developing hyperparathyroidism. Although CKD is typically associated with parathyroid hyperplasia, preoperative assessment may include a 99mTc‑MIBI localization scan, performed selectively rather than routinely, which may demonstrate findings suggestive of a parathyroid adenoma. Diagnosing an adenoma potentially eliminates the need for four-gland exploration. However, the clinical meaning of pre-operative scans among renal patients remains unclear.The study objectives are: Determine adenoma and hyperplasia prevalence in the study population and the pre-operative MIBI scan localization outcomes. Identify potential predictors for either adenoma or hyperplasia.
MATERIALS AND METHODS: Retrospective cohort study, with at least 6 months post-operative follow-up, based on laboratory, imaging, medical, and operative notes in referral medical center between 2012 and 2022.
RESULTS: Among 871 parathyroidectomies, 59 patients had a relevant renal background and long-term follow-up. Of these, 31 (53%) had hyperplasia. Preoperative 99m Tc-MIBI scan demonstrated positive localization for adenoma in 73% of patients. However, 22% were later diagnosed with hyperplasia (false positive), resulting in an effective localization rate of only 56.9%. The scan had 78.6% accuracy and positive and negative predictive values of 76.7% and 83.3%, respectively.Hyperplasia was significantly associated with younger age (p = 0.009) and dialysis dependence (p = 0.007). Hyperplasia was correlated with relative subtle hypercalcemia (p = 0.015), significant higher phosphorus (p = 0.001), higher alkaline phosphatase (p < 0.001), and higher PTH levels (p = 0.004).
DISCUSSION: Over half of CKD patients had hyperplasia. The majority of patients underwent a localization parathyroid MIBI scan. About 3/4 of scanned patients had positive adenoma localization, but only 3/4 were eventually operated on and cured as adenoma.
CONCLUSIONS: We demonstrate a limited benefit of MIBI scans in CKD and kidney transplant patients. We recommend either omitting the scan or performing bilateral neck exploration or at least two same-side parathyroid glands exploration to improve cure rates.
MATERIALS AND METHODS: Retrospective cohort study, with at least 6 months post-operative follow-up, based on laboratory, imaging, medical, and operative notes in referral medical center between 2012 and 2022.
RESULTS: Among 871 parathyroidectomies, 59 patients had a relevant renal background and long-term follow-up. Of these, 31 (53%) had hyperplasia. Preoperative 99m Tc-MIBI scan demonstrated positive localization for adenoma in 73% of patients. However, 22% were later diagnosed with hyperplasia (false positive), resulting in an effective localization rate of only 56.9%. The scan had 78.6% accuracy and positive and negative predictive values of 76.7% and 83.3%, respectively.Hyperplasia was significantly associated with younger age (p = 0.009) and dialysis dependence (p = 0.007). Hyperplasia was correlated with relative subtle hypercalcemia (p = 0.015), significant higher phosphorus (p = 0.001), higher alkaline phosphatase (p < 0.001), and higher PTH levels (p = 0.004).
DISCUSSION: Over half of CKD patients had hyperplasia. The majority of patients underwent a localization parathyroid MIBI scan. About 3/4 of scanned patients had positive adenoma localization, but only 3/4 were eventually operated on and cured as adenoma.
CONCLUSIONS: We demonstrate a limited benefit of MIBI scans in CKD and kidney transplant patients. We recommend either omitting the scan or performing bilateral neck exploration or at least two same-side parathyroid glands exploration to improve cure rates.