Original Scientific Articles
Cost-Effectiveness of Preoperative Sestamibi Scan for Primary Hyperparathyroidism Is Dependent Solely upon the Surgeon’s Choice of Operative Procedure

Presented at the 83rd Annual American College of Surgeons Clinical Congress Papers Sessions, October 1997. Dr. Denham is the recipient of the LifeLink Research Scholarship, Tampa, Florida, 1997–1998, given for basic science research.
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Abstract

Background: In 1991, a National Institutes of Health Consensus Panel stated that preoperative localization for primary hyperparathyroidism is not cost effective. Since then, the sestamibi scan has been applied to parathyroid disease with excellent results, even allowing unilateral exploration under local anesthesia.

Study Design: A metaanalysis of the English literature over the past 10 years was performed to determine the collective sensitivity and specificity of sestamibi scanning to establish its utility in directing a unilateral procedure. The cost effectiveness of scanning all patients with sporadic primary hyperparathyroidism was examined by determining the costs of seven operative technique–dependent variables that could be reduced with a limited procedure.

Results: The average sensitivity and specificity of sestamibi were 90.7% and 98.8%, respectively, indicating its ability to guide an accurate unilateral exploration. The analysis of 6,331 patients showed that 87% had solitary adenomas. An average cost savings of $650 was demonstrated for a unilateral operation, which could be realized in as many as 90% (sestamibi sensitivity) of those with solitary adenomas.

Conclusions: A preoperative sestamibi scan is specific enough in identifying solitary adenomas to allow unilateral exploration with a < 1% failure rate. The sensitivity of this scan suggests that 78% of all patients with sporadic primary hyperparathyroidism (90% of the 87% with solitary adenomas) are candidates for unilateral exploration. This rate is significantly higher than the 51% rate at which scanning all patients becomes cost effective.

Section snippets

Methods

Before addressing the issue of cost, one must evaluate the sensitivity and specificity of sestamibi scanning for detecting single adenomatous disease to determine whether in fact it is accurate enough to encourage its use to guide a limited exploration. Another issue that must be established is the true incidence of single-gland disease in patients with non-multiple endocrine neoplasia (MEN), nonfamilial primary hyperparathyroidism. Although this has been reviewed in the past (1981), at that

Sensitivity and Specificity of Sestamibi Scanning

The average sensitivity in all qualifying reports of sestamibi scans in 784 patients ranged between 80% and 100%, with an average of 90.74% (Table 1). It has been demonstrated recently that regardless of the acquisition method, localization of adenomas (with sestamibi) should be > 90%; otherwise, the technique is suboptimal.[13]After omitting all “suboptimal” scans, the average sensitivity became 94.54%, but to remain conservative, we used 90% for all further calculations.

In determining the

Discussion

The use of preoperative scanning for patients with sporadic primary hyperparathyroidism has been a controversial topic for many years. The potential benefits for the majority of patients afflicted with this disease are often discounted because of the lack of a single test that is sensitive enough to be applied to the entire population in question, and specific enough to allow an acceptably low failure rate. Although few would argue that a smaller operation would be preferable provided success

Authors’ Note

Because of the extent of the metaanalysis, all articles reviewed could not be cited in the references. The complete reference list may be obtained by contacting the authors or via the Internet at www. endocrine-surgery.com/authors.html.

Acknowledgements

The authors thank Kathy Sheehan, PhD, for her assistance with the statistical analysis.

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