Primary Hyperparathyroidism With Negative Imaging: A Significant Clinical Problem

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To the Editor:
We read the article by Fraker et al1 with interest and would like to congratulate the authors for highlighting an untold story. In today's era, with availability of newer imaging modalities, more emphasis is being laid on performing minimally invasive/focused parathyroidectomy but in developing countries this is very often not possible, either because of lack of facilities or due to the high cost of these imaging modalities. Series on primary hyperparathyroidism are available from almost all centers, but the authors have done a commendable job by highlighting this issue. However, there are certain observations in the article that need further clarification and comment.
The authors have performed localization studies in patients of multiple endocrine neoplasia with a success rate of only 18%. As in these syndromic settings, hyperparathyroidism is usually due to multigland disease and sensitivity of both anatomical and functional imaging is low as reported in other series too.2 So, do the authors recommend doing localization studies in these situations?
In your localized and nonlocalized groups, either Sestamibi or ultrasound alone was performed in (23% and 21% of) the patients. For performing focused parathyroidectomy, 2 imaging results should be concordant.3 What is the authors’ opinion regarding localization with both anatomical and functional imaging?
The authors have performed minimally invasive parathyroidectomy (defined as directed unilateral exploration performed through a 2- to 3-cm incision) in 48 (5.7%) of their patients, even though imaging studies did not localize the lesion. How did they perform directed surgery without localization?
Even from the data, it is not clear if there is any difference in outcome among patients who underwent focused parathyroidectomy versus conventional bilateral neck exploration in terms of cure rates.
One comment we would like to make is that the patients’ safety and curative intent is more important than any other factor as highlighted by author. We agree that focused parathyroidectomy is also a standard of care for concordant lesions with similar outcome,4 but in resource-limited settings, bilateral neck exploration can be considered upfront if imaging modalities are not available.

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