The ectopic parathyroid adenoma -: A cost justification for routine preoperative localization with technetium Tc 99m sestamibi scan

Objectives: To evaluate the cumulative costs of failure to identify the ectopic parathyroid adenoma when exploration without preoperative localization is performed and to compare these costs with the expenses of routine preoperative localization in every patient. Design: A consecutive series of 59 patients with primary hyperparathyroidism studied with preoperative scans using technetium Tc 99m sestamibi and ultrasound was submitted to a cost analysis. A subset of 5 cases of ectopic adenomas, presumed to be unidentifiable on routine surgery, was similarly analyzed. Setting: Academic tertiary referral center. Methods: The operative, anesthesia, hospitalization, imaging, and physician reimbursement costs of a failed exploration are compared with the costs of preoperative technetium Tc 99m sestamibi and ultrasound scans in every patient. Results: Two cases of mediastinal parathyroid adenomas in this consecutive series of 59 patients were given a theoretical cost, including hospitalization, physician reimbursement, and anesthesia fees. These costs were based on a failed cervical exploration and extracted from the record of an actual patient who underwent such a process at the University of Vermont, Burlington, in 1995. In addition, the records of 2 patients with intrathyroidal adenomas were submitted to the same theoretical cost analysis with the exception that these patients were assumed to have adenomas that could be discovered after prolonged cervical exploration and thyroid lobectomy. The net management and imaging costs for 4 cases of ectopic parathyroid adenomas undergoing theoretical failed exploration are compared with the cost of obtaining routine technetium Tc 99m sestamibi and ultrasound scans for each of the 59 patients. Conclusion: The added cost of protracted or failed cervical exploration nearly neutralized the costs of a routine preoperative localization with technetium Tc 99m sestamibi and ultrasound scans.