Clinical Characterization of a Large Cohort of Primary Hyperparathyroid Filipino Patients who underwent Parathyroidectomy and the Accuracy of Preoperative Parathyroid Localization Studies used at a Multispecialty Tertiary Hospital in Manila, Philippines

  • Danica Chan Francisco The Medical City, Pasig City
  • Elizabeth Paz Pacheco The Medical City, Pasig City
  • Perie Adorable Wagan The Medical City, Pasig City
Keywords: Primary hyperparathyroidism, parathyroidectomy, parathyroid localization


Background: Philippine data on demographics and clinical profiles of primary hyperparathyroidism (pHPT) are scarce and the advancement to minimally invasive parathyroidectomies with better outcomes require accurate localization imaging.1,2 However, due to inadequate local data, recognition of disease and progression to more minimally invasive parathyroid surgeries in the Philippines are particularly difficult.

Objective: To characterize Filipino patients seen at The Medical City diagnosed with pHPT who underwent parathyroidectomy and determine the sensitivity and specificity of current preoperative localization imaging modalities, ultrasound (UTZ) and 99mTc-MIBI scan.

Methodology: A retrospective cross-sectional study of Filipino patients with pHPT who underwent parathyroidectomy at The Medical City from January 2004 to August 2018 was conducted. Demographic profile, clinical and biochemical presentations were described and compared with international data. Diagnostic accuracy test was used to determine the sensitivity and specificity of UTZ and 99mTc-MIBI scan.

Results: 35 patients were included in the analysis with female predominance (2:1) and an average age of 53 years. Prevailing manifestations and indications for surgery were skeletal abnormalities (51%), renal calculi (49%) and nonspecific gastrointestinal (49%) and musculoskeletal (43%) symptoms, similar to India, Saudi Arabia and Thailand. This is contrast to data from America and Europe those with evident symptoms compose less than 20% of patients.3,4 Adenomas are the most common pathology at 86.1%. Sensitivity of UTZ was 51.5% while 99mTc-MIBI scan was 87.9%. Specificity was 96.8% for UTZ and 80% for 99mTc-MIBI scan. Data suggests multinodular goiter contributes to the difficulty in parathyroid localization with UTZ vs 99mTc-MIBI scan (56% vs 88%). Combined sensitivity, specificity and accuracy are at 93.5%, 83.9% and 88.7% respectively, as opposed to individual accuracies of 73.4% for UTZ and 83.8% for 99mTc-MIBI scan.

Conclusion: Our population demonstrates comparable presentations, as well as surgical indications, with our neighboring Asian countries which are predominantly of symptomatic disease as opposed to more asymptomatic surgical patients in developed countries. With high specificity, a positive UTZ result alone may be sufficient as a preoperative localization modality, but a negative UTZ result would require adding a sestamibi scan. Nonetheless, performing both is recommended whenever able in order to give the best preoperative localization accuracy especially in patients with nodular goiter to aid in more minimally invasive surgeries.


Download data is not yet available.

Author Biographies

Danica Chan Francisco, The Medical City, Pasig City

Section of Endocrinology, Diabetes and Metabolism, Department of Medicine

Elizabeth Paz Pacheco, The Medical City, Pasig City

Section of Endocrinology, Diabetes and Metabolism, Department of Medicine


Bilezikian JP, Bandeira L, Khan A, Cusano NE. Hyperparathyroidism. Lancet. 2018;391(10116):168-78.

Wermers RA, Khosla S, Atkinson EJ, et al. Incidence of primary hyperparathyroidism in Rochester, Minnesota, 1993-2001: An update on the changing epidemiology of the disease. J Bone Miner Res. 2006;21:171-7.

Heath H 3rd, Hodgson SF, Kennedy MA. Primary Hyperparathyroidism. Incidence, morbidity and potential economic impact in a community. N Engl J Med. 1980;302(4): 189-93.

Abood A, Vestergaard P. Increasing incidence of primary hyperparathyroidism in Denmark. Dan Med J. 2013;60(2): A4567.

Stephen AE, Mannstadt M, Hodin RA. Indications for surgical management of hyperparathyroidism: A review. JAMA Surg. 2017;152(9):878-82. PMID: 28658490.

Medas F, Erdas E, Longheu A, et al. Retrospective evaluation of the pre- and postoperative factors influencing the sensitivity of localization studies in primary hyperparathyroidism. Int J Surg. 2016;25:82-7.

Norman J, Lopez J, Politz D. Abandoning unilateral parathyroidectomy: Why we reversed our position after 15,000 parathyroid operations. J Am Coll Surg. 2012;214(3):260-9. 22265807.

Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: A combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery. 1999;126(6):1016-21.

Cohen MS, Finkelstein SE, Brunt LM, et al. Outpatient minimally invasive parathyroidectomy using local/ regional anesthesia: A safe and effective operative approach for selected patients. Surgery. 2005;138(4):681-9.

Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1650 consecutive patients with primary hyperparathyroidism. Ann Surg. 2011;253(3):585-91.

Purcell GP, Dirbas FM, Jeffrey RB, et al. Parathyroid localization with high-resolution ultrasound and technetium Tc 99m sestamibi. Arch Surg. 1999;134(8):824-30.

Șișman P, Gül ÖÖ, Cander S, et al. Sensitivity of localization studies performed by various radiologists in the evaluation of parathyroid lesions. Eur Res J. 2018;4(2):112-7.

Mohammadi A, Moloudi F, Ghasemi-Rad M. Preoperative localization of parathyroid lesion: Diagnostic usefulness of color doppler ultrasonography. Int J Clin Exp Med. 2012;5(1):80-6.

Kunstman JW, Kirsch JD, Mahajan A, Udelsman R. Clinical Review: Parathyroid localization and implications for clinical management. J Clin Endocrinol Metab. 2013;98(3):902-12.

Elaraj DM, Sippel RS, Lindsay S, et al. Are additional localization studies and referral indicated for patients with primary hyperparathyroidism who have negative sestamibi scan results? Arch Surg. 2010;145(6):578-81.

Chua CC, Rivero W, Gutierrez MJ, Jasul GV Jr. Prevalence of secondary hyperparathyroidism among outpatient type 2 diabetic patients undergoing hemodialysis in a tertiary hospital. Philipp J Int Med. 2010;48(1):4-8.

Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: Summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3561-9.

Gasser RW. Clinical aspects of primary hyperparathyroidism: Clinical manifestations, diagnosis, and therapy. Wien Med Wochenschr. 2013;163(17-18):397-402.

Bilezikian JP. Primary hyperparathyroidism [Updated 2017 Jan 15]. In: KR Feingold, B Anawalt, A Boyce, et al, eds. Endotext [Internet]. South Dartmouth:, Inc.; 2000-. Available from

Silverberg SJ, Bilezikian JP. Primary hyperparathyroidism. In: JAH Wass, P Stewart, eds. Oxford Textbook of Endocrinology and Diabetes, 2nd ed. Oxford: Oxford University Press,

Gopal RA, Acharya SV, Bandgar T, Menon PS, Dalvi AN, Shah NS. Clinical profile of primary hyperparathyroidism from western India: A single center experience. J Postgrad Med. 2010;56(2):79-84.

Malabu UH, Founda MA. Primary hyperparathyroidism in Saudi Arabia: A review of 46 cases. Med J Malaysia. 2007;62(5):394-7.

Prasarttong-Osoth P, Wathanaoran P, Imruetaicharoenchoke W, Rojananin S. Primary hyperparathyroidism: 11-year experience in a single institute in Thailand. Int J Endocrinol. 2012;2012:952426.

Padilla-Baraoidan RZM, Capuli-Isidro MJ, Cudal BIB, Embestro-Pontillas AA. Hungry bone syndrome (HBS) in patients operated for primary hyperparathyroidism (PHPT): A six-year experience. Philipp J Otolaryngol Head Neck Surg. 2017;32(2):11-6.

Erbil Y, Barbaros U, Yanik BT, et al. Impact of gland morphology and concomitant thyroid nodules on preoperative localization of parathyroid adenomas. Laryngoscope. 2006;116(4):580-5.

Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016;26(1):1-133. 26462967.

Carlos-Raboca J, Jimeno CA, Kho SA, et al. The Philippine Thyroid Diseases Study (PhilTiDeS 1): Prevalence of thyroid disorders among adults in the Philippines. J ASEAN Fed Endocr Soc. 2012;27(1):27-33.

Kus LH, Shah M, Eski S, Walfish PG, Freeman JL. Thyroid cancer outcomes in Filipino patients. Arch Otolaryngol Head Neck Surg. 2010;136(2):138-42. PMID: 20157058.

Rossing MA, Schwartz SM, Weiss NS. Thyroid cancer incidence in Asian migrants

to the United States and their descendants. Cancer Causes Control. 1995;6(5):439-44. PMID: 8547542.

Clark JR, Eski SJ, Freeman JL. Risk of malignancy in Filipinos with thyroid nodules—a matched pair analysis. Head Neck. 2006;28(5):427-31. PMID: 16287137.

McHugh ML. Interrater reliability: The kappa statistic. Biochem Med (Zagreb). 2012;22(3):276-82.

How to Cite
Francisco, D. C., Pacheco, E. P., & Wagan, P. A. (2020). Clinical Characterization of a Large Cohort of Primary Hyperparathyroid Filipino Patients who underwent Parathyroidectomy and the Accuracy of Preoperative Parathyroid Localization Studies used at a Multispecialty Tertiary Hospital in Manila, Philippines. Journal of the ASEAN Federation of Endocrine Societies, 35(1). Retrieved from
Original Articles