Preoperative 4D CT Scan Facilitates Localization of Small and Ectopic Parathyroid Adenomas in Primary Hyperparathyroidism

Purpose: To evaluate the significance of preoperative localization of abnormal parathyroid glands to the surgical outcome in patients with primary hyperparathyroidism. Material and Methods: Thirty-nine patients with primary hyperparathyroidism were studied preoperatively with US (39 patients), CT (30 patients) and MR imaging (18 patients). The overall diagnostic accuracy for US was 87%, CT 66% and MR 94%. In patients with a single parathyroid adenoma US was the most cost-effective localization technique with a detection rate of 96%. CT had a lower detection rate (78%) but was of particular value for fairly large ectopic adenomas in the root of the neck. MR imaging was a good confirmatory test (93%). In patients with multiple gland disease (primary hyperplasia and multiple adenomas), no single localization study alone was sufficient. Combination of all 3 studies, however, alerted the physician to the presence of disease in more than one gland in 87% of these patients. Conclusion: US, CT and MR imaging followed by surgery performed by an experienced surgeon provided good clinical results in 39 patients with primary hyperparathyroidism. Preoperative localization was especially useful in patients with primary parathyroid hyperplasia or multiple adenomas and in patients with ectopic parathyroid adenomas in the root of the neck. We recommend identification of all abnormal parathyroid glands prior to surgery.

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Use of Preoperative Imaging in Primary Hyperparathyroidism

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgaa779 ◽

2020 ◽

Vol 106 (1) ◽

pp. e328-e337

Author(s):

David T Broome ◽

Robert Naples ◽

Richard Bailey ◽

Zehra Tekin ◽

Moska Hamidi ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Ct Scan ◽

Predictive Value ◽

Imaging Modalities ◽

Preoperative Imaging ◽

Multiglandular Disease ◽

Cure Rate ◽

4D Ct ◽

Operative Findings ◽

Double Adenomas

Abstract Context Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. Objective Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. Design, Setting, and Patients This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. Main Outcome Measures Surgical cure rate, concordance of imaging with operative findings, and imaging performance. Results The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. Conclusions Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

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Faculty Opinions recommendation of Diagnostic performance of 4D CT and sestamibi SPECT/CT in localizing parathyroid adenomas in primary hyperparathyroidism.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.735249064.793571280 ◽

2020 ◽

Author(s):

Frederick Singer

Keyword(s):

Primary Hyperparathyroidism ◽

Diagnostic Performance ◽

4D Ct ◽

Parathyroid Adenomas

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Undescended retropharyngeal parathyroid adenoma with adjacent thymic tissue in a 13-year-old boy with primary hyperparathyroidism

Oxford Medical Case Reports ◽

10.1093/omcr/omz129 ◽

2019 ◽

Vol 2019 (12) ◽

pp. 519-523 ◽

Cited By ~ 1

Author(s):

Anthony M Kordahi ◽

Ron S Newfield ◽

Stephen W Bickler ◽

Jun Q Mo ◽

Paritosh C Khanna ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Ct Scan ◽

Parathyroid Adenoma ◽

Pharyngeal Pouch ◽

Rare Presentation ◽

Thymic Tissue ◽

The Third ◽

Parathyroid Adenomas ◽

Preoperative Ct ◽

Third Pharyngeal Pouch

ABSTRACT We describe a rare presentation of a symptomatic parathyroid adenoma located in an ectopic retropharyngeal position in a 13-year-old boy. Preoperative CT scan and MRI demonstrated the ectopic location of the parathyroid adenoma. The patient underwent successful parathyroidectomy with cure of his hyperparathyroidism. On pathologic exam, the specimen was made up of a parathyroid adenoma and adjacent thymic tissue, indicating that it was likely an undescended lower parathyroid gland arising from the third pharyngeal pouch. Ectopic retropharyngeal parathyroid adenomas are very rare and to our knowledge, none have been previously described in adolescents.

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Multiple ectopic parathyroid adenomas

Sao Paulo Medical Journal ◽

10.1590/s1516-31802004000100008 ◽

2004 ◽

Vol 122 (1) ◽

pp. 32-34 ◽

Cited By ~ 5

Author(s):

Rogério Aparecido Dedivitis ◽

André Vicente Guimarães ◽

Gustavo Bastos de Goes Pontes

Keyword(s):

Primary Hyperparathyroidism ◽

Histopathological Examination ◽

Thyroid Cartilage ◽

Elevated Serum ◽

Neck Surgery ◽

Tissue Mass ◽

Serum Total Calcium ◽

Parathyroid Adenomas ◽

Sestamibi Scanning ◽

Ectopic Parathyroid

CONTEXT: Primary hyperparathyroidism is the most common cause of hypercalcemia in unselected patients. The ectopic gland locations should be known for appropriate surgical exploration and for avoiding subsequent re-exploration that would represent higher morbidity. Multiple ectopic glands are rare and present a particular challenge in parathyroid surgery. CASE REPORT: A 65-year-old female presented with nephrolithiasis. Her serum total calcium was found to be elevated. The diagnosis of primary hyperparathyroidism was confirmed by the elevated serum intact parathyroid hormone levels. Ultrasound was only successful in localizing one adenoma in the lower right gland. Technetium sestamibi scanning correctly localized the same adenoma and showed another contralateral image, lateral to the thyroid cartilage. Fiber optic laryngoscopy showed an extrinsic mass pushing against the lateral and posterior walls of the left pyriform sinus. Resonance imaging revealed a soft tissue mass. RESULTS: The patient underwent bilateral neck exploration. Histopathological examination confirmed the diagnosis of parathyroid double adenomas. The late-stage postoperative checkups were normal. DISCUSSION: Routine bilateral neck surgery should be performed as a rule. We use ultrasound and technetium sestamibi scanning as a routine for preoperative localization studies. It is helpful to have an experienced surgeon for the localization.

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Accuracy of Dual Phase Single-Photon Emission Computed Tomography/Computed Tomography in Primary Hyperparathyroidism: Correlation with Serum Parathyroid Hormone Levels

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2015.06.002 ◽

2016 ◽

Vol 67 (2) ◽

pp. 115-121 ◽

Cited By ~ 4

Author(s):

Wade Koberstein ◽

Christopher Fung ◽

Kristy Romaniuk ◽

Jonathan T. Abele

Keyword(s):

Computed Tomography ◽

Primary Hyperparathyroidism ◽

Predictive Value ◽

Single Photon ◽

Photon Emission ◽

Emission Computed Tomography ◽

Dual Phase ◽

Parathyroid Adenomas ◽

Ectopic Parathyroid ◽

Serum Pth

Purpose The objectives of this study were: 1) to determine the accuracy of dual-phase 99mTc -methoxyisobutylisonitrile (MIBI) with single-photon emission computed tomography/computed tomography (SPECT/CT) for the preoperative localization of parathyroid adenomas in the setting of primary hyperparathyroidism; 2) to determine the accuracy of localization for ectopic glands; and 3) to assess the relationship between accuracy and serum parathyroid hormone (PTH) levels. Methods Eighty-eight patients who underwent 99mTc-MIBI SPECT/CT imaging for primary hyperparathyroidism at our institution over a 27-month period were retrospectively assessed. The preoperative SPECT/CT results were compared to intraoperative findings (within 1 year of imaging). The relationship between serum PTH level (within 3 months) and SPECT/CT accuracy was then evaluated. Results Accuracy indices for the retrothyroid subgroup were sensitivity 86.7%, specificity 96.4%, positive predictive value 98.1%, negative predictive value 77.1%, and accuracy 89.8%. Accuracy indices for ectopic parathyroid adenomas were sensitivity 81.5%, specificity 100%, positive predictive value 100%, negative predictive value 92.4%, and accuracy 94.3%. For the overall group, SPECT/CT demonstrated a sensitivity of 85.1% and a PPV of 98.7%. SPECT/CT correctly identified the abnormal parathyroid gland in 60% of patients with a normal serum PTH (<6.9 pmol/L), 73% between 6.9-9.9 pmol/L, 86% between 10.0-14.9 pmol/L, 100% between 15.0-19.9 pmol/L, 88% between 20.0-24.5 pmol/L, and 100% of patients with a PTH greater than 25.0 pmol/L. Conclusions Dual-phase 99mTc- MIBI with SPECT/CT is an accurate and reliable means to correctly localize both retrothyroid and ectopic parathyroid adenomas for the purpose of surgical planning. The accuracy of SPECT/CT increases with increasing serum PTH levels.

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Intrathyroid parathyroid adenoma: report of two cases and literature review

International Journal of Research in Medical Sciences ◽

10.18203/2320-6012.ijrms20204911 ◽

2020 ◽

Vol 8 (11) ◽

pp. 4096

Author(s):

Camilo Levi Acuna Pinzon ◽

Eduardo Morales Valencia ◽

Jefferson Nieves Condoy ◽

Luis Abraham Zuniga Vasquez ◽

Arturo Jorge Sotelo

Keyword(s):

Literature Review ◽

Primary Hyperparathyroidism ◽

Parathyroid Adenoma ◽

Clinical Suspicion ◽

Definitive Treatment ◽

Preoperative Period ◽

Imaging Studies ◽

High Clinical Suspicion ◽

Parathyroid Adenomas ◽

Ectopic Parathyroid

Approximately 80% of patients with primary hyperparathyroidism have a parathyroid adenoma, with surgery being the only definitive treatment. Sometimes in surgery there is difficulty in identifying the pathological parathyroid gland at which time the possibility of ectopic parathyroid should be considered. We present two cases of patients which after hemithyroidectomy histopathological report, reported intrathyroid parathyroid adenoma. Intrathyroid parathyroid adenomas are an infrequent presentation of parathyroid adenomas that require high clinical suspicion if they are not detected by imaging studies in the preoperative period.

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