SAT-398 The Use of Imaging in Primary Hyperparathyroidism

Abstract Primary hyperparathyroidism is characterized by excessive dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Preoperative localization is important for surgical planning in primary hyperparathyroidism. Previously, it had been published that ultrasound (sensitivity of 76.1%, positive predictive value of 93.2%) and nuclear scintigraphy (Sestamibi-SPECT) (sensitivity of 78.9%, and a positive predictive value of 90.7%) are first line imaging modalities1. Currently, the imaging modality of choice varies according to region and institutional protocol. The aim of this study was to evaluate the imaging modality that is associated with an improved remission rate based on concordance with operative findings. A secondary aim was to determine the effect of additive imaging on remission rates. This was an IRB-approved retrospective review of 2657 patients with primary hyperparathyroidism undergoing surgery at a tertiary referral center from 2004–2017. Analyses were performed with SAS software using a 95% confidence interval (p<0.05) for statistical significance. After excluding re-operative and familial cases, 2079 patients met study criteria. There were 422 (20.3%) male and 1657 (79.7%) female patients with a mean age of 66 (+12.2) years, of which 1723 (82.9%) of patients were white and 294 (14.1%) patients were black. Ultrasound (US) was performed in 1891 (91.9%), sestamibi with SPECT (sestamibi/SPECT) in 1945 (93.6%), and CT in 98 (4.7%) patients. Of these, 1721 (82.8%) had combined US and sestamibi/SPECT. US was surgeon-performed in 94.2% of cases and 89.9% of the patients underwent a four gland exploration. Overall, US concordance was 52.4%, sestamibi/SPECT was 45.5%, and CT was 45.9%.US and sestamibi/SPECT both had an improved remission rate if concordant with operative findings, while CT had no effect (US p=0.04; sestamibi/SPECT p=0.01; CT p=0.50). The overall remission rate was 94% (CI=0.93–0.95), however, increasing the number of imaging modalities performed did not increase the remission rate (p=0.76) or concordance with operative findings (p=0.05). Despite having low concordance rates, US and sestamibi/SPECT that agreed with operative findings were associated with higher remission rates. Therefore, when imaging is to be used for localization, our data support the use of US and sestamibi/SPECT as the initial imaging modalities of choice for preoperative localization. 1Kuzminski SJ, Sosa JA, Hoang JK. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018;26(1): 151–166.

Download Full-text

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.

Download Full-text

S178 – Utility of CT-Sestamibi Fusion in Parathyroid Exploration

Otolaryngology ◽

10.1016/j.otohns.2008.05.352 ◽

2008 ◽

Vol 139 (2_suppl) ◽

pp. P135-P136

Author(s):

Michael J Clark ◽

Phillip Pellitteri

Keyword(s):

Primary Hyperparathyroidism ◽

Minimally Invasive ◽

Image Fusion ◽

Fusion Imaging ◽

Parathyroid Glands ◽

Preoperative Localization ◽

Minimally Invasive Surgical ◽

Sestamibi Imaging ◽

Invasive Surgical Approach ◽

Operative Findings

Objectives 1) Delineate the role of CT-technetium 99m sestamibi (CT-MIBI) fusion in directed parathyroidectomy. 2) Determine the clinical situations where CT-MIBI fusion would be strongly recommended. Methods Charts from 190 patients with primary hyperparathyroidism who underwent CT-MIBI mage fusion as a part of a scan directed, minimally invasive parathyroid exploration protocol were reviewed. The results of conventional sestamibi imaging and CT-MIBI image fusion were compared with operative findings. Results CT-MIBI image fusion accurately localized solitary hyperfunctional parathyroid glands in 70% of patients imaged; 55% of patients were localized with conventional sestamibi imaging. CT-MIBI fusion imaging was most accurate and predictive when conventional images suggested that the solitary gland was separated from the thyroid or when the adenoma was located in the retro-thyroidal/ retro-esophageal plane or mediastinum. Conclusions CT-MIBI image fusion is not superior to conventional sestamibi imaging when utilized for routine localization of hyperfunctional parathyroid glands. CT-MIBI fusion is of greatest benefit in guiding the directed approach to solitary glands, which are separate from the thyroid or ectopically located, regions where conventional imaging has proven to be less accurate. This imaging technique will augment the minimally invasive surgical approach in selected patients with primary hyperparathyroidism in order to further refine the focused technique. Its utility as the standard preoperative localization modality is not yet established and requires further investigation. Evaluation of differences in facility utilization with CT-MIBI image fusion and conventional sestamibi imaging may be helpful in determining its role in preoperative localization for hyperparathyroidism.

Download Full-text

The impact of surgeon-based ultrasonography for parathyroid disease on a British endocrine surgical practice

Annals of The Royal College of Surgeons of England ◽

10.1308/003588412x13171221498389 ◽

2012 ◽

Vol 94 (1) ◽

pp. 17-23 ◽

Cited By ~ 9

Author(s):

SR Aspinall ◽

S Nicholson ◽

RD Bliss ◽

TWJ Lennard

Keyword(s):

Minimally Invasive Surgery ◽

Primary Hyperparathyroidism ◽

Minimally Invasive ◽

Negative Predictive Value ◽

Invasive Surgery ◽

Predictive Value ◽

Surgical Practice ◽

Parathyroid Disease ◽

Operative Findings ◽

The Impact

INTRODUCTION Surgeon-based ultrasonography (SUS) for parathyroid disease has not been widely adopted by British endocrine surgeons despite reports worldwide of accuracy in parathyroid localisation equivalent or superior to radiology-based ultrasonography (RUS). The aim of this study was to determine whether SUS might benefit parathyroid surgical practice in a British endocrine unit. METHODS Following an audit to establish the accuracy of RUS and technetium sestamibi (MIBI) in 54 patients, the accuracy of parathyroid localisation by SUS and RUS was compared prospectively with operative findings in 65 patients undergoing surgery for primary hyperparathyroidism (pHPT). RESULTS The sensitivity of RUS (40%) was below and MIBI (57%) was within the range of published results in the audit phase. The sensitivity (64%), negative predictive value (86%) and accuracy (86%) of SUS were significantly greater than RUS (37%, 77% and 78% respectively). SUS significantly increased the concordance of parathyroid localisation with MIBI (58% versus 32% with RUS). CONCLUSIONS SUS improves parathyroid localisation in a British endocrine surgical practice. It is a useful adjunct to parathyroid practice, particularly in centres without a dedicated parathyroid radiologist, and enables more patients with pHPT to benefit from minimally invasive surgery.

Download Full-text

Accuracy of ultrasound in pediatric undescended testes

Asian Biomedicine ◽

10.2478/abm-2010-0131 ◽

2010 ◽

Vol 4 (6) ◽

pp. 983-986

Author(s):

Teerasak Phewplung ◽

Atchara Mahayosnond ◽

Panruethai Trinavarat

Keyword(s):

Positive Predictive Value ◽

Negative Predictive Value ◽

Surgical Procedures ◽

Predictive Value ◽

Undescended Testis ◽

Clinical Implications ◽

Common Condition ◽

Undescended Testes ◽

Ultrasonographic Diagnosis ◽

Operative Findings

Abstract Background: The undescended testis represents a common condition affecting male infants with significant clinical implications such as infertility and testicular malignancy. There is controversy as to the diagnosis when a clinical examination fails to identify a testis. Objective: Investigate the value of ultrasound in the diagnosis of undescended testis, and evaluate the correlation between the preoperative ultrasonographic data and operative findings. Material and method: Thirty-nine boys (age: 3months -12 years) with undescended testes were examined between January 2003 and December 2007. All the boys had undergone a sonogram performed for localizing the undescended testes. Only 20 boys were sent for inguinal exploration, or other surgical procedures for localizing the undescended testes. We calculated specificity, sensitivity, positive predictive value (PPV), negative predictive value (NPV), and the accuracy of ultrasonographic diagnosis in boys with undescended testes. Results: Twenty-nine undescended testes were included in this study. Ultrasonography had a sensitivity of 82%, a specificity of 0%, PPV of 96%, NPV of 0%, and accuracy of 79% in the diagnosis of the undescended testis. Conclusions: The sensitivity and specificity including NPV of uetrasound had the unsatisfactory outcomes.

Download Full-text

Suicide intent scale in the prediction of suicide

European Psychiatry ◽

10.1016/s0924-9338(11)73353-3 ◽

2011 ◽

Vol 26 (S2) ◽

pp. 1649-1649

Author(s):

J. Stefansson ◽

P. Nordström ◽

J. Jokinen

Keyword(s):

Positive Predictive Value ◽

Predictive Value ◽

Suicide Risk ◽

Statistical Significance ◽

Item Analysis ◽

Roc Curves ◽

Short Version ◽

Suicide Prediction ◽

Suicide Intent

ObjectiveTo assess the predictive value of the Suicide Intent Scale in patients with a high suicide risk. The secondary aim was to assess if the use of the factors of the Suicide Intent Scale would offer a better predictive value in case detection. Finally a short version of the scale was created after an item analysis.MethodEighty-one suicide attempters were assessed with the Beck‘s Suicide Intent Scale (SIS). All patients were followed up for cause of death. Receiver-operating characteristic (ROC) curves and tables were created to establish the optimal cut-off values for SIS and SIS factors to predict suicide.ResultsSeven patients committed suicide during a mean follow up of 9.5 years. The major finding was that mean SIS distinguished between suicides and survivors. The positive predictive value was 16.7% and the AUC was 0.74. Only the planning subscale reached the statistical significance. Four items were used to test a short version of SIS in the suicide prediction. The positive predictive value was 19% and the AUC was 0.82.ConclusionsThe Suicide Intent Scale is a valuable tool in clinical suicide risk assessment, a short version of the scale may offer a better predictive value.

Download Full-text

Employing electronic health record data to predict risk of emergency department visits for new patients.

Journal of Clinical Oncology ◽

10.1200/jco.2018.36.30_suppl.314 ◽

2018 ◽

Vol 36 (30_suppl) ◽

pp. 314-314 ◽

Cited By ~ 1

Author(s):

Robert Michael Daly ◽

Dmitriy Gorenshteyn ◽

Lior Gazit ◽

Stefania Sokolowski ◽

Kevin Nicholas ◽

...

Keyword(s):

Positive Predictive Value ◽

Predictive Value ◽

Symptom Management ◽

Predictive Analytics ◽

Statistical Significance ◽

Emergency Department Visits ◽

Multivariate Logistic Regression Model ◽

Training Set ◽

Electronic Health Record Data ◽

Test Set

314 Background: Acute care accounts for half of cancer expenditures and is a measure of poor quality care. Identifying patients at high risk for ED visits enables institutions to target symptom management resources to those most likely to benefit. Risk stratification models developed to date have not been meaningfully employed in oncology, and there is a need for clinically relevant models to improve patient care. Methods: We established a predictive analytics framework for clinical use with attention to the modeling technique, clinician feedback, and application metrics. The model employs EHR data from initial visit to first antineoplastic administration for new patients at our institution from January 2014 to June 2017. The binary dependent variable is occurrence of an ED visit within the first 6 months of treatment. From over 1,400 data features, the model was refined to include 400 clinically relevant ones spanning demographics, pathology, clinician notes, labs, medications, and psychosocial information. Clinician review was performed to confirm EHR data input validity. The final regularized multivariate logistic regression model was chosen based on clinical and statistical significance. Parameter selection and model evaluation utilized the positive predictive value for the top 25% of observations ranked by model-determined risk. The final model was evaluated using a test set containing 20% of randomly held out data. The model was calibrated based on a 5-fold cross-validation scheme over the training set. Results: There are 5,752 antineoplastic starts in our training set, and 1,457 in our test set. The positive predictive value of this model for the top 25% riskiest new start antineoplastic patients is 0.53. The 400 clinically relevant features draw from multiple areas in the EHR. For example, those features found to increase risk include: combination chemotherapy, low albumin, social work needs, and opioid use, whereas those found to decrease risk include stage 1 disease, never smoker status, and oral antineoplastic therapy. Conclusions: We have constructed a framework to build a clinically relevant model. We are now piloting it to identify those likely to benefit from a home-based, digital symptom management intervention.

Download Full-text

The Diagnostic Accuracy of Magnetic Resonance Imaging and Ultrasonography in Gluteal Tendon Tears -A Systematic Review

Hip International ◽

10.5301/hip.2011.8759 ◽

2011 ◽

Vol 21 (6) ◽

pp. 637-645 ◽

Cited By ~ 53

Author(s):

Daniel J. Westacott ◽

Jonathon I. Minns ◽

Pedro Foguet

Keyword(s):

Magnetic Resonance Imaging ◽

Magnetic Resonance ◽

Positive Predictive Value ◽

Predictive Value ◽

Imaging Modality ◽

High Signal ◽

Diagnostic Strategy ◽

Resonance Imaging ◽

Trochanteric Bursitis ◽

Tendon Tears

Gluteal tendon tears are one of the many pathologies causing pain around the greater trochanter that are often labelled as trochanteric bursitis. We systematically reviewed the peer-reviewed literature to establish the accuracy of magnetic resonance imaging and ultrasonography in the diagnosis of gluteal tendon tears in patients with persistent lateral hip pain or Greater Trochanteric Pain Syndrome (GTPS). 7 studies met the inclusion criteria, comparing either imaging modality with a reference standard of surgical findings. Included studies were assessed for methodological quality using the QUADAS checklist. MRI had sensitivity of 33–100%, specificity of 92–100%, positive predictive value of 71–100% and negative predictive value of 50%. False-positives were common. High signal located superior to the trochanter had a stronger association with tears. Ultrasonography had a sensitivity of 79–100% and positive predictive value of 95–100%. The amount and quality of literature on the subject is limited and further well-designed studies are required to establish the optimum diagnostic strategy in this condition. Ultrasonography may prove to be the investigation of choice, despite requiring a skilled practitioner. The orthopaedic surgeon should liaise with an experienced musculoskeletal radiologist to best investigate and diagnose gluteal tendon tears in the clinical picture of GTPS.

Download Full-text

Usefulness of Grey Scale and Doppler transvaginal sonography in diagnosis of ovarian torsion

Journal of Fatima Jinnah Medical University ◽

10.37018/kori7947 ◽

2020 ◽

Vol 14 (2) ◽

pp. 97-102

Author(s):

Khalid Rehman `Yousaf ◽

Shahzad Saeed ◽

Saman Chaudhry ◽

Rabia Bashrat ◽

Abadullah Khalid ◽

...

Keyword(s):

Positive Predictive Value ◽

Diagnostic Accuracy ◽

Predictive Value ◽

Ovarian Function ◽

Imaging Modality ◽

Ovarian Torsion ◽

Transvaginal Sonography ◽

Predictive Values ◽

Grey Scale ◽

Sensitivity Specificity

Background: Ovarian torsion diagnosis is a great challenge as delay in diagnosis can cause severe morbidity. Early accurate diagnosis is crucial to preserve ovarian function. Ultrasonography being the primary imaging modality plays a vital role in the evaluation of suspected ovarian torsion by helping surgeons reach the correct diagnosis, thus avoiding unnecessary intervention. This study aims to determine the diagnostic accuracy of isolated and combined sonographic features of ovarian torsion on grey scale and Doppler transvaginal ultrasonography. Patients and methods: From radiology database, from January 2016 till December 2019, sonographic signs of ovarian torsion in 113 women with suspected ovarian torsion on ultrasonography and subsequent surgical diagnosis were evaluated. Ultrasound findings were compared with surgical findings to determine the accuracy, sensitivity, specificity, and positive and negative predictive values of individual and combined ultrasound signs. Results: Diagnostic accuracy of ultrasound for ovarian torsion was 85.8%. Abnormal ovarian Doppler flow was the most accurate individual sonographic sign with accuracy, sensitivity, specificity and positive predictive value of 85.8%, 83.5%, 100% and 100% respectively followed by ovarian enlargement and ovarian edema. Combined ultrasound signs resulted in higher sensitivity and positive predictive values, and lower specificity and negative predictive values for ovarian torsion. Increasing the number of sonographic parameters increased the specificity but decreased sensitivity. High accuracy, sensitivity, positive predictive value, specificity and negative predictive value was seen when combination of three or two sonographic parameters was used as diagnostic criteria. Conclusion: Transvaginal sonography is a convenient, reliable and extremely useful imaging modality for preoperative diagnosis of ovarian torsion with high specificity, sensitivity, positive predictive value and diagnostic accuracy helping treating physicians to take prompt decisions regarding timely surgical intervention. However, due to low negative predictive values, absence of sonographic signs does not rule out ovarian torsion and high index of clinical suspicion remains of utmost importance.

Download Full-text

Comparison of the diagnostic accuracy of 18F-Fluorocholine PET and 11C-Methionine PET for parathyroid localization in primary hyperparathyroidism: a systematic review and meta-analysis

Acta Endocrinologica ◽

10.1530/eje-21-0038 ◽

2021 ◽

Author(s):

Fabio Bioletto ◽

Marco Barale ◽

Mirko Parasiliti-Caprino ◽

Nunzia Prencipe ◽

Alessandro Maria Berton ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Positive Predictive Value ◽

Diagnostic Accuracy ◽

Predictive Value ◽

Meta Analysis ◽

Random Effect ◽

Random Effect Model ◽

Superior Performance ◽

Parathyroid Localization ◽

The Moment

Background. Primary hyperparathyroidism is characterized by an autonomous hypersecretion of parathyroid hormone by one or more parathyroid glands. Preoperative localization of the affected gland(s) is of key importance in order to allow minimally invasive surgery. At the moment, 11C-Methionine and 18F-Fluorocholine PET studies appear to be among the most promising second-line localization techniques; their comparative diagnostic performance, however, is still unknown. Methods. PubMed/Medline and Embase databases were searched up to October 2020 for studies estimating the diagnostic accuracy of 11C-Methionine PET or 18F-Fluorocholine PET for parathyroid localization in patients with primary hyperparathyroidism. Pooled sensitivity and positive predictive value were calculated for each tracer on a “per-lesion” basis and then compared using a random-effect model subgroup analysis. Results. Twenty-two studies were finally considered in the meta-analysis. Among these, 8 evaluated the diagnostic accuracy of 11C-Methionine and 14 that of 18F-Fluorocholine. No study directly comparing the two tracers was found. The pooled sensitivity of 18F-Fluorocholine was higher than that of 11C-Methionine (92% vs 80%, p < 0.01), while the positive predictive value was similar (95% vs 94%, p = 0.99). These findings were confirmed in multivariable meta-regression models, demonstrating their apparent independence from other possible predictors or confounders at a study level. Conclusion. This was the first meta-analysis that specifically compared the diagnostic accuracy of 11C-Methionine and 18F-Fluorocholine PET for parathyroid localization in patients with primary hyperparathyroidism. Our results suggested a superior performance of 18F-Fluorocholine in terms of sensitivity, while the two tracers had comparable accuracy in terms of positive predictive value.

Download Full-text

Hyperfunctioning parathyroid tumours in patients with thyroid nodules. Sensitivity and positive predictive value of high-resolution ultrasonography and 99mTc-sestamibi scintigraphy.

Endocrine Related Cancer ◽

10.1677/erc.0.0100419 ◽

2003 ◽

pp. 419-423 ◽

Cited By ~ 20

Author(s):

F Lumachi ◽

M C Marzola ◽

P Zucchetta ◽

A Tregnaghi ◽

D Cecchin ◽

...

Keyword(s):

High Resolution ◽

Primary Hyperparathyroidism ◽

Positive Predictive Value ◽

Predictive Value ◽

Frozen Section ◽

Group A ◽

Parathyroid Tumours ◽

Group B ◽

High Resolution Ultrasonography ◽

99Mtc Sestamibi

A series of 112 consecutive patients with primary hyperparathyroidism who underwent both high-resolution neck ultrasonography (US) and 99mTc-sestamibi/99mTc-pertechnetate subtraction scintigraphy (SS) prior to successful parathyroidectomy was reviewed. There were 29 (25.9%) men and 83 (74.1%) women, with a median age of 58 years (range 13-78 years). Patients were divided into two groups, according to the preoperative US findings: group A (87 patients, 77.7%) without thyroid diseases, and group B (25 patients, 22.3%) with either multinodular goitre or a solitary nontoxic thyroid nodule. In group B patients partial or total thyroidectomy was also performed, according to the intraoperative findings and frozen-section examination results. Final histopathology showed 99 (88.4%) solitary parathyroid (PT) adenomas and 3 (2.7%) PT carcinomas, while 10 (8.9%) patients had a multiglandular disease. The sensitivity and positive predictive value (PPV) were (group A vs group B) 79.8% vs 70.8% (P=0.25) and 95.7% vs 94.4% (P=0.58) for US, and 83.3% vs 87.0% (P=0.47) and 95.9% vs 90.9% (P=0.32) for SS respectively. Better but similar (P=not significant) results were obtained in patients with solitary PT tumours: 81.5% vs 77.8% (US) and 85.0 vs 94.1% (SS) sensitivity; 97.1% vs 93.3% (US) and 95.8% vs 88.9% (SS) PPV. Overall, the combination of US and SS was 92.9% sensitive (group A=93.1%, group B=92.0%; P=0.55), and the PPV reached 100% in each group. In conclusion, in patients with primary hyperparathyroidism the results of both US and SS are independent of coexistent thyroid disease, especially in patients with solitary PT tumours.

Download Full-text