Diagnostic performance of computed tomography for parathyroid adenoma localization; a systematic review and meta-analysis

Imaging Recommendations for Diagnosis and Management of Primary Parathyroid Pathologies: A Comprehensive Review

Parathyroid pathologies are suspected based on the biochemical alterations and clinical manifestations, and the predominant roles of imaging in primary hyperparathyroidism are localisation of tumour within parathyroid glands, surgical planning, and to look for any ectopic parathyroid tissue in the setting of recurrent disease. This article provides a comprehensive review of embryology and anatomical variations of parathyroid glands and their clinical relevance, surgical anatomy of parathyroid glands, differentiation between multiglandular parathyroid disease, solitary adenoma, atypical parathyroid tumour, and parathyroid carcinoma. The roles, advantages and limitations of ultrasound, four-dimensional computed tomography (4DCT), radiolabelled technetium-99 (99mTc) sestamibi or dual tracer 99mTc pertechnetate and 99mTc-sestamibi with or without single photon emission computed tomography (SPECT) or SPECT/CT, dynamic enhanced magnetic resonance imaging (4DMRI), and fluoro-choline positron emission tomography (18F-FCH PET) or [11C] Methionine (11C -MET) PET in the management of parathyroid lesions have been extensively discussed in this article. The role of fluorodeoxyglucose PET (FDG-PET) has also been elucidated in this article. Management guidelines for parathyroid carcinoma proposed by the American Society of Clinical Oncology (ASCO) have also been described. An algorithm for management of parathyroid lesions has been provided at the end to serve as a quick reference guide for radiologists, clinicians and surgeons.

The Parathyroid Gland: An Overall Review of the Hidden Organ for Radiologists

Parathyroid glands are small endocrine glands that regulate calcium metabolism by producing parathyroid hormone (PTH). These are located at the back of the thyroid gland. Typically, four glands comprise the parathyroid glands, although their numbers may vary among individuals. Parathyroid diseases are related to parathyroid gland dysfunction and can be caused by problems with the parathyroid gland itself or abnormal serum calcium levels arising from renal disease. In recent years, as comprehensive health checkups have become more common, abnormal serum calcium levels are often found incidentally in blood tests, after which several additional tests, including a PTH test, ultrasonography (US), technetium-99m sestamibi parathyroid scan, single-photon-emission CT (SPECT)/CT, four-dimensional CT (4D-CT), and PET/CT, are performed for further evaluation. However, the parathyroid gland remains an organ less familiar to radiologists. Therefore, the normal anatomy, pathophysiology, imaging, and clinical findings of the parathyroid gland and its associated diseases are discussed here.

Head-to-head comparison of [11C]methionine PET, [11C]choline PET, and 4-dimensional CT as second-line scans for detection of parathyroid adenomas in primary hyperparathyroidism

PURPOSE

Accurate preoperative localization is imperative to guide surgery in primary hyperparathyroidism (pHPT). It remains unclear which second-line imaging technique is most effective after negative first-line imaging. In this study, we compare the diagnostic effectiveness of [11C]methionine PET/CT, [11C]choline PET/CT, and four dimensional (4D)-CT head-to-head in patients with pHPT, to explore which of these imaging techniques to use as a second-line scan.

METHODS

We conducted a powered, prospective, blinded cohort study in patients with biochemically proven pHPT and prior negative or discordant first-line imaging consisting of ultrasonography and 99mTc-sestamibi. All patients underwent [11C]methionine PET/CT, [11C]choline PET/CT, and 4D-CT. At first, all scans were interpreted by a nuclear medicine physician, and a radiologist who were blinded from patient data and all imaging results. Next, a non-blinded scan reading was performed. The scan results were correlated with surgical and histopathological findings. Serum calcium values at least 6 months after surgery were used as gold standard for curation of HPT.

RESULTS

A total of 32 patients were included in the study. With blinded evaluation, [11C]choline PET/CT was positive in 28 patients (88%), [11C]methionine PET/CT in 23 (72%), and 4D-CT in 15 patients (47%), respectively. In total, 30 patients have undergone surgery and 32 parathyroid lesions were histologically confirmed as parathyroid adenomas. Based on the blinded evaluation, lesion-based sensitivity of [11C]choline PET/CT, [11C]methionine PET/CT, and 4D-CT was respectively 85%, 67%, and 39%. The sensitivity of [11C]choline PET/CT differed significantly from that of [11C]methionine PET/CT and 4D-CT (p = 0.031 and p < 0.0005, respectively).

CONCLUSION

In the setting of pHPT with negative first-line imaging, [11C]choline PET/CT is superior to [11C]methionine PET/CT and 4D-CT in localizing parathyroid adenomas, allowing correct localization in 85% of adenomas. Further studies are needed to determine cost-benefit and efficacy of these scans, including the timing of these scans as first- or second-line imaging techniques.

Diagnostic Performance of Magnetic Resonance Imaging for Parathyroid Localization of Primary Hyperparathyroidism: A Systematic Review

Accurate preoperative localization is crucial for successful minimally invasive parathyroidectomy in primary hyperparathyroidism (PHPT). Preoperative localization can be challenging in patients with recurrent and/or multigland disease (MGD). This has led clinicians to investigate multiple imaging techniques, most of which are associated with radiation exposure. Magnetic resonance imaging (MRI) offers ionizing radiation-free and accurate imaging, making it an attractive alternative imaging modality. The objective of this systematic review is to provide an overview of the diagnostic performance of MRI in the localization of PHPT. PubMed and Embase libraries were searched from 1 January 2000 to 31 March 2023. Studies were included that investigated MRI techniques for the localization of PHPT. The exclusion criteria were (1) secondary/tertiary hyperparathyroidism, (2) studies that provided no diagnostic performance values, (3) studies published before 2000, and (4) studies using 0.5 Tesla MRI scanners. Twenty-four articles were included in the systematic review, with a total of 1127 patients with PHPT. In 14 studies investigating conventional MRI for PHPT localization, sensitivities varied between 39.1% and 94.3%. When employing more advanced MRI protocols like 4D MRI for PHPT localization in 11 studies, sensitivities ranged from 55.6% to 100%. The combination of MR imaging with functional techniques such as 18F-FCH-PET/MRI yielded the highest diagnostic accuracy, with sensitivities ranging from 84.2% to 100% in five studies. Despite the limitations of the available evidence, the results of this review indicate that the combination of MR imaging with functional imaging techniques such as 18F-FCH-PET/MRI yielded the highest diagnostic accuracy. Further research on emerging MR imaging modalities, such as 4D MRI and PET/MRI, is warranted, as MRI exposes patients to minimal or no ionizing radiation compared to other imaging modalities.

Diagnostic Value of Four-Dimensional Dynamic Computed Tomography for Primary Hyperparathyroidism in Patients with Low Baseline Parathyroid Hormone Levels

Low baseline levels of parathyroid hormone (PTH) are associated with a higher rate of multiglandular disease, lower localization rates of preoperative imaging modalities, and a higher rate of unsuccessful minimally invasive parathyroidectomies. The objective of this study is to assess the diagnostic value of four-dimensional dynamic computed tomography (4D-CT) in localizing primary hyperparathyroidism (pHPT) in patients with low baseline PTH levels, compared to patients with high baseline PTH levels. Patients with pHPT who received a 4D-CT scan as part of their standard diagnostic evaluation were divided into two groups based on the following criteria: (1) preoperative PTH levels less than 100 pg/mL and (2) patients with preoperative PTH levels greater than 100 pg/mL. All patients underwent parathyroidectomy based on 4D-CT findings, with intraoperative parathyroid hormone monitoring. The lesion-based sensitivity of 4D-CT was 88% in patients with low baseline PTH levels and 94.7% in patients with high baseline PTH levels (p = 0.33). However, the success rate of image-guided resection based on 4D-CT findings was 71.4% in the low baseline PTH group compared to 90.6% in the high baseline PTH group (p = 0.06). Our study demonstrated that 4D-CT has a high lesion-based sensitivity in patients with pHPT and low baseline PTH levels but led to a relatively low rate of successful image-guided resection in patients with low baseline PTH levels. Therefore, it is important to exercise increased caution during 4D-CT-guided surgical exploration of patients with low baseline PTH levels to ensure successful surgical resection of all parathyroid lesions.

Preoperative imaging in primary hyperparathyroidism patients using 4DCT subtraction maps, a report of three cases

Four-dimensional computed tomography (4DCT) is one of the preoperative imaging modalities that can be used to localize a parathyroid adenoma in primary hyperparathyroidism patients however, sensitivity differs in literature and could be improved especially for multiglandular hyperplasia or double adenomas. The most robust feature on the 4DCT for the differentiation between parathyroid adenoma and thyroid gland tissue is arterial enhancement. To make this better visible, we have developed a subtraction map that shows arterial enhancement as a color scale to increase sensitivity for 4DCT. In this report of 3 cases, we present the usefulness of this subtraction map in a 54-year-old male, a 57-year-old female and a 51-year-old male. Subtraction maps may increase sensitivity for 4DCT, especially for multiglandular hyperplasia or double adenomas.

4D-CT as a second line preoperative localization test for the evaluation of primary hyperparathyroidism

INTRODUCTION

Four-dimensional computerized tomography (4D-CT) offers a good sensitivity for the localization of the pathological gland responsible of primary hyperparathyroidism. The aim was to evaluate its results as a second line preoperative localization test after inconclusive or discordant results of usual preoperative studies.

MATERIAL AND METHODS

Observational retrospective study that included all patients intervened for primary hyperparathyroidism with 4D-CT scan as preoperative study, from 1st October 2016 to 1st October 2021, in a tertiary referral centre. The results of 4D-CT, cervical ultrasound, and Nuclear Medicine explorations (scintigraphy, SPECT and SPECT-CT) were compared with the gold standard of the surgical exploration and the pathological result. The correct lateralization and the approximate localization rates of the pathological gland were evaluated.

RESULTS

A total of 64 patients were analysed, with a 93,8% (60/64) remission rate. 4DCT showed a correct lateralization in 57,8% (37/64) of the cases and revealed the approximate localization of the gland in 48,4% (31/64) of the cases. The cervical ultrasound had a rate of 31,1% (19/61) and 18% (11/61) for the correct lateralization and approximate localization, respectively, compared to 34,9% (22/63) and 28,6% (18/63) in Nuclear Medicine explorations, and 32,7% (16/49) and 24,5% (12/49) in SPECT-CT. These differences were statistically significant.

CONCLUSION

4D-CT demonstrated acceptable results for the localization of the lesions responsible of primary hyperparathyroidism, thus its use should be considered with the absence of localization in routinely studies.

Parathyroid 4D CT in Primary Hyperparathyroidism: Exploration of Size Measurements for Identifying Multigland Disease and Guiding Biochemically Successful Parathyroidectomy

BACKGROUND. In patients with primary hyperparathyroidism (PHPT), bilateral neck exploration is necessary for multigland disease (MGD), whereas minimally invasive parathyroidectomy is often preferred for single-gland disease (SGD). An existing system (the 4D-CT MGD score) for differentiating SGD from MGD with the use of preoperative parathyroid CT considers the size of only the largest candidate lesion. OBJECTIVE. The purpose of this study was to assess the utility of the size of the second-largest lesion on parathyroid CT for differentiating SGD from MGD as well as the utility of individual gland size for predicting the need for surgical removal and to derive optimal size thresholds for these purposes. METHODS. This retrospective study included patients with PHPT who underwent biochemically successful parathyroidectomy after preoperative parathyroid CT. Clinical radiology reports were reviewed to classify reported candidate parathyroid lesions as low-, intermediate-, or high-confidence lesions. Resected hypercellular parathyroid lesions were correlated with clinically reported candidate lesions. Patients were classified as having SGD or MGD on the basis of operative and pathology reports, independent of CT findings. One observer retrospectively determined the estimated volume (0.52 × length × width × height) and maximum diameter of clinically reported high-confidence lesions, as well as the 4D-CT MGD scores from the examinations. Diagnostic performance was assessed. RESULTS. The sample comprised 62 patients (41 women, 21 men; median age, 65 years), 47 of whom had SGD and 15 of whom had MGD, with 151 candidate lesions, including 106 high-confidence lesions. Based on the second-largest high-confidence lesions, an estimated volume threshold of 60 mm3 or greater achieved 53% sensitivity and 96% specificity, whereas a maximum diameter threshold of 7 mm or greater achieved 67% sensitivity and 96% specificity for MGD; a 4D-CT MGD score of 3 or greater achieved 47% sensitivity and 68% specificity for MGD. For predicting the need to remove a gland for successful parathyroidectomy, an estimated volume threshold of 114 mm3 or greater achieved 84% sensitivity and 97% specificity, and a threshold of 55 mm3 or greater achieved 93% sensitivity and 87% specificity; a maximum diameter threshold of 7 mm or greater achieved 93% sensitivity and 84% specificity. CONCLUSION. The estimated volume and maximum diameter of high-confidence candidate lesions can differentiate SGD from MGD and identify individual glands requiring removal for successful parathyroidectomy. Differentiating SGD from MGD may be aided by considering both the first- and second-largest high-confidence lesions. CLINICAL IMPACT. The findings will help identify patients who are likely to require bilateral neck explorations, informing preoperative patient counseling and individualized operative planning.

Parathyroid Imaging: Past, Present, and Future

The goal of parathyroid imaging is to identify all sources of excess parathyroid hormone secretion pre-operatively. A variety of imaging approaches have been evaluated and utilized over the years for this purpose. Ultrasound relies solely on structural features and is without radiation, however is limited to superficial evaluation. 4DCT and 4DMRI provide enhancement characteristics in addition to structural features and dynamic enhancement has been investigated as a way to better distinguish parathyroid from adjacent structures. It is important to recognize that 4DCT provides valuable information however results in much higher radiation dose to the thyroid gland than the other available examinations, and therefore the optimal number of phases is an area of controversy. Single-photon scintigraphy with 99mTc-Sestamibi, or dual tracer 99mTc-pertechnetate and 99mTc-sestamibi with or without SPECT or SPECT/CT is part of the standard of care in many centers with availability and expertise in nuclear medicine. This molecular imaging approach detects cellular physiology such as mitochondria content found in parathyroid adenomas. Combining structural imaging such as CT or MRI with molecular imaging in a hybrid approach allows the ability to obtain robust structural and functional information in one examination. Hybrid PET/CT is widely available and provides improved imaging and quantification over SPECT or SPECT/CT. Emerging PET imaging techniques, such as 18F-Fluorocholine, have the exciting potential to reinvent parathyroid imaging. PET/MRI may be particularly well suited to parathyroid imaging, where available, because of the ability to perform dynamic contrast-enhanced imaging and co-registered 18F-Fluorocholine PET imaging simultaneously with low radiation dose to the thyroid. A targeted agent specific for a parathyroid tissue biomarker remains to be identified.

Four-dimensional computed tomography (4D-CT) for preoperative parathyroid localization: A good study but are we using it?

BACKGROUND

Four-dimensional computed tomography (4D-CT) scan to localize abnormal parathyroid glands is diagnostically superior to ultrasound (US) and sestamibi. The implementation of 4D-CT imaging is unknown.

METHODS

The Collaborative Endocrine Surgery Quality Improvement Program (CESQIP) database from 2014 to 2018 was utilized. Patients with hyperparathyroidism undergoing an initial operation were included. The rate of US, sestamibi and 4D-CT performance was calculated for the entire study population, and for each institution.

RESULTS

7,959 patients were included. In 311(3.9%) patients, no preoperative imaging was recorded. Of patients with imaging, US was performed in 6,872(86.3%), sestamibi in 5,094(64.0%), and 4D-CT in 1,630(20.4%). The combination of US and sestamibi was most frequent (3,855, 48.4%). Institutional rates of 4D-CT performance varied from 0.1% to 88.7%.

CONCLUSIONS

Of the imaging modalities, 4D-CT was utilized least frequently and with greatest variability. Given the high accuracy of 4D-CT, efforts to reduce this variation may improve overall preoperative localization in patients with hyperparathyroidism.

The use of computed tomography as a first-line imaging modality in patients with primary hyperparathyroidism

BACKGROUND

The success of minimally invasive parathyroidectomy (MIP) relies on accurate localization of the abnormal parathyroid glands. Concordant findings on ultrasound (US) and ^99mTc-scintigraphy (sestamibi) are currently considered the 'gold standard'. Computed tomography (CT) has also recently been used in preoperative planning. We sought to assess the accuracy of CT for localization of abnormal parathyroid glands in such patients.

METHODS

An audit of 75 patients with primary hyperparathyroidism (PHPT) who underwent neck US and CT between 2017 and 2019 at our center as their first-line imaging.

RESULTS

All 75 patients underwent US and CT and 54 (72.0%) also had sestamibi. CT alone identified a potential target in all patients, of which the location was correct in 63 (84.0%). The overall combined sensitivity of US and CT was 88% (95% CI 78-94) and was higher than the combined sensitivity of US and sestamibi (65% [95% CI 53-76]; p < 0.001). Twenty-one patients (28.0%) had an ectopic gland, and the sensitivity of US and CT was 86% (95% CI 64-96) versus US and sestamibi (57% [95% CI 34-77]; p = 0.016). For adenomas < 1.0 g (n = 36; 48%), the accuracy of CT was 81% (95% CI 64-91) compared with 62% (95% CI 44-77) for US and sestamibi (p = 0.04). The correct preoperative diagnosis of multiglandular disease (n = 9; 12%) seemed to be the most difficult, with similar accuracy for US and sestamibi (40% [95% CI 14-73]) and US and CT (50% [95% CI 20-80]) (p > 0.99).

CONCLUSION

The combination of US and CT was able to correctly identify the location of the abnormal parathyroid in 88% of patients and, in comparison with US and sestamibi, had better diagnostic accuracy, especially for smaller and ectopic adenomas. This finding suggests that US and CT could be considered as a first-line imaging modality in patients with PHPT considered for MIP.

[The clinical practice guidelines for primary hyperparathyroidism, short version]

Primary hyperparathyroidism (PHPT) is an endocrine disorder of parathyroid glands characterized by excessive secretion of parathyroid hormone (PTH) with an upper normal or elevated blood calcium level. Classical PHPT refers to a symptomatic, multi-system disorder, wich can lead to a significant decrease in the quality of life, disability of patients, and even an increased risk of premature death. Hypercalcemia and the catabolic effect of PTH on various cells are considered as the main pathogenetic mechanisms of the PHPT associated complications. In the last two decades, there has been an increase in the incidence of PHPT, mainly due to the mild forms of the disease, primarily due to the routine calcium screening in North America, Western Europe and, Asia. High prevalence of the disease, as well as the variety of clinical manifestations, cause the attention of different specialists - physicians, rheumatologists, urologists, nephrologists, cardiologists and other doctors. This review cover the main issues of Russian guidelines for the management of PHPT, approved in 2020, including laboratory and instrumental methods, differential diagnosis, surgical and conservative approach, short-term and long-term follow-up. This guidelines also include the recommendations for special groups of patients with hereditary forms of PHPT, parathyroid carcinoma, PHPT during pregnancy.

The EANM practice guidelines for parathyroid imaging

INTRODUCTION

Nuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration.

METHODS

Over a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT.

CONCLUSION

These guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.

A cost-utility analysis of 18F-fluorocholine-positron emission tomography imaging for localizing primary hyperparathyroidism in the United States

BACKGROUND

Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States.

METHODS

A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed.

RESULTS

Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy.

CONCLUSION

Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations.

Characterization of Glycosphingolipids in the Human Parathyroid and Thyroid Glands

As part of a systematic investigation of the glycosphingolipids in human tissues, acid and non-acid glycosphingolipids from human thyroid and parathyroid glands were isolated and characterized with mass spectrometry and binding of carbohydrate-recognizing ligands, with a focus on complex compounds. The glycosphingolipid patterns of the human parathyroid and thyroid glands were very similar. The major acid glycosphingolipids were sulfatide and the gangliosides GM3, GD3, GD1a, GD1b, GT1b and Neu5Ac-neolactotetraosylceramide, and the major non-acid glycosphingolipids were globotriaosylceramide and globoside. We also found neolactotetra- and neolactohexaosylceramide, the x₂ glycosphingolipid, and complex glycosphingolipids with terminal blood group O and A determinants in both tissues. A glycosphingolipid with blood group Le^b determinant was identified in the thyroid gland, and the parathyroid sample had a glycosphingolipid with terminal blood group B determinant. Immunohistochemistry demonstrated the expression of blood group A antigens in both the thyroid and parathyroid glands. A weak cytoplasmatic expression of the GD1a ganglioside was present in the thyroid, while the parathyroid gland had a strong GD1a expression on the cell surface. Thus, the glycosylation of human thyroid and parathyroid glands is more complex than previously appreciated. Our findings provide a platform for further studies of alterations of cell surface glycosphingolipids in thyroid and parathyroid cancers.

The preoperative localisation of small parathyroid adenomas improves when adding Tc-99m-Sestamibi SPECT to multiphase contrast-enhanced CT

OBJECTIVES

To investigate the incremental value of Sestamibi SPECT combined with a non-enhanced and contrast-enhanced CT, using SPECT/CT, for the preoperative localisation of small parathyroid adenomas (PTA).

METHODS

Retrospectively, 147 patients surgically cured from primary hyperparathyroidism, as verified by biochemistry 6 months postoperatively, were included. All patients had preoperatively undergone a dual time ^99mTechnetium-Sestamibi SPECT (S) with multiphase CT including native (N), arterial (A) and venous (V) phases. Independently, two radiologists blinded from both the surgical and the preoperative imaging reports, sequentially performed PTA localisation starting with either [A] or [V], thereafter [A + N] or [V + N] and finally with the complete [A + N + S] or [V + N + S]. PTA localisation was reported for each image-set. The readers results were combined and the diagnostic performance for each image set was determined. Sensitivity was also calculated for the different quartiles of PTA weight distribution.

RESULTS

The median adenoma weight was 315 mg. No statistically significant differences in diagnostic performance between arterial and venous based image sets were found. The net effect of adding [N] was to increase specificity. Sestamibi SPECT significantly increased the overall diagnostic accuracy for arterial- and venous-based image sets, p = 0.0008 and p = 0.001, respectively. [A + N + S] was found to have the highest diagnostic performance with 86.5% sensitivity and 94.9% overall accuracy. [A + N + S] was particularly advantageous for locating PTA in the lower weight quartiles.

CONCLUSIONS

Native CT-phase and dual time point Sestamibi SPECT increase specificity and sensitivity, respectively. These, in combination with a single contrast-enhanced CT-phase is the most optimal examination protocol for preoperative localisation of PTA using SPECT/CT.

Pediatric hyperparathyroidism: review and imaging update

Hyperparathyroidism, due to increased secretion of parathyroid hormones, may be primary, secondary or tertiary. Most pediatric patients with sporadic primary hyperparathyroidism will be symptomatic, presenting with either end-organ damage or nonspecific symptoms. In younger patients with primary hyperparathyroidism, there is a higher prevalence of familial hyperparathyroidism including germline inactivating mutations of the calcium-sensing receptor genes that result in either neonatal severe hyperparathyroidism or familial hypocalciuric hypercalcemia. Parathyroid scintigraphy and ultrasound are complementary, first-line imaging modalities for localizing hyperfunctioning parathyroid glands. Second-line imaging modalities are multiphase computed tomography (CT) and magnetic resonance imaging. In pediatrics, multiphase CT protocols should be adjusted to optimize radiation dose. Although, the role of these imaging modalities is better established in preoperative localization of hyperfunctioning parathyroid glands in primary hyperparathyroidism, the same principles apply in secondary and tertiary hyperparathyroidism. In this manuscript, we will review the embryology, anatomy, pathophysiology and preoperative localization of parathyroid glands as well as several subtypes of primary familial hyperparathyroidism. While most of the recent imaging literature centers on adults, we will focus on the issues that are pertinent and applicable to pediatrics.

Preoperative prediction of parathyroid carcinoma in an Asian Indian cohort

BACKGROUND

Parathyroid carcinoma (PC) requires preoperative prediction for appropriate surgical management. Differentiation from symptomatic primary hyperparathyroidism (sPHPT) cohort is difficult.

METHODS

Patients with sPHPT from a tertiary-care center, Western India, including Cohort-A (n = 19 [10/M; 9/F]) with PC and Cohort-B (n = 93 [33/M; 60/F] with benign parathyroid lesions) were compared to derive predictors for differential diagnosis.

RESULTS

There were no differences in clinical or biochemical parameters between the two cohorts. Comparison of CECT parameters showed that irregular shape, tumor heterogeneity, infiltration, short/long-axis ratio >0.76, and long-diameter >30 mm had high negative-predictive value and intratumoral calcification had 100% positive-predictive value to diagnose PC; whereas there were no differences in contrast-enhancement patterns. Long diameter, short/long-axis ratio, and heterogeneity were significant predictors on multivariate analysis.

CONCLUSION

It is difficult to predict diagnosis of PC in an Indian sPHPT cohort based on clinical and biochemical parameters, whereas CECT parathyroid-based parameters can aid in diagnosis.

Comparing the diagnostic accuracy of 4D CT and 99mTc-MIBI SPECT/CT for localizing hyperfunctioning parathyroid glands: a systematic review and meta-analysis

PURPOSE

To compare the diagnostic accuracy of dual-phase 99mTc-MIBI single photon emission computed tomography/computed tomography (SPECT/CT) and 4D CT for the localization of hyperfunctioning parathyroid glands, a systematic review and meta-analysis was performed. Whether 4D CT combined to SPECT/CT [contrast-enhanced (CE)-SPECT/CT] had a better diagnostic performance than SPECT/CT alone in this scenario was also evaluated.

MATERIAL AND METHODS

PubMed and Embase databases were searched for eligible studies. To reduce interstudy heterogeneity, only studies with clear head-to-head comparison were included. Publication bias was assessed by the Deeks funnel plot. The pooled sensitivity, specificity and the area under the curve (AUC) for 4D CT, SPECT/CT and CE-SPECT/CT were determined by random-effect analysis, respectively.

RESULTS

Nine studies met the inclusion criteria, with a total of 911 participants. The sensitivity and specificity of 4D CT were 0.85 [95% confidence interval (CI), 0.69-0.94] and 0.93 (95% CI, 0.88-0.96), whereas the sensitivity and specificity for SPECT/CT were 0.68 (95% CI, 0.51-0.82; P = 0.048 compared with 4D CT) and 0.98 (95% CI, 0.95-0.99; P = 0.014 compared with 4D CT), respectively. CE-SPECT/CT is comparable to SPECT/CT in specificity and AUC, but it may improve the sensitivity (although there was a lack of statistical difference, 0.87 vs. 0.78; P = 0.125).

CONCLUSION

Although 4D CT shows comparable AUC and borderline better sensitivity than SPECT/CT, its clinical application is confined by relatively low specificity and high radiation exposure. CE-SPECT/CT may improve the sensitivity without compromising the specificity and AUC of SPECT/CT.

Factors That Affect the Sensitivity of Imaging Modalities in Primary Hyperparathyroidism

BACKGROUND

Cervical ultrasound, 99mTc-sestamibi single-photon emission computed tomography/computed tomography (99mTc-MIBI SPECT/CT), and cervical CT are routinely used in preoperative localization of primary hyperparathyroidism (PHPT). However, false-negative imaging results are also frequently encountered in clinical practice. Exploring the factors that affect the sensitivity of these imaging modalities is important for the surgical management of PHPT patients.

METHODS

Clinical data of 352 PHPT patients hospitalized in our center from January 2011 to December 2015 were retrospectively collected to evaluate the sensitivity of 3 imaging modalities in the preoperative localization of parathyroid lesions. The ROC curve analysis was used to explore the clinical factors affecting the sensitivity of localization, and the cut-point(s) of related factors were determined.

RESULTS

99mTc-MIBI SPECT/CT has the highest sensitivity among the localization modalities commonly used, reaching 91.1% (86.0%-94.8%). When the lengths of parathyroid lesions were ≤1.3 cm, the sensitivity of neck ultrasonography significantly decreased, while the sensitivity of 99mTc-MIBI SPECT/CT decreased with parathyroid lesions ≤1.3 cm or serum PTH≤252 pg/ml. 99mTc-MIBI SPECT/CT was less effective in localizing the hyperplasia lesions. Neck ultrasonography combined with 99mTc-MIBI SPECT/CT can effectively improve the accuracy of preoperative localization of parathyroid lesions to 96.2% (92.7%-98.1%).

CONCLUSIONS

Small parathyroid lesion and mild elevation of serum PTH would reduce the accuracy of parathyroid localization in PHPT patients.

Will 18F-fluorocholine PET/CT replace other methods of preoperative parathyroid imaging?

INTRODUCTION

Primary hyperparathyroidism (PHPT) is a common endocrine disorder usually due to hyperfunctioning parathyroid glands (HPs). Surgical removal of the HPs is the main treatment for PHPT, making the correct detection and localization of HPs crucial to guiding targeted and minimally invasive surgical treatment in patients with PHPT. To date, different imaging methods have been used to detect and localize HPs, including radiology, nuclear medicine, and hybrid techniques.

METHODS

The present work discusses the role and value of different imaging methods in PHPT and, particularly, evaluates the potential role of ¹⁸F-fluorcholine PET/CT as a "one-stop-shop" method for preoperative parathyroid localization in patients with PHPT.

DISCUSSION

Cervical ultrasound (US) and parathyroid scintigraphy using ^99mTc-MIBI are the most commonly employed methods in clinical practice. More recently, four-dimensional computed tomography (4D CT) and positron emission tomography (PET) with radiolabeled choline have emerged as useful alternatives in cases of negative or discordant findings from first-line imaging methods.

CONCLUSIONS

Due to the excellent diagnostic performance of radiolabeled choline PET/CT and the low radiation burden, this technique seems to be an ideal candidate to substitute current imaging procedures including US, MIBI scintigraphy, 4D CT and MRI and perform a fast and reliable "one-stop-shop" preoperative localization of HP in patients with PHPT, including challenging cases of postoperative persistent/recurrent disease.

Application of transoral endoscopic parathyroidectomy via vestibular approach, endoscopic parathyroidectomy via areola approach for parathyroid adenoma

BACKGROUND

Transoral endoscopic parathyroidectomy via vestibular approach (TOEPVA) and total endoscopic parathyroidectomy via areola approach (EPA) are commonly used endoscopic parathyroidectomy approaches. This study compares effectiveness of these approaches with conventional open parathyroidectomy (COP) in relation to safety, associated trauma, and feasibility in the treatment of parathyroid adenoma (PTA).

METHODS

We examined patients who had undergone TOEPVA (n = 15), EPA (n = 14), and COP (n = 30). All patients had a pathological diagnosis of PTA. We analyzed operative time, intraoperative blood loss, postoperative visual analog scale (VAS) score, postoperative drainage volume, hospital stay and complications such as changes in parathyroid hormone (PTH) and serum calcium before and after surgery.

RESULTS

Clinical variables across the three experimental groups were similar except for patient age. TOEPVA and EPA groups had a higher proportion of young patients than COP group. Operation time for endoscopic group was longer than that of open group, and the longest operation time was recorded in TOEPVA group (P = 0.000). Postoperative VAS score: postoperative pain in patients in the endoscopic group was less than that of patients in the open group on the first day (P = 0.001). Postoperative pain in patients of the endoscopic group was significant on the second day (P = 0.044). Pain experienced by patients in the three groups was the same on the third day after surgery (P = 0.312). Postoperative drainage volume in the endoscopic group was more than that in the open group (P = 0.000). There were no significant differences between intraoperative blood loss (P = 0.089), complications (P = 0.407) and hospital stay (P = 0.389) in TOEPVA, EPA and COP groups. PTH and serum calcium levels in the three experimental groups were considerably lower after surgery (P < 0.05). Tumor recurrence was not recorded in the three groups during a follow-up period of between 3 and 36 months.

CONCLUSIONS

TOEPVA and EPA are safe treatment options for PTA. The therapeutic effects of TOEPVA and EPA were similar to those of COP in the treatment of PTA.

Parathyroid 4D CT: What the Surgeon Wants to Know

Parathyroid four-dimensional (4D) CT is an increasingly used and powerful tool for preoperative localization of abnormal parathyroid tissue in the setting of primary hyperparathyroidism. Accurate and precise localization of a single adenoma facilitates minimally invasive parathyroidectomy, and localization of multiglandular disease aids bilateral neck exploration. However, many radiologists find the interpretation of these examinations to be an intimidating challenge. The authors review parathyroid 4D CT findings of typical and atypical parathyroid lesions and provide illustrative examples. Relevant anatomy, embryology, and operative considerations with which the radiologist should be familiar to provide clinically useful image interpretations are also discussed. The most important 4D CT information to the surgeon includes the number, size, and specific location of candidate parathyroid lesions with respect to relevant surgical landmarks; the radiologist's opinion and confidence level regarding what each candidate lesion represents; and the presence or absence of ectopic or supernumerary parathyroid tissue, concurrent thyroid pathologic conditions, and arterial anomalies associated with a nonrecurrent laryngeal nerve. The authors provide the radiologist with an accessible and practical approach to performing and interpreting parathyroid 4D CT images, detail what the surgeon really wants to know from the radiologist and why, and provide an accompanying structured report outlining the key information to be addressed. By accurately reporting and concisely addressing the key information the surgeon desires from a parathyroid 4D CT examination, the radiologist substantially impacts patient care by enabling the surgeon to develop and execute the best possible operative plan for each patient. ^©RSNA, 2020.

18F-Fluorocholine PET and Multiphase CT Integrated in Dual Modality PET/4D-CT for Preoperative Evaluation of Primary Hyperparathyroidism

The present retrospective study evaluates the diagnostic value of integrated ¹⁸F-Fluorocholine positron emission tomography/four-dimensional contrast-enhanced computed tomography (¹⁸F-FCH PET/4D-CT) as second-line imaging in preoperative work-up of primary hyperparathyroidism (pHPT), and compares ¹⁸F-FCH PET with 4D-CT. Patients with pHPT and negative/discordant first-line imaging addressed for integrated ¹⁸F-FCH PET/4D-CT were retrospectively selected. Sensitivity and detection rate (DR%) of ¹⁸F-FCH PET/CT, 4D-CT, and PET/4D-CT were calculated according to the per patient and per lesion analyses, and afterwards compared. Histology associated with a decrease more than 50% of perioperative parathyroid hormone (PTH) blood level was used as a gold standard. Persistent high serum PTH and calcium levels during a 6-month follow-up was considered as presence of pHPT in both operated and non-operated patients. 50 patients (55 glands) were included. 44/50 patients (88%) were surgically treated. On a per patient analysis, sensitivity was 93%, 80%, and 95%, and DR% was 82%, 68%, and 84%, respectively for PET/CT, 4D-CT, and PET/4D-CT. PET/CT was more sensitive than 4D-CT (p = 0.046). PET/4D-CT performed better than 4D-CT (p = 0.013) but was equivalent to PET/CT alone. On a per gland analysis, sensitivity PET/CT, 4D-CT, and PET/4D-CT was 88%, 66%, and 92%, and DR% was 79%, 57%, and 83%, respectively. PET/CT and PET/4D-CT were more sensitive than 4D-CT alone (p = 0.01, p < 0.001, respectively). However, PET/CT and PET/4D-CT performed similarly. In conclusion, ¹⁸F-FCH PET provides better identification of hyperfunctioning parathyroids than 4D-CT and the combination of both did not significantly improve diagnostic sensitivity. Further investigations involving larger populations are necessary to define the role of ¹⁸F-FCH PET/4D-CT as a “one-stop shop” second-line imaging in preoperative work-up of pHPT, especially considering the additional patient radiation exposure due to multi-phase CT.

4D-Dynamic Contrast-Enhanced MRI for Preoperative Localization in Patients with Primary Hyperparathyroidism

BACKGROUND AND PURPOSE

Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation.

MATERIALS AND METHODS

Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results.

RESULTS

Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%).

CONCLUSIONS

The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.

Multiphase Iodine Contrast-Enhanced SPECT/CT Outperforms Nonenhanced SPECT/CT for Preoperative Localization of Small Parathyroid Adenomas

PURPOSE

The aim of this study was to assess the value of intravenously contrast-enhanced CT in conjunction with Tc-MIBI SPECT for preoperative localization of parathyroid adenoma.

METHODS

One hundred ninety-two patients with primary hyperparathyroidism were enrolled in the study between May 2015 and May 2017. The patients underwent a preoperative "one-stop shop" examination with Tc-MIBI SPECT/CT by using dual time-point (10 and 90 minutes) protocol and both nonenhanced CT and contrast-enhanced CT acquisition in the arterial and venous phase, 35 and 75 seconds, respectively, after contrast medium injection start. For 149 patients, the imaging results could be correlated to those at surgery and histopathology.

RESULTS

The median adenoma weight was 330 mg. The addition of contrast-enhanced CT increased the sensitivity from 81.1% to 89.9% (P = 0.003). The specificity of nonenhanced SPECT/CT was similar to contrast-enhanced CT (96.1% vs 97.9%; P = 0.077). For patients with uniglandular disease (n = 140, 94.0%), the sensitivity increased from 86.4% to 93.6% (P = 0.021) and the specificity from 96.2% to 97.9% (P = 0.118) by adding contrast-enhanced CT. In patients with multiglandular disease (n = 9, 6.0%), adding contrast-enhanced CT improved detection sensitivity from 42.1% to 63.2%. However, these patients were few and significance was not reached (P = 0.125).

CONCLUSIONS

In this cohort, with generally small parathyroid adenomas, the sensitivity in preoperative localization was greatly improved by adding contrast-enhanced CT to Tc-MIBI SPECT/CT.

Parathyroid imaging with 18F-fluorocholine PET/CT as a first-line imaging modality in primary hyperparathyroidism: a retrospective cohort study

BACKGROUND

¹⁸F-fluorocholine (FCH) PET/CT is a promising technique for visualizing hyperfunctioning parathyroid glands in hyperparathyroidism. It is still under debate whether to use this technique as a first-line imaging modality or to use it when conventional techniques such as ^99mTc-sestamibi scintigraphy or ultrasonography are inconclusive. This study evaluates FCH PET/CT as a first-line modality.

METHODS

Patients with primary hyperparathyroidism, referred between June 2015 and December 2018 for FCH PET/CT as a first-line imaging method, were included in this study. Baseline characteristics, clinical data, scan results, and type of treatment were recorded. The rate of correct detection was calculated on a per patient-based and a per lesion-based analysis. The reference standard comprised histopathological results, intraoperative response to parathyroidectomy, and clinical follow-up.

RESULTS

Two hundred and seventy-one patients were included, of which 139 patients underwent parathyroidectomy, 48 were treated with calcimimetics, and 84 patients received further follow-up without active treatment. In the surgically treated group, a single adenoma was suspected in 127 scans, double adenoma in three scans, and one scan showed evidence of three hyperfunctioning glands. In eight scans, no lesions were visualized. A total of 154 parathyroid glands were surgically removed. The rate of correct detection was calculated at 96% and 90%, on a per patient-based and per lesion-based analysis, respectively.

CONCLUSION

This retrospective study in a large cohort shows high detection rates of FCH PET/CT in primary hyperparathyroidism, which is in accordance to literature. The use of FCH PET/CT as a first-line imaging modality in preoperative planning of parathyroid surgery may therefore be a suitable choice.

Update of the role of Nuclear Medicine techniques in the pre-surgical localization of primary hyperparathyroidism

Primary hyperparathyroidism is one of the most frequent endocrine disorders. Its diagnosis is biochemical. Imaging techniques are not useful for the diagnosis of this pathology; they are just tools for pre-surgical localization. In this continuing education, we will analyze the different imaging modalities used in this indication, focusing on Nuclear Medicine. The most commonly used imaging technique in this context is the parathyroid scintigraphy, nowadays double phase protocol with ^99mTc-MIBI and the double tracer with ^99mTc-MIBI/^99mTc-pertechnetate, associated in the first case to SPECT or SPECT/CT, in an early or late phase. The PET/CT with different tracers is showing good results, especially applied to cases of failure in the pre-surgical scintigraphic localization. We expose the results of the morphological imaging techniques as well as the usefulness of combining techniques.

Choline PET/CT in parathyroid imaging: a systematic review

One of the most promising imaging techniques in primary hyperparathyroidism is PET/CT with choline-based tracers. To investigate the current evidence of these tracers in localizing parathyroid adenoma, a systematic review was performed. A comprehensive literature search was carried out and eligible studies were analyzed. Data were extracted, the level of evidence was scored, and performance data were pooled to calculate the weighted detection rate. Eleven articles were included in this study. The pooled detection rate was 97 and 94% on per patient-based and per lesion-based analysis, respectively. There was considerable heterogeneity between studies and the level of evidence was determined to be 3a-, following Oxford criteria. Choline PET/CT has shown favorable results in detection of hyperfunctioning parathyroid tissue and may replace conventional technetium-99m-sestamibi scintigraphy in preoperative planning of parathyroid surgery. However, the quality of current evidence is moderate, and additional high-quality studies are needed to confirm these numbers.

Feasibility of Hyperfunctioning Parathyroid Gland Localization Using [18F]fluciclovine PET/CT

PURPOSE

To evaluate the ability of anti-1-amino-3-anti-1-amino-3-[¹⁸F]fluorocyclobutane-1-carboxylic acid ([¹⁸F]fluciclovine) positron emission tomography/X-ray computed tomography (PET/CT) in comparison to Technetium-99m 2-methoxy isobutyl isonitrile ([^99mTc]sestamibi) single-photon emission computed tomography/CT (SPECT/CT) for the localization of hyperfunctioning parathyroid glands in patients with hyperparathyroidism.

PROCEDURES

Four patients with hyperparathyroidism underwent 60-minutes sequential neck and thorax PET/CT after [¹⁸F]fluciclovine (352 ± 28 MBq) injection. Lesion uptake and target-to-background ratios (TBR) were compared with [^99mTc]sestamibi (798 ± 27 MBq) SPECT/CT in the same patient.

RESULTS

Both techniques detected 4/5 hyperfunctioning parathyroid glands identified at surgery. The highest [¹⁸F]fluciclovine uptake and TBRs were at 5-9 min with rapid washout. [^99mTc]sestamibi had significantly higher TBRs compared with [¹⁸F]fluciclovine (5-9 min) for blood pool (10.9 ± 4.7 vs 1.3 ± 0.6; p < 0.01) and reference muscle backgrounds (5.8 ± 3.0 vs 1.7 ± 0.6; p < 0.01), with non-significant trend for thyroid tissue background (1.3 ± 0.5 vs 1.1 ± 0.5; p = 0.73).

CONCLUSION

Hyperfunctioning parathyroid glands can be detected on [¹⁸F]fluciclovine PET/CT at early imaging, but conspicuity (TBR) is better with [^99mTc]sestamibi. [¹⁸F]fluciclovine PET/CT does not seem promising in the detection of hyperfunctioning parathyroid glands.

Solitary Parathyroid Adenoma Localization in Technetium Tc99m Sestamibi SPECT and Multiphase Multidetector 4D CT

BACKGROUND AND PURPOSE

Minimally invasive parathyroid surgery relies critically on image guidance, but data comparing the efficacy of various imaging modalities are scarce. Our aim was to perform a blinded comparison of the localizing capability of technetium Tc99m sestamibi SPECT, multiphase multidetector 4D CT, and the combination of these 2 modalities (technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT).

MATERIALS AND METHODS

We reviewed the records of 31 (6 men, 25 women; median age, 56 years) consecutive patients diagnosed with biochemically confirmed primary hyperparathyroidism between November 2009 and March 2010 who underwent preoperative technetium Tc99m sestamibi SPECT and multiphase multidetector 4D CT performed on the same scanner with pathologic confirmation by resection of a single parathyroid adenoma. Accuracy was determined separately for localization to the correct side and quadrant using surgical localization as the standard of reference.

RESULTS

Surgical resection identified 14 left and 17 right parathyroid adenomas and 2 left inferior, 12 left superior, 11 right inferior, and 6 right superior parathyroid adenomas. For left/right localization, technetium Tc99m sestamibi SPECT achieved an accuracy of 93.5% (29 of 31), multiphase multidetector 4D CT achieved 96.8% accuracy (30 of 31), and technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT achieved 96.8% accuracy (30 of 31). For quadrant localization, technetium Tc99m sestamibi SPECT accuracy was 67.7% (21 of 31), multiphase multidetector 4D CT accuracy was 87.1% (27 of 31), and technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT accuracy was 93.5% (29 of 31). Reader diagnostic confidence was consistently ranked lowest for technetium Tc99m sestamibi SPECT and highest for technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT.

CONCLUSIONS

For left/right localization of parathyroid adenomas, all modalities performed equivalently. For quadrant localization, technetium Tc99m sestamibi SPECT + multiphase multidetector 4D CT is superior to technetium Tc99m sestamibi SPECT.

Validation of a novel method for localization of parathyroid adenomas using SPECT/CT

Background

Accurate localization of parathyroid adenomas is of critical importance in surgical planning for minimally invasive parathyroidectomy. SPECT/CT is considered the investigation of choice but has limitations regarding localization of superior versus inferior adenomas. We proposed a novel method for localization using SPECT/CT by determining the anterior-posterior relationship of the adenoma to a horizontal line in the coronal plane through the tracheoesophageal groove. Our objective was to determine the accuracy, validity, and inter-rater reliability of this method.

Method

This was a retrospective review of patients who underwent parathyroidectomy for a single adenoma between 2010-2017. SPECT/CT images were reviewed by two staff Otolaryngologists, a Radiologist, an Otolaryngology fellow and Otolaryngology resident. Results were compared using intra-operative report as the gold standard.

Overall accuracy in determining superior/inferior and right/left adenomas was calculated, as well as Cohen's Kappa to determine agreement with operative report and inter-rater reliability. The performance was compared to that of the original radiology report.

Results

One hundred thirty patients met criteria and were included. Our method correctly identified the location of the adenoma in terms of both side and superior/inferior position in 80.4% [76 - 84%] of patients, which considerably outperformed the original radiology report at 48.5% [4-78%] accuracy. The agreement level between our method and operative report was high (Kappa=0.717 [0.691-0.743]), as was the inter-rater reliability (Kappa=0.706 [0.674-0.738]).

Conclusion

We report a novel method for localization of parathyroid adenomas using SPECT/CT which outperforms standard radiology reporting. This tool can be used by surgeons and radiologists to better inform and plan for minimally invasive parathyroidectomy.

Preoperative localization modalities in primary hyperparathyroidism: Correlation with postoperative cure

BACKGROUND

Accurate preoperative localization is critical to the success of minimally invasive parathyroidectomy. This investigation aimed to assess the correlation among preoperative imaging results, intraoperative findings, and postoperative cure rates in patients undergoing operation for primary hyperparathyroidism.

METHODS

A retrospective review of all patients who underwent operation for primary hyperparathyroidism between June 2010 and March 2016 was performed.

RESULTS

During the study period, 398 patients underwent parathyroidectomy. The overall cure rate was 97.5%. The ultrasonography performed by the surgeon was superior to the ultrasonography performed by the radiologist and to the sestamibi scan in lateralizing the adenoma correctly (80% vs 62% vs 70%, P < .001, respectively), and had the greatest sensitivity (93%) and accuracy (80%) among all tests (P < .001). Age ≥65 was found to be associated with lesser cure rates (94% vs 99.2%, P = .003). The number of positive preoperative studies correlated with cure rate, ranging from 80% for patients with 0 positive studies, to 100% in those with 4 positive studies (P = .0004). In patients with a negative sestamibi and an ultrasonography performed by the radiologist, there was no significant difference in the cure rates among those with no preoperative computed tomography, a positive preoperative computed tomography, or a negative preoperative computed tomography.

CONCLUSION

An ultrasonography performed by an experienced surgeon is an extremely valuable preoperative localization modality. The cure rate obtained is proportional to the number of positive imaging studies. In patients with negative ultrasonography performed by a nonexperienced radiologist and a negative sestamibi scan, the performance of computed tomography does not seem to increase cure rate. Patients with no positive preoperative scans represent a challenging subgroup, with cure rates of approximately 80%.

Clinical value of 11C-methionine positron emission tomography in persistent primary hyperparathyroidism-A case report with a mediastinal parathyroid adenoma

INTRODUCTION

Primary hyperparathyroidism (PHPT) is a common endocrine disorder caused by pathologic growth of one or more of the parathyroid glands. Parathyroidectomies (PTX) in patients with PHPT are procedures with low morbidity, few complications, and a high cure rate. However, the parathyroid glands may be found at various anatomical locations and occasionally they are intrathoracic.

CASE PRESENTATION

We present a 57-year-old patient with PHPT. Before the first and second operation, the preoperative imaging indicated pathologic parathyroid tissue in the neck. Due to postoperative persistent hypercalcemia we performed a 11C-methionine positron emission tomography (11C-MET-PET/CT). The scan showed a focus with increased activity in the mediastinum. Due to persistent disease, an ectopic parathyroid gland in the mediastinum was suspected. At a third operation, the parathyroid adenoma was resected through an anterolateral thoracotomy. Biochemical values normalized and bone mineral density improved postoperatively. Hence, an ectopic localization of a parathyroid gland should be considered during the preoperative planning of a PTX, especially in the re-operative setting. A multidisciplinary effort is necessary to address an intrathoracic adenoma.

CONCLUSION

Ectopic parathyroid glands should be suspected when positive sestaMIBI uptake is seen in the mediastinum and other types of imaging (e.g. contrast enhanced CT scan or PET-CT) may confirm the finding of an ectopic parathyroid adenoma. From the present case and previous studies we found 11C-MET-PET/CT valuable in difficult PHPT cases.

Update in Parathyroid Imaging

Primary hyperparathyroidism (PHPT) is characterized by excessive, dysregulated production of parathyroid hormone (PTH) by 1 or more abnormal parathyroid glands. Minimally invasive surgical techniques have created a need for more precise localization of the parathyroid lesion by imaging. A variety of imaging protocols and techniques have been used for this purpose, but no one modality is clearly superior. Nuclear medicine scintigraphy and ultrasound imaging are established modalities, although multiphase or 4-dimensional computed tomography is an emerging modality with several advantages. This review provides a background regarding PHPT and key anatomy, and discusses these alternative parathyroid imaging modalities with updates.