1
|
Luong TV, Le LD, Nguyen NVD, Dang HNN. Persistent challenges in the diagnosis of acute pancreatitis due to primary hyperparathyroidism during pregnancy. World J Gastroenterol 2025; 31:100973. [DOI: 10.3748/wjg.v31.i7.100973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 12/01/2024] [Accepted: 01/02/2025] [Indexed: 01/20/2025] Open
Abstract
In this manuscript, we provide critical commentary on the systematic review by Augustin et al, which investigated acute pancreatitis induced by primary hyperparathyroidism during pregnancy. Although this is an infrequent complication, it poses severe risks to both maternal and fetal health. Due to its infrequent occurrence in clinical practice, this review is based on an analysis of individual case reports over the past 55 years. While this is not the first study to utilize this sampling method for primary hyperparathyroidism-induced acute pancreatitis, it is unique in that it has a sufficiently large sample size with statistically significant results. Our discussion focuses on the diagnostic challenges associated with this condition, which are grounded in the mechanisms of parathyroid hormone secretion and variations in serum calcium levels. We also address the limitations of the current review and suggest potential strategies to increase diagnostic accuracy and improve health outcomes for both mothers and fetuses during pregnancy.
Collapse
Affiliation(s)
- Thang Viet Luong
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue 530000, Viet Nam
| | - Linh Duy Le
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue 530000, Viet Nam
| | - Nam Van Duc Nguyen
- Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue 530000, Viet Nam
| | | |
Collapse
|
2
|
van der Zant FM, Wondergem M, Broos WAM, Lazarenko SV, Knol RJJ. Frequency and characteristics of ectopic parathyroid adenomas in a cohort of patients referred for 18 F-fluorocholine PET/CT. Nucl Med Commun 2025; 46:89-94. [PMID: 39434614 DOI: 10.1097/mnm.0000000000001920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2024]
Abstract
AIM This article aimed to study the frequency and characteristics of ectopic/intrathyroidal parathyroid adenomas in patients referred for 18 F-fluorocholine PET/computed tomography (CT). PATIENTS AND METHODS From 11 June 2015 to 15 January 2024, 729 patients were studied. Recorded patient variables included hyperparathyroidism type, sex, age, presence of symptoms, renal involvement, bone involvement, parathyroid hormone (PTH), and serum calcium, phosphate, and vitamin D as well as 24-h urine calcium excretion. PET/CT results were also collected. In case of parathyroidectomy, the weight of the adenomas was recorded. Continuous variables were expressed as mean ± SD. Differences were evaluated with Mann-Whitney U -tests or two-sample t -tests, when appropriate. P -values ≤0.05 were considered statistically significant. RESULTS PET/CT showed no adenoma in 163 (22%), adenoma in 451 (62%), hyperplasia/multiglandular disease in 32 (4%), and equivocal results in 83 (11%) patients. A total of 6/729 (1%) adenomas were located intrathyroidally and 16/729 (2%) had an ectopic location. Patients with ectopic/intrathyroidal adenoma showed significantly higher serum PTH levels than patients with no visualization of adenoma on PET. The mean mass of the adenoma was 1 ± 2.3 g in patients with orthotopic adenomas versus 2.7 ± 3.3 g in patients with ectopic/intrathyroidal adenomas; however, this was not significantly different ( P = 0.09). CONCLUSION In the presented cohort, the frequency of ectopic/intrathyroidal parathyroid adenomas was 3%. No significant difference in weight was found between orthotopic and ectopic/intrathyroidal parathyroid adenomas.
Collapse
Affiliation(s)
| | | | - Wouter A M Broos
- Department of Nuclear Medicine, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | | | - Remco J J Knol
- Department of Nuclear Medicine, Northwest Clinics, Alkmaar
| |
Collapse
|
3
|
Tsoy U, Pogosian K, Ryzhkova D, Yudina O, Yakovenko K, Ryazanov P, Matsueva I, Sokolnikova P, Salov M, Karonova T, Grineva E. Somatostatin Receptor Imaging in the Diagnosis and Management of Parathyroid Neuroendocrine Neoplasia. Diagnostics (Basel) 2024; 14:2718. [PMID: 39682626 DOI: 10.3390/diagnostics14232718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2024] [Revised: 11/28/2024] [Accepted: 11/28/2024] [Indexed: 12/18/2024] Open
Abstract
BACKGROUND Parathyroid tumors are classified as parathyroid neuroendocrine neoplasia (NEN) by the IARC-WHO classification. These tumors can occur with NENs from other sites, which often require total-body [68Ga]-DOTA-peptides PET/CT. This study aimed to assess the utility of [68Ga]-DOTA-peptide PET/CT in imaging parathyroid NENs and to evaluate the underlying mechanisms. METHODS Fifty patients with primary hyperparathyroidism (PHPT) and parathyroid NENs histologically confirmed as parathyroid adenomas (PAs) were included. PET/CT with [68Ga]-DOTA-peptide was performed in 16 patients with localized PAs, including 10 with MEN1 syndrome. Somatostatin receptor types 2 and 5 (SST2 and SST5) staining was performed on PAs from 48 patients. Somatostatin analogs (SSA) were prescribed in four patients with MEN 1 syndrome and 1 with persistent acromegaly, all with PAs and PHPT. The therapy effects on calcium and parathyroid hormone (iPTH) were evaluated. RESULTS [68Ga]-DOTA-peptide PET/CT detected 20 PAs with high radiopharmaceutical uptake. SST2 expression was negative on PA cell membranes in all cases and positive on endothelium in 39 (81%) PAs. Membrane SST5 expression was positive in 25 (52%) PAs and endothelial was positive in 40 (83%). Serum calcium levels decreased in patients on SSA therapy, while iPTH did not. CONCLUSIONS PET/CT with [68Ga]-DOTA-peptides can detect parathyroid NENs. The incidental detection of high [68Ga]-DOTA-peptide uptake in the parathyroid region during whole-body PET/CT may prompt biochemical evaluation for PHPT. We suggest that endothelial SST expression mediates high radiopharmaceutical uptake by PAs and that SSA treatment can reduce hypercalcemia in PHPT patients.
Collapse
Affiliation(s)
- Uliana Tsoy
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Karina Pogosian
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Daria Ryzhkova
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Olga Yudina
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Ksenia Yakovenko
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Pavel Ryazanov
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Irina Matsueva
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Polina Sokolnikova
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Maksim Salov
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Tatiana Karonova
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| | - Elena Grineva
- Almazov National Medical Research Centre, 2 Akkuratova Street, Saint Petersburg 197341, Russia
| |
Collapse
|
4
|
Hannabass KR, Austerlitz J, Noel JE, Orloff LA. Parathyroid Adenoma Orientation for Gland Embryologic Origin on Ultrasonography. JAMA Otolaryngol Head Neck Surg 2024; 150:756-762. [PMID: 39023906 PMCID: PMC11258637 DOI: 10.1001/jamaoto.2024.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 05/13/2024] [Indexed: 07/20/2024]
Abstract
Importance Accurate preoperative localization is critical to success in targeted parathyroidectomy for primary hyperparathyroidism. Objective To determine if the association between the long axis of a parathyroid adenoma (PTA) candidate and strap musculature on sagittal ultrasonography (US) can be used to predict the embryologic origin of the gland. Design, Setting, and Participants This diagnostic study was performed using the Stanford Research Repository. Patients 18 years or older with primary hyperparathyroidism who underwent parathyroidectomy between January 2009 and October 2021 were considered. Additional inclusion criteria were having clear sagittal view of the adenoma candidate on US, confirmation of the gland of origin intraoperatively, and confirmation of hypercellular parathyroid on final pathology. Data were analyzed from October 2021 to June 2022. Exposures B-mode US and surgical parathyroidectomy. Main Outcomes and Measures The index test was using US to measure the angle between the long axis of an adenoma candidate and the strap musculature in the sagittal plane. This angle was used to test whether inferior and superior PTAs could be accurately assigned. The hypothesis was formulated prior to data collection. Results A total of 426 patients (mean [range] age, 61.1 [20-96] years; 316 [74.2%] female) with 442 adenomas met inclusion criteria. Of the 442 adenomas, 314 (71.0%) had measurable angles, of which 204 (46.2%) were assigned a superior origin, 238 (53.8%) were assigned an inferior origin, and 128 (29%) were indeterminate. Of the surgically identified superior PTAs, 144 (70.6%) had a definable angle, and of the surgically identified inferior PTAs, 170 (71.4%) had a definable angle. The receiver operating characteristic analysis found 94° as the optimized angle for differentiating true negatives from true positives, with an overall sensitivity of 74% and specificity of 72%. This supported using 90° as a break point for US review. True positives were considered superior adenomas with an angle greater than 90°; true negatives were inferior adenomas with an angle less than 90°. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of angulation analysis for determining PTA origin were 72.2% (95% CI, 64.9%-79.5%), 73.5% (95% CI, 66.9%-80.1%), 69.8% (95% CI, 62.5%-77.1%), 75.8% (95% CI, 69.3%-82.3%), and 72.9%, respectively. A subgroup analysis of 426 adenomas using the posterior carotid artery border on transverse US as a surrogate for predicting gland origin showed the following for sensitivity, specificity, positive predictive value, negative predictive value, and accuracy: 49.5% (95% CI, 42.6%-56.4%), 82.3% (95% CI, 77.3%-87.3%), 71.4% (95% CI, 63.9%-78.9%), 64.6% (95% CI, 59.1%-70.1%), and 66.9%, respectively. Conclusions and Relevance This diagnostic study showed that PTA angulation on sagittal plane US can be used to predict gland of origin and guide surgery. The relationship between adenoma and posterior carotid artery border on transverse US can also be used to predict gland origin. These easy-to-apply US-based tests can be used in conjunction with other imaging modalities to guide targeted parathyroidectomy.
Collapse
Affiliation(s)
- Kyle R. Hannabass
- Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
- Contra Costa ENT, Bass Medical Group, Walnut Creek, California
| | - Joaquin Austerlitz
- Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
- California University of Science and Medicine, Colton
| | - Julia E. Noel
- Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
- Division of Otolaryngology–Head & Neck Surgery, Santa Clara Valley Medical Center, Santa Clara, California
| | - Lisa A. Orloff
- Department of Otolaryngology–Head & Neck Surgery, Stanford University School of Medicine, Stanford, California
| |
Collapse
|
5
|
Bakuła-Zalewska E, Długosińska J, Stanek-Widera A, Góralski P, Gałczyński J, Żyłka A, Durzyńska M, Dedecjus M. Fine needle aspiration biopsy of parathyroid; is it meaningful? A cytologic study of 81 cases with histological and clinical correlations. Cytopathology 2024; 35:362-370. [PMID: 38213192 DOI: 10.1111/cyt.13356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 12/26/2023] [Accepted: 01/03/2024] [Indexed: 01/13/2024]
Abstract
BACKGROUND Recognizing the parathyroid gland and distinguishing the parathyroid from thyroid lesions in fine needle aspiration (FNA) is challenging. This study aimed to identify cytomorphologic features suggestive of parathyroid origin and to assess the utility of cytopathology in conjunction with ancillary tests in the identification of parathyroid glands. MATERIALS AND METHODS Ultrasound (US) guided FNA of parathyroid gland and lesions in 81 patients were reviewed concerning clinical history and correlated to histopathologic findings in available cases. FNA smears were evaluated for cellularity, architectural patterns, cellular and nuclear features, and background of the smears. In 78 cases, FNA was supplemented by a measurement of parathormone (PTH) levels in the needle washout fluid (FNA-PTH assay) and/or GATA3/PTH/chromogranin-A immunostainings. RESULTS Sixty-four cases were diagnosed cytologically as parathyroid lesions in conjunction with FNA-PTH assay and/or immunocytochemical examinations. In an additional nine cases, a diagnosis of parathyroid lesions was rendered after repeated FNA with FNA-PTH assay. The histolopathologic diagnosis of surgically excised cases (n = 75) included parathyroid adenoma (60 cases), atypical parathyroid adenoma (4 cases), parathyroid hyperplasia (10 cases), and parathyroid carcinoma (1 case). Major cytological findings of parathyroid tissue included high cellularity, scattered naked nuclei, cribriform and three-dimensional clusters, stippled chromatin, and oxyphilic cytoplasm while papillary pattern or colloid-like material was identified in three cases respectively. No nuclear grooves or inclusions were seen in any case. CONCLUSIONS High cellularity scattered naked nuclei, cribriform and three-dimensional patterns, stippled chromatin and oxyphilic cytoplasm are cytomorphologic features that favour parathyroid origin. A combination of these features with FNA-PTH assay and/or GATA3, PTH, and chromogranin-A immunostainings on cytologic specimens aid in the identification of parathyroid glands and the distinguishing of parathyroid from thyroid lesions.
Collapse
Affiliation(s)
- Elwira Bakuła-Zalewska
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | - Joanna Długosińska
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | | | - Piotr Góralski
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | - Jacek Gałczyński
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | - Agnieszka Żyłka
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | - Monika Durzyńska
- Department of Pathology and Laboratory Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| | - Marek Dedecjus
- Department of Oncological Endocrinology and Nuclear Medicine, Maria Sklodowska-Curie National Research Institute of Oncology (MSCNRIO), Warsaw, Poland
| |
Collapse
|
6
|
Kim S, Shin JH, Hahn SY, Kim H, Kim MK. The Parathyroid Gland: An Overall Review of the Hidden Organ for Radiologists. JOURNAL OF THE KOREAN SOCIETY OF RADIOLOGY 2024; 85:327-344. [PMID: 38617871 PMCID: PMC11009140 DOI: 10.3348/jksr.2022.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 06/15/2023] [Accepted: 08/08/2023] [Indexed: 04/16/2024]
Abstract
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.
Collapse
|
7
|
Moise A, Abdulhaleem M, Bandargal S, Daniela da Silva S, Payne RJ, Forest VI. A Positive Parathyroid Washout May Obviate the Need for Nuclear Scintigraphy in Parathyroid Adenoma Localization: A Retrospective Study. J Otolaryngol Head Neck Surg 2024; 53:19160216241304366. [PMID: 39698961 PMCID: PMC11656425 DOI: 10.1177/19160216241304366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 10/14/2024] [Indexed: 12/20/2024] Open
Abstract
BACKGROUND Minimally invasive parathyroidectomy (MIP) in patients with a parathyroid adenoma (PA) requires imaging modalities for precise localization. Parathyroid hormone assay on ultrasound-guided fine-needle aspiration washout, or PTH washout, can be used for this purpose. It is unclear whether PTH washout complements traditional PA localization techniques such as a sestamibi (MIBI) scan or diminishes its need. This study aims to determine whether a positive PTH washout obviates the need for an MIBI scan in the preoperative localization of a PA. METHOD A multi-center retrospective, comparative review comprised adult patients who underwent MIP at 2 McGill University teaching hospitals between 2018 and 2022. Patients who had both PTH washout and MIBI scan for preoperative localization of PA, final histopathology reports available, and preoperative/postoperative results recorded were included in the final analysis. RESULTS Of the 193 patients' charts reviewed, 87 were included in this study. Of these 87 patients, 74.7% (65/87) had a positive PTH washout result. Among those, MIBI correctly detected 90.8% (59/65) of the PAs. The MIBI scan did not contribute meaningful information for any of the 65 patients who had positive PTH washout results. CONCLUSION These findings strongly support the use of preoperative dedicated ultrasound as the initial standard procedure. When a PA candidate on ultrasound is found, a PTH washout should be performed. If positive, it could suffice as the sole localization method for MIP surgery. When a PA was identified on ultrasound and confirmed with PTH washout, the MIBI scan did not add more information. Benefits include fewer patient tests, less exposure to ionizing radiation, and reduced healthcare expenses.
Collapse
Affiliation(s)
- Alexander Moise
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Mawaddah Abdulhaleem
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, Montreal, Canada
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Center, Montreal, Canada
| | - Saruchi Bandargal
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
| | - Sabrina Daniela da Silva
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, Montreal, Canada
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Center, Montreal, Canada
| | - Richard J. Payne
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, Montreal, Canada
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Center, Montreal, Canada
| | - Veronique-Isabelle Forest
- Department of Otolaryngology—Head and Neck Surgery, Jewish General Hospital, Montreal, Canada
- Department of Otolaryngology—Head and Neck Surgery, McGill University Health Center, Montreal, Canada
| |
Collapse
|
8
|
He Y, Luo Y, Jin S, Wang O, Liao Q, Zhu Q, Liu H. Can we skip technetium-99 m sestamibi scintigraphy in pediatric primary hyperparathyroidism patients with positive neck ultrasound results? Pediatr Radiol 2023; 53:2253-2259. [PMID: 37438472 PMCID: PMC10562501 DOI: 10.1007/s00247-023-05702-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (PHPT). Ultrasound (US) and technetium-99 m sestamibi (99mTc-MIBI) scintigraphy are recommended as the first-line localization imaging modalities for PHPT in adults, but the value of preoperative imaging in pediatric patients has not been reported. OBJECTIVE To evaluate the added value of 99mTc-MIBI scintigraphy in pediatric PHPT patients with positive ultrasound results. MATERIALS AND METHODS Pediatric patients (≤18 years old) who were diagnosed with PHPT and underwent surgical treatment in Peking Union Medical College Hospital between January 2003 and January 2021 were included in this study. Demographic and clinical characteristics, preoperative localization US, 99mTc-MIBI scintigraphy and pathology results were collected. Preoperative localization results were evaluated by comparison with surgical and pathological findings. RESULTS There were 32 pediatric PHPT patients with median age of 14.7 ± 2.5 years who all proved to have single-gland disease without ectopic lesions. The median lesion size was 2.85 cm (range 1.0-5.8 cm). All patients underwent US and 99mTc-MIBI scintigraphy. Neck US demonstrated 100% sensitivity. Of 32 patients with a positive US, 99mTc-MIBI scintigraphy was concordant in 30 (93.8%). In 2 patients (6.3%), US reported suspected multigland disease, which was correctly diagnosed by 99mTc-MIBI scintigraphy as single lesions. CONCLUSION In pediatric PHPT patients, US achieved high sensitivity for preoperative localization. 99mTc-MIBI scintigraphy for pediatric patients with positive US results would not increase the sensitivity. Implementation of 99mTc-MIBI scintigraphy could increase the specificity in pediatric patients with multigland disease suspected by US.
Collapse
Affiliation(s)
- Yudi He
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Yanwen Luo
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Siqi Jin
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Ou Wang
- Key Laboratory of Endocrinology, Department of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China
| | - Qingli Zhu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| | - He Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, No. 1 Shuaifuyuan Wangfujing Dongcheng District, Beijing, 100730, China.
| |
Collapse
|
9
|
Abraham BM, Sharkey E, Kwatampora L, Ranzinger M, von Holzen U. Mediastinal Intrathymic Parathyroid Adenoma: A Case Report and Review of the Literature. Cureus 2023; 15:e42306. [PMID: 37609099 PMCID: PMC10442188 DOI: 10.7759/cureus.42306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 08/24/2023] Open
Abstract
The classic clinical vignette of primary hyperparathyroidism is well described as "bones, stones, abdominal moans, and psychiatric overtones" to reflect the effects of excess parathyroid hormone (PTH) and calcium. Most commonly, primary hyperparathyroidism is due to a functional parathyroid adenoma situated by the thyroid gland. Rarely, the primary focus of autonomously produced PTH is located ectopically within the mediastinum. A 19-year-old Caucasian female with no relevant past medical history presented to the emergency department with tachycardia, nausea, vomiting, and a five-day history of vague, mid-abdominal pain. Initial computed tomography (CT) with contrast of the abdomen and pelvis was negative for acute findings, and she subsequently underwent biochemical screening. The patient was found to have elevated serum calcium and PTH, raising suspicion for the diagnosis of primary hyperparathyroidism. Further evaluation for a parathyroid adenoma was negative by a CT scan of the neck and thyroid ultrasound. A nuclear medicine parathyroid single-photon emission computed tomography (SPECT)/CT with technetium (Tc) 99m sestamibi found an abnormal nodular uptake within the left prevascular mediastinum suggestive of an ectopic parathyroid adenoma. A left-sided, video-assisted thoracoscopic surgery (VATS) with successful excision of the ectopic mediastinal parathyroid adenoma was performed. Surgical pathology revealed that the parathyroid adenoma was completely excised and surrounded by thymus and adipose tissue. The patient tolerated the procedure well and was discharged without further complications. The rarity of mediastinal, intrathymic parathyroid adenomas resulted in delayed diagnosis in this patient, understandably so as errant embryogenesis does not occur commonly. Visualization with SPECT/CT and successful specimen excision by minimally invasive VATS resulted in the accurate diagnosis and ultimate cure of this patient's primary hyperparathyroidism.
Collapse
|
10
|
Kurokawa M, Kurokawa R, Tamura K, Baba A, Ota Y, Nakaya M, Yokoyama K, Kim J, Moritani T, Abe O. Imaging Features of Ectopic Tissues and Their Complications: Embryologic and Anatomic Approach. Radiographics 2023; 43:e220111. [PMID: 37141139 DOI: 10.1148/rg.220111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Ectopic tissue is an anatomic abnormality in which tissue develops in an area outside its normal location. It is primarily caused by abnormalities during the process of embryologic development. Although the majority of individuals with ectopic tissues remain asymptomatic, various symptoms and associated complications can occur. Failure in normal embryologic development leads to loss of normal physiologic function or may result in harmful functions such as ectopic hormonal secretion in the ectopic pituitary adenoma. Ectopic tissues may also frequently mimic tumors. For example, developmental abnormalities in the pharyngeal pouches may result in an ectopic parathyroid gland and ectopic thymus, both of which are frequently misdiagnosed as tumors. Adequate knowledge of embryology is essential for understanding the differential diagnoses of ectopic tissues and facilitating appropriate management. The authors summarize the embryologic development and pathogenesis of ectopic tissues by using illustrations to facilitate a deeper understanding of embryologic development and anatomy. Characteristic imaging findings (US, CT, MRI, and scintigraphy) are described for ectopic tissues of the brain, head, neck, thorax, abdomen, and pelvis by focusing on common conditions that radiologists may encounter in daily practice and their differential diagnoses. ©RSNA, 2023 Quiz questions for this article are available through the Online Learning Center.
Collapse
Affiliation(s)
- Mariko Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Ryo Kurokawa
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Kentaro Tamura
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Akira Baba
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Yoshiaki Ota
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Moto Nakaya
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Kota Yokoyama
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - John Kim
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Toshio Moritani
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| | - Osamu Abe
- From the Division of Neuroradiology, Department of Radiology, University of Michigan, 1500 E Medical Center Dr, UH B2, Ann Arbor, MI 48109 (M.K., R.K., A.B., Y.O., J.K., T.M.); Department of Radiology, Graduate School of Medicine, University of Tokyo, Tokyo, Japan (M.K., R.K., M.N., O.A.); Department of Radiology, National Institutes for Quantum Science and Technology, Chiba, Japan (K.T.); and Department of Radiology and Department of Diagnostic Radiology, Tokyo Medical and Dental University, Tokyo, Japan (K.Y.)
| |
Collapse
|
11
|
Michaelsen SH, Bay M, Gerke O, Vestergaard S, Graumann O, Nielsen VE, Madsen AR, Bonnema SJ, Godballe C. Evaluation of Surgeon-Performed Ultrasonography With or Without Contrast Enhancement vs Scintigraphy in Patients With Primary Hyperparathyroidism. JAMA Otolaryngol Head Neck Surg 2023; 149:531-539. [PMID: 37052913 PMCID: PMC10102920 DOI: 10.1001/jamaoto.2023.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 02/12/2023] [Indexed: 04/14/2023]
Abstract
Importance Scintigraphy and ultrasonography are common imaging modalities for the preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism. When comparing the 2 modalities, the benefits of ultrasonography in terms of convenience, patient comfort, duration, cost, and lack of radiation should be taken into account. Objective To investigate whether surgeon-performed ultrasonography, with or without contrast-enhanced ultrasonography (CEUS), is noninferior to scintigraphy for localizing pathological parathyroid glands in patients with primary hyperparathyroidism. Design, Setting, and Participants Prospective, paired, noninferiority cohort study performed at a high-volume tertiary referral center for parathyroidectomy with blinded examiners and a 6-month follow-up. Participants were adults (age ≥18 years) referred for parathyroidectomy due to primary hyperparathyroidism. Of 207 eligible patients, 35 were excluded, leaving 172 enrolled in the study. Inclusion lasted from September 2019 until February 2021. Follow-up ended in December 2021. Exposures 99mTechnetium-pertechnetate/99mtechnetium-sestamibi subtraction scintigraphy with 99mtechnetium-sestamibi single-photon emission computed tomography/computed tomography, followed by surgeon-performed ultrasonography and CEUS. Main Outcomes and Measures The sensitivity of each imaging modality in localizing pathological parathyroid glands, calculated on a per-quadrant and a per-patient basis, respectively. The a priori noninferiority margin was a lower 95% confidence limit for the difference in sensitivity not falling below -10%. Results Out of 172 participants, 139 (80.8%) were women, the median (range) age was 65 (24-87) years, and the median (IQR) follow-up was 200.5 (181-280.25) days. Quadrant sensitivity (95% CI) was 70.9% (63.2%-78.5%) for ultrasonography, 68.4% (60.4%-76.5%) for ultrasonography plus CEUS, and 67.0% (60.0%-74.0%) for scintigraphy. The sensitivity difference (95% CI) compared with scintigraphy was 3.9% (-4.1% to 11.8%) for ultrasonography and 1.5% (-6.4% to 9.3%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Per-patient sensitivity was 81.4% (74.8%-86.9%) for ultrasonography and 79.1% (72.2%-84.9%) for both scintigraphy and ultrasonography plus CEUS. The sensitivity difference compared with scintigraphy was 2.3% (-6.8% to 11.4%) for ultrasonography and 0.0% (-9.1% to 9.1%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Conclusions and Relevance In this cohort study, conventional ultrasonography by an experienced parathyroid surgeon-sonographer was noninferior to scintigraphy and may constitute a valid first-line imaging modality in patients with primary hyperparathyroidism, even without the addition of CEUS. Further imaging should be reserved for cases that are equivocal or nonlocalizing on ultrasonography.
Collapse
Affiliation(s)
- Sanne Høxbroe Michaelsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mette Bay
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Oke Gerke
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Sys Vestergaard
- Department of Nuclear Medicine, Odense University Hospital, Odense, Denmark
| | - Ole Graumann
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Radiology, Odense University Hospital, Odense, Denmark
| | - Viveque Egsgaard Nielsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Anders Rørbæk Madsen
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Christian Godballe
- Research Unit for ORL–Head & Neck Surgery and Audiology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| |
Collapse
|
12
|
Aymard S, Leroy-Freschini B, Kaseb A, Marx D, Helali M, Averous G, Betz V, Riehm S, Vix M, Perrin P, Imperiale A. 18F-Fluorocholine PET/CT Compared with Current Imaging Procedures for Preoperative Localization of Hyperfunctioning Parathyroids in Patients with Chronic Kidney Disease. Diagnostics (Basel) 2023; 13:diagnostics13081374. [PMID: 37189475 DOI: 10.3390/diagnostics13081374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Hyperparathyroidism (HPT) in patients with chronic kidney disease (CKD) includes secondary (sHPT) and tertiary hyperparathyroidism (tHPT). Considering that the role of preoperative imaging in the clinical setting is controversial, in the present study we have retrospectively compared pre-surgical diagnostic performances of 18F-Fluorocholine (18F-FCH) PET/CT, cervical ultrasonography (US), parathyroid scintigraphy, and 4D-CT in a group of 30 patients with CKD and HPT (18/12 sHPT/tHPT), 21 CKD G5 including 18 in dialysis, and 9 kidney transplant recipients. All patients underwent 18F-FCH, and 22 had cervical US, 12 had parathyroid scintigraphy, and 11 had 4D-CT. Histopathology was the gold standard. Seventy-four parathyroids were removed: 65 hyperplasia, 6 adenomas, and 3 normal glands. In the whole population, in a per gland analysis, 18F-FCH PET/CT was significantly more sensitive and accurate (72%, 71%) than neck US (25%, 43%), parathyroid scintigraphy (35%, 47%), and 4D-CT (40%, 47%). The specificity of 18F-FCH PET/CT (69%) was lower than that of neck US (95%) and parathyroid scintigraphy (90%), without, however, achieving significance. 18F-FCH PET/CT was more accurate than all other diagnostic techniques when sHPT and tHPT patients were considered separately. 18F-FCH PET/CT sensitivity was significantly higher in tHPT (88%) than in sHPT (66%). Three ectopic hyperfunctioning glands (in three different patients) were all detected by 18F-FCH PET/CT, two by parathyroid scintigraphy, and none by cervical US and 4D-CT. Our study confirms that 18F-FCH PET/CT is an effective preoperative imaging option in patients with CKD and HPT. These findings may be of greater importance in patients with tHPT (who could benefit from minimally invasive parathyroidectomy) than in patients with sHPT, who often undergo bilateral cervicotomy. In these cases, preoperative 18F-FCH PET/CT may be helpful in locating ectopic glands and may guide the surgical choice for gland preservation.
Collapse
Affiliation(s)
- Samuel Aymard
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Benjamin Leroy-Freschini
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Ashjan Kaseb
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
- Department of Radiology, College of Medicine, University of Jeddah, Jeddah 23890, Saudi Arabia
| | - David Marx
- Department of Medicine C, Hôpital de Sélestat, 67600 Sélestat, France
- Department of Nephrology and Transplantation, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Mehdi Helali
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Valérie Betz
- Department of Nephology, Hôpital de Colmar, 68024 Colmar, France
- AURAL Dialysis Center, 68000 Colmar, France
| | - Sophie Riehm
- Department of Radiology, Strasbourg University Hospitals, 67098 Strasbourg, France
| | - Michel Vix
- Department of General, Digestive, and Endocrine Surgery, IRCAD-IHU, Strasbourg University Hospitals, 67000 Strasbourg, France
| | - Peggy Perrin
- Department of Nephrology and Transplantation, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Alessio Imperiale
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
- Department of General, Digestive, and Endocrine Surgery, IRCAD-IHU, Strasbourg University Hospitals, 67000 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS, University of Strasbourg, 67093 Strasbourg, France
| |
Collapse
|
13
|
Gulati S, Chumber S, Puri G, Spalkit S, Damle NA, Das CJ. Multi-modality parathyroid imaging: A shifting paradigm. World J Radiol 2023; 15:69-82. [PMID: 37035829 PMCID: PMC10080580 DOI: 10.4329/wjr.v15.i3.69] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/20/2023] [Accepted: 03/01/2023] [Indexed: 03/27/2023] Open
Abstract
The goal of parathyroid imaging in hyperparathyroidism is not diagnosis, rather it is the localization of the cause of hyperparathyroidism for planning the best therapeutic approach. Hence, the role of imaging to accurately and precisely localize the abnormal parathyroid tissue is more important than ever to facilitate minimally invasive parathyroidectomy over bilateral neck exploration. The common causes include solitary parathyroid adenoma, multiple parathyroid adenomas, parathyroid hyperplasia and parathyroid carcinoma. It is highly imperative for the radiologist to be cautious of the mimics of parathyroid lesions like thyroid nodules and lymph nodes and be able to differentiate them on imaging. The various imaging modalities available include high resolution ultrasound of the neck, nuclear imaging studies, four-dimensional computed tomography (4D CT) and magnetic resonance imaging. Contrast enhanced ultrasound is a novel technique which has been recently added to the armamentarium to differentiate between parathyroid adenomas and its mimics. Through this review article we wish to review the imaging features of parathyroid lesions on various imaging modalities and present an algorithm to guide their radiological differentiation from mimics.
Collapse
Affiliation(s)
- Shrea Gulati
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Sunil Chumber
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Gopal Puri
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - Stanzin Spalkit
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - N A Damle
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| | - CJ Das
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi 110029, Delhi, India
| |
Collapse
|
14
|
Luo Y, Jin S, He Y, Fang S, Wang O, Liao Q, Li J, Jiang Y, Zhu Q, Liu H. Predicting multigland disease in primary hyperparathyroidism using ultrasound and clinical features. Front Endocrinol (Lausanne) 2023; 14:1088045. [PMID: 37051192 PMCID: PMC10083379 DOI: 10.3389/fendo.2023.1088045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/26/2023] [Indexed: 03/28/2023] Open
Abstract
Background The identification of multigland disease (MGD) in primary hyperparathyroidism (PHPT) patients is essential for minimally invasive surgical decision-making. Objective To develop a nomogram based on ultrasound (US) findings and clinical factors to predict MGD in PHPT patients. Materials and methods Patients with PHPT who had surgery between March 2021 and January 2022 were consecutively enrolled to this study. Biochemical and clinicopathological data were recorded. US images were analyzed to extract US features for prediction. Logistic regression analyses were used to identify MGD risk factors. A nomogram was constructed based on these factors and its performance evaluated by area under the receiver operating characteristic curve (AUC), calibration curve, Hosmer-Lemeshow tests, and decision curve analysis (DCA). Results A total of 102 PHPT patients were included; 82 (80.4%) had single-gland disease (SGD) and 20 (19.6%) had MGD. Using multivariate analyses, MGD was positively correlated with age (odds ratio (OR) = 1.033, 95% confidence interval (CI): 0.190-4.047), PTH levels (OR = 1.001, 95% CI: 1.000-1.002), multiple endocrine neoplasia type 1 (MEN1) (OR = 29.730, 95% CI: 3.089-836.785), US size (OR = 1.198, 95% CI: 0.647-2.088), and US texture (cystic-solid) (OR = 5.357, 95% CI: 0.499-62.912). MGD was negatively correlated with gender (OR = 0.985, 95% CI: 0.190-4.047), calcium levels (OR = 0.453, 95% CI: 0.070-2.448), and symptoms (yes) (OR = 0.935, 95% CI: 0.257-13.365). The nomogram showed good discrimination with an AUC = 0.77 (0.68-0.85) and good agreement in predicting MGD in PHPT patients. Also, 65 points was recommended as a cut-off value, with specificity = 0.94 and sensitivity = 0.50. Conclusion US was useful in evaluating MGD. Combining US and clinical features in a nomogram showed good diagnostic performance for predicting MGD.
Collapse
Affiliation(s)
- Yanwen Luo
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Siqi Jin
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yudi He
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Song Fang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ou Wang
- Key Laboratory of Endocrinology, Department of Endocrinology, National Commission of Health, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, China
| | - Quan Liao
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jianchu Li
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yuxin Jiang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qingli Zhu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - He Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| |
Collapse
|
15
|
Centello R, Sesti F, Feola T, Sada V, Pandozzi C, Di Serafino M, Pacini P, Cantisani V, Giannetta E, Tarsitano MG. The Dark Side of Ultrasound Imaging in Parathyroid Disease. J Clin Med 2023; 12:jcm12072487. [PMID: 37048571 PMCID: PMC10095081 DOI: 10.3390/jcm12072487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
The diagnosis of parathyroid diseases by imaging still has some intrinsic technical limitations due to the differential diagnosis of different structures of the neck that mimic the parathyroid glands. In this view, ultrasound (US) is an established, low-cost, and non-invasive imaging technique that still represents the first-line approach for evaluating patients with parathyroid disease. The objective of this article is to provide a comprehensive review of the applications of USs in clinical practice, discussing the histopathological and US characteristics of the parathyroid glands in normal and pathological conditions, the advantages of preoperative imaging, and novel updates on the most useful and currently available multiparameter US techniques.
Collapse
|
16
|
Pappachan JM, Lahart IM, Viswanath AK, Borumandi F, Sodi R, Metzendorf MI, Bongaerts B. Parathyroidectomy for adults with primary hyperparathyroidism. Cochrane Database Syst Rev 2023; 3:CD013035. [PMID: 36883976 PMCID: PMC9995748 DOI: 10.1002/14651858.cd013035.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT), a disorder in which the parathyroid glands produce excessive amounts of parathyroid hormone, is most common in older adults and postmenopausal women. While most people with PHPT are asymptomatic at diagnosis, symptomatic disease can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities and reduced quality of life. Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT. However, the benefits and risks of parathyroidectomy compared to simple observation or medical therapy for asymptomatic and mild PHPT are not well established. OBJECTIVES To evaluate the benefits and harms of parathyroidectomy in adults with PHPT compared to simple observation or medical therapy. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, ClinicalTrials.gov and WHO ICTRP from their date of inception until 26 November 2021. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing parathyroidectomy with simple observation or medical therapy for the treatment of adults with PHPT. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. cure of PHPT, 2. morbidity related to PHPT and 3. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. health-related quality of life and 3. hospitalisation for hypercalcaemia, acute renal impairment or pancreatitis. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We identified eight eligible RCTs that included 447 adults with (mostly asymptomatic) PHPT; 223 participants were randomised to parathyroidectomy. Follow-up duration varied from six months to 24 months. Of the 223 participants (37 men) randomised to surgery, 164 were included in the analyses, of whom 163 were cured at six to 24 months (overall cure rate 99%). Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up: 163/164 participants (99.4%) in the parathyroidectomy group and 0/169 participants in the observation or medical therapy group were cured of their PHPT (8 studies, 333 participants; moderate certainty). No studies explicitly reported intervention effects on morbidities related to PHPT, such as osteoporosis, osteopenia, kidney dysfunction, urolithiasis, cognitive dysfunction or cardiovascular disease, although some studies reported surrogate outcomes for osteoporosis and cardiovascular disease. A post-hoc analysis revealed that parathyroidectomy, compared to observation or medical therapy, may have little or no effect after one to two years on bone mineral density (BMD) at the lumbar spine (mean difference (MD) 0.03 g/cm2,95% CI -0.05 to 0.12; 5 studies, 287 participants; very low certainty). Similarly, compared to observation, parathyroidectomy may have little or no effect on femoral neck BMD after one to two years (MD -0.01 g/cm2, 95% CI -0.13 to 0.11; 3 studies, 216 participants; very low certainty). However, the evidence is very uncertain for both BMD outcomes. Furthermore, the evidence is very uncertain about the effect of parathyroidectomy on improving left ventricular ejection fraction (MD -2.38%, 95% CI -4.77 to 0.01; 3 studies, 121 participants; very low certainty). Four studies reported serious adverse events. Three of these reported zero events in both the intervention and control groups; consequently, we were unable to include data from these three studies in the pooled analysis. The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events (RR 3.35, 95% CI 0.14 to 78.60; 4 studies, 168 participants; low certainty). Only two studies reported all-cause mortality. One study could not be included in the pooled analysis as zero events were observed in both the intervention and control groups. Parathyroidectomy compared to observation may have little or no effect on all-cause mortality, but the evidence is very uncertain (RR 2.11, 95% CI 0.20 to 22.60; 2 studies, 133 participants; very low certainty). Three studies measured health-related quality of life using the 36-Item Short Form Health Survey (SF-36) and reported inconsistent differences in scores for different domains of the questionnaire between parathyroidectomy and observation. Six studies reported hospitalisations for the correction of hypercalcaemia. Two studies reported zero events in both the intervention and control groups and could not be included in the pooled analysis. Parathyroidectomy, compared to observation, may have little or no effect on hospitalisation for hypercalcaemia (RR 0.91, 95% CI 0.20 to 4.25; 6 studies, 287 participants; low certainty). There were no reported hospitalisations for renal impairment or pancreatitis. AUTHORS' CONCLUSIONS In accordance with the literature, our review findings suggest that parathyroidectomy, compared to simple observation or medical (etidronate) therapy, probably results in a large increase in cure rates of PHPT (with normalisation of serum calcium and parathyroid hormone levels to laboratory reference values). Parathyroidectomy, compared with observation, may have little or no effect on serious adverse events or hospitalisation for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as BMD, all-cause mortality and quality of life. The high uncertainty of evidence limits the applicability of our findings to clinical practice; indeed, this systematic review provides no new insights with regard to treatment decisions for people with (asymptomatic) PHPT. In addition, the methodological limitations of the included studies, and the characteristics of the study populations (mainly comprising white women with asymptomatic PHPT), warrant caution when extrapolating the results to other populations with PHPT. Large-scale multi-national, multi-ethnic and long-term RCTs are needed to explore the potential short- and long-term benefits of parathyroidectomy compared to non-surgical treatment options with regard to osteoporosis or osteopenia, urolithiasis, hospitalisation for acute kidney injury, cardiovascular disease and quality of life.
Collapse
Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- University of Manchester Medical School, Manchester, UK
| | - Ian M Lahart
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | | | - Farzad Borumandi
- Department of Oral and Maxillofacial Surgery, University Hospitals Sussex NHS Foundation Trust, St. Richard's Hospital, Chichester and Worthing Hospital, Worthing, UK
| | - Ravinder Sodi
- Biochemistry, Pathology Department, Broomfield Hospital, Mid & South Essex NHS Foundation Trust, Chelmsford, UK
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Brenda Bongaerts
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
17
|
Localization Strategy Prior to Radiofrequency Ablation for Primary and Secondary Hyperparathyroidism. Biomedicines 2023; 11:biomedicines11030672. [PMID: 36979651 PMCID: PMC10045656 DOI: 10.3390/biomedicines11030672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 02/17/2023] [Accepted: 02/20/2023] [Indexed: 02/25/2023] Open
Abstract
Objective: Preoperative localization in patients with primary or secondary hyperparathyroidism before radiofrequency ablation (RFA) is crucial. There is currently a lack of consensus regarding imaging protocol. Evaluating the diagnostic performance of ultrasound, four-dimensional computed tomography (4D-CT), and technetium 99m-sestamibi single-photon-emission-computed tomography/computed tomography (SPECT/CT) is necessary for RFA of hyperparathyroidism. Methods: This retrospective study recruited patients with primary or secondary hyperparathyroidism who underwent ultrasound, 4D-CT, and SPECT/CT before RFA at a single institution. The sensitivity, accuracy, and receiver operating characteristic curve analysis were used to evaluate the diagnostic performance of the imaging modalities. Results: A total of 33 patients underwent RFA for hyperparathyroidism (8 patients with primary hyperparathyroidism, 25 patients with secondary hyperparathyroidism). Ultrasound had the highest sensitivity (0.953) and accuracy (0.943), while 4D-CT had higher sensitivity and accuracy than SPECT/CT (sensitivity/accuracy, 4D-CT vs. SPECT/CT: 0.929/0.920 vs. 0.741/0.716). Combined ultrasound with 4D-CT and the three combined modalities achieved equivalent, and the highest, diagnostic performance (sensitivity 1.000, accuracy 0.989). The lesion length and volume were important predictors of the diagnostic performance of 4D-CT and SPECT/CT (area under curve of length in 4D-CT/volume in 4D-CT/length in SPECT/volume in SPECT: 0.895/0.834/0.767/0.761). Conclusion: Combined ultrasound with 4D-CT provides optimal preoperative localization prior to RFA in patients with primary or secondary hyperparathyroidism. The length and volume of parathyroid lesions are determinative of the diagnostic performance of 4D-CT and SPECT/CT.
Collapse
|
18
|
Singhal T, Singh P, Veerwal H, Narayan ML. The Vital Role of 131I-MIBG in Localization of Paraganglioma at Unusual Sites. World J Nucl Med 2022; 21:251-254. [PMID: 36060086 PMCID: PMC9436520 DOI: 10.1055/s-0042-1751054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Paragangliomas (PGLs) are extra-adrenal neuroendocrine tumors. PGL of the urinary bladder are very rare and commonly present with features of hypertensive crisis, headache, syncope, and other symptoms of sympathetic excess. A few of these tumors are silent at the presentation. Here, we report a case of a urinary bladder PGL, presenting with lower abdominal pain.
Collapse
Affiliation(s)
- Tejasvini Singhal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Parneet Singh
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Hardik Veerwal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Manishi L Narayan
- Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| |
Collapse
|
19
|
Zajíčková K, Včelák J, Lešková Z, Grega M, Goltzman D, Zogala D. Multiglandular Parathyroid Disease in Primary Hyperparathyroidism With Inconclusive Conventional Imaging. Physiol Res 2022; 71:233-240. [PMID: 35275696 PMCID: PMC9150553 DOI: 10.33549/physiolres.934851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/14/2022] [Indexed: 11/25/2022] Open
Abstract
Inconclusive preoperative imaging is a strong predictor of multiglandular parathyroid disease (MGD) in patients with primary hyperparathyroidism (PHPT). MGD was investigated in a cohort of 17 patients with PHPT (mean age 64.9 years, total calcium 2.75 mmol/l and parathyroid hormone (PTH) 113.3 ng/l) who underwent 18F-fluorocholine PET/CT (FCH) imaging before surgery. The initial MIBI SPECT scintigraphy (MIBI) and/or neck ultrasound were not conclusive or did not localize all pathological parathyroid glands, and PHPT persisted after surgery. Sporadic MGD was present in 4 of 17 patients with PHPT (24 %). In 3 of 4 patients with MGD, FCH correctly localized 6 pathological parathyroid glands and surgery was successful. Excised parathyroid glands were smaller (p <0.02) and often hyperplastic in MGD than in single gland disease. In two individuals with MGD, excision of a hyperplastic parathyroid gland led to a false positive decline in intraoperative PTH and/or postoperative serum calcium. Although in one patient it was associated with partial false negativity, parathyroid imaging with FCH seemed to be superior to neck ultrasound and/or MIBI scintigraphy in MGD.
Collapse
Affiliation(s)
- K Zajíčková
- Institute of Nuclear Medicine, First Faculty of Medicine, Charles University and the General University Hospital, Prague, Czech Republic.
| | | | | | | | | | | |
Collapse
|
20
|
Zarei A, Karthik S, Chowdhury F, Patel C, Scarsbrook A, Vaidyanathan S. Multimodality imaging in primary hyperparathyroidism. Clin Radiol 2022; 77:e401-e416. [DOI: 10.1016/j.crad.2022.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/25/2022] [Indexed: 11/16/2022]
|
21
|
Obołończyk Ł, Karwacka I, Wiśniewski P, Sworczak K, Osęka T. The Current Role of Parathyroid Fine-Needle Biopsy (P-FNAB) with iPTH-Washout Concentration (iPTH-WC) in Primary Hyperparathyroidism: A Single Center Experience and Literature Review. Biomedicines 2022; 10:biomedicines10010123. [PMID: 35052802 PMCID: PMC8773275 DOI: 10.3390/biomedicines10010123] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 02/04/2023] Open
Abstract
Introduction. Primary hyperparathyroidism (PHPT) is a condition characterized by disorders of calcium–phosphate metabolism and bone metabolism caused by pathological overproduction of parathyroid hormone (PTH). The diagnosis of overt PHPT is based on the presence of clinical symptoms and laboratory abnormalities typical of this condition: hypercalcemia, hypercalciuria and elevated iPTH levels. Imaging studies are not used for diagnostic purposes; they are performed to localize the parathyroid glands prior to potential surgical treatment. Technetium 99 m sestamibi scintigraphy (Tc99 m-MIBI) is the gold standard in the assessment of pathologically altered parathyroid glands. Other diagnostic options include cervical ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET). Parathyroid biopsy (P-FNAB) with iPTH washout concentration (iPTH-WC) assessment is still an underestimated method of preoperative parathyroid gland localization. Few studies have reported the utility of US-guided P-FNAB in preoperative assessment of parathyroid lesions. The aim of the study was to present our experience with 143 P-FNAB with iPTH-WC assessment. Material and methods. Laboratory results, US findings, P-FNAB complications and comparison with other imaging techniques were described and analyzed. Results. In 133 (93.0) patients, iPTH washout-to-serum ratio exceeded threshold level 0.5 and were classified as positive results. Median iPTH-WC in this group was 16,856 pg/mL, and the iPTH-WC to serum iPTH ratio was 158. There was no correlation between iPTH-WC and serum PTH, serum calcium, parathyroid gland volume and shape index. In the group of 46 operated patients, 44 demonstrated positive iPTH-WC results, which corresponds to a sensitivity of 95.6%. In Tc99-MIBI, radiotracer retention was found in 17 cases (in 24 MIBI performed), which corresponds to a sensitivity of 52.2%. P-FNAB did not cause any major side effects −92.5% of all patients had no or mild adverse events after this procedure. Conclusions. P-FNAB with iPTH-WC is a reliable method in parathyroid adenoma localization during PHPT. Its sensitivity for diagnosis of PHPT is much higher than that of Tc99-MIBI, and in some situations, P-FNAB with iPTH-WC may even replace that method. Furthermore, cost-effectiveness of iPTH-WC is at least similar to that of Tc99-MIBI. Complications of P-FNAB are mild and we can describe this method as a safe procedure.
Collapse
Affiliation(s)
- Łukasz Obołończyk
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdansk, Poland; (Ł.O.); (P.W.); (K.S.)
| | - Izabela Karwacka
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdansk, Poland; (Ł.O.); (P.W.); (K.S.)
- Correspondence:
| | - Piotr Wiśniewski
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdansk, Poland; (Ł.O.); (P.W.); (K.S.)
| | - Krzysztof Sworczak
- Department of Endocrinology and Internal Medicine, Medical University of Gdańsk, 80-210 Gdansk, Poland; (Ł.O.); (P.W.); (K.S.)
| | - Tomasz Osęka
- Independent Public Healthcare Center of the Ministry of Interior and Administration in Gdańsk, Department of Surgery, 80-104 Gdansk, Poland;
| |
Collapse
|
22
|
Imaging of parathyroid adenomas by gamma camera. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
23
|
Contrast-Enhanced Ultrasound Qualitative and Quantitative Characteristics of Parathyroid Gland Lesions. Medicina (B Aires) 2021; 58:medicina58010002. [PMID: 35056309 PMCID: PMC8778856 DOI: 10.3390/medicina58010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Objectives: preoperative differentiation of enlarged parathyroid glands may be challenging in conventional B-mode ultrasound. The aim of our study was to analyse qualitative and quantitative characteristics of parathyroid gland lesions, using multiparametric ultrasound protocol—B-mode, Colour Doppler (CD), and contrast-enhanced ultrasound (CEUS)—and to evaluate correlation with morphology in patients with hyperparathyroidism (HPT). Materials and Methods: consecutive 75 patients with 88 parathyroid lesions and biochemically confirmed HPT prior to parathyroidectomy were enrolled in the prospective study. B-mode ultrasound, CD, and CEUS were performed with the subsequent qualitative and quantitative evaluation of acquired data. We used 1 mL or 2 mL of intravenous ultrasound contrast agent during the CEUS examination. Correlation with post-surgical morphology was evaluated. Results: seventy parathyroid adenomas were hypoechoic and well contoured with increased central echogenicity (44.3%), peripheral-central vascularization (47%), and polar feeding vessel (100%). Twelve hyperplasias presented with similar ultrasound appearance and were smaller in volume (p = 0.036). Hyperplasias had a tendency for homogenous, marked intense enhancement vs. peripherally enhanced adenomas with central wash-out in CEUS after quantitative analysis. No significant difference was observed in contrasting dynamics, regardless of contrast media volume use (1 mL vs. 2 mL). We achieved 90.9% sensitivity and 72.7% specificity, 93% positive predictive value (PPV), 87.3% negative predictive value (NPV), and 87.3% accuracy in the differentiation of parathyroid lesions prior to post-processing. In a quantitative lesion analysis, our sensitivity increased up to 98%, specificity 80%, PPV 98%, and NPV 80% with an accuracy of 96.4%. Conclusions: CEUS of parathyroid lesions shows potential in the differentiation of adenoma from hyperplasia, regardless of the amount of contrast media injected. The quantitative analysis improved the sensitivity and specificity of differentiation between parathyroid lesions. Hyperplasia was characterized by homogeneous enhancement, fast uptake, and homogeneous wash-out appearance; adenoma—by peripheral uptake, central wash-out, and reduced hemodynamics. The use of CEUS quantification methods are advised to improve the ultrasound diagnostic role in suspected parathyroid lesions.
Collapse
|
24
|
Abstract
Sporadic primary hyperparathyroidism is a common endocrinopathy, particularly afflicting postmenopausal women and both African American men and women. Although classic signs and symptoms of the disease are well appreciated and described, because of the ease and availability and low threshold for screening, the disorder often is diagnosed in patients who are minimally symptomatic or asymptomatic. Surgery conducted by experienced endocrine surgeons has a high cure rate, particularly if guided by concordant imaging. In patients who cannot safely undergo surgery or who fail to be cured, medical therapy with the oral calcimimetic cinacalcet is a validated option for controlling serum calcium levels.
Collapse
Affiliation(s)
- Stephanie J Kim
- Division of Endocrinology and Metabolism, University of California, 400 Parnassus Avenue A549, San Francisco, CA 94143, USA.
| | - Dolores M Shoback
- Endocrine Research Unit - 111N, San Francisco Department of Veterans Affairs Medical Center, Division of Endocrinology and Metabolism, San Francisco VA Medical Center, University of California, 1700 Owens Street, 3rd floor Room 369, San Francisco, CA 94158, USA
| |
Collapse
|
25
|
Zander D, Bunch PM, Policeni B, Juliano AF, Carneiro-Pla D, Dubey P, Gule-Monroe MK, Hagiwara M, Hoang JK, Jain V, Kim LT, Moonis G, Parsons MS, Rath TJ, Solórzano CC, Subramaniam RM, Taheri MR, DuChene Thoma K, Trout AT, Zafereo ME, Corey AS. ACR Appropriateness Criteria® Parathyroid Adenoma. J Am Coll Radiol 2021; 18:S406-S422. [PMID: 34794597 DOI: 10.1016/j.jacr.2021.08.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 08/28/2021] [Indexed: 12/20/2022]
Abstract
Hyperparathyroidism is defined as excessive parathyroid hormone production. The diagnosis is made through biochemical testing, in which imaging has no role. However, imaging is appropriate for preoperative parathyroid gland localization with the intent of surgical cure. Imaging is particularly useful in the setting of primary hyperparathyroidism whereby accurate localization of a single parathyroid adenoma can facilitate minimally invasive parathyroidectomy. Imaging can also be useful to localize ectopic or supernumerary parathyroid glands and detail anatomy, which may impact surgery. This document summarizes the literature and provides imaging recommendations for hyperparathyroidism including primary hyperparathyroidism, recurrent or persistent primary hyperparathyroidism after parathyroid surgery, secondary hyperparathyroidism, and tertiary hyperparathyroidism. Recommendations include ultrasound, CT neck without and with contrast, and nuclear medicine parathyroid scans. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- David Zander
- Chief, Head and Neck Radiology, University of Colorado Denver, Denver, Colorado.
| | - Paul M Bunch
- Research Author, Wake Forest School of Medicine, Winston Salem, North Carolina
| | - Bruno Policeni
- Panel Chair; and Director, Research and Academic Affairs, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Amy F Juliano
- Panel Vice-Chair, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts; and ACR Chair, NI-RADS Committee
| | - Denise Carneiro-Pla
- Medical University of South Carolina, Charleston, South Carolina; American Thyroid Association
| | | | - Maria K Gule-Monroe
- Medical Director, Division of Imaging, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Mari Hagiwara
- New York University Langone Medical Center, New York, New York; and Secretary, Eastern Neuroradiological Society
| | | | - Vikas Jain
- Associate Radiology Residency Program Director, MetroHealth Medical Center, Cleveland, Ohio
| | - Lawrence T Kim
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; American College of Surgeons
| | - Gul Moonis
- Columbia University Medical Center, New York, New York
| | | | - Tanya J Rath
- Director, Neuroradiology Division Education, Mayo Clinic Arizona, Phoenix, Arizona; and President, Eastern Neuroradiological Society
| | - Carmen C Solórzano
- Vanderbilt University Medical Center, Nashville, Tennessee; Society of Surgical Oncology
| | - Rathan M Subramaniam
- University of Otago, Dunedin, Otepoti, New Zealand; and PET Center of Excellence, Society of Nuclear Medicine and Molecular Imaging
| | - M Reza Taheri
- George Washington University Hospital, Washington, District of Columbia
| | | | - Andrew T Trout
- Director, Radiology Clinical Research, Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; JRCNMT, Board Member and Vice-Chair; and ACR representative
| | - Mark E Zafereo
- Associate Medical Director, Head & Neck Center, The University of Texas MD Anderson Cancer Center, Houston, Texas; American Academy of Otolaryngology-Head and Neck Surgery
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
| |
Collapse
|
26
|
Zheng Y, Chi X, Qi Y, Jiang Y, Huang K, He Y, Wang S, Li G. [Preoperative diagnostic value of 99mTc- MIBI SPECT/CT imaging combined with semiquantitative analysis in hyperparathyroidism and factors affecting its efficacy]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2021; 41:1577-1582. [PMID: 34755675 DOI: 10.12122/j.issn.1673-4254.2021.10.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the diagnostic efficacy of technetium-99m methoxyisobutylisonitrile single photon emission/ computed tomography (99mTc- MIBI SPECT/CT), 99mTc- MIBI double- phase scintigraphy (DPS) DPS and ultrasound (US) in preoperative localization of hyperparathyroidism (HPT) and explore the factors affecting the diagnostic efficacy of 99mTc-MIBI SPECT/CT. METHODS We retrospectively analyzed the data of 104 patients with HPT undergoing surgical resection between January, 2015 and July, 2019. Preoperative 99mTc-MIBI imaging was performed in all the patients, and 82 patients also received US examination preoperatively. Semi-quantitative analysis was used to draw the region of interest and calculate the lesion/ ipsilateral deltoid muscle (T/NT) uptake ratio. The sensitivity and detection performance of 99mTc-MIBI SPECT/CT, DPS and US in the diagnosis of HPT patients were compared, and the correlations of the T/NT ratios of parathyroid adenoma (PA) and parathyroid hyperplasia (PH) with the expression levels of COX-2 and Bcl-2 were analyzed. RESULTS The diagnostic sensitivity of 99mTc- MIBI SPECT/CT, DPS and US for HPT was 95.19% (99/104), 91.3% (95/104) and 81.71% (67/82), respectively, demonstrating a significantly higher diagnostic sensitivity of 99mTc-MIBI SPECT/CT than US (χ2=9.59, P=0.008). For PH lesions, 99mTc-MIBI SPECT/CT had the highest diagnostic sensitivity, followed by DPS and then by US (P < 0.05), but their sensitivity did not differ significantly for PA (P>0.05). The T/NT ratio in fatty hyperplastic glands was significantly lower than that in fat-free hyperplastic glands (P=0.009). In PA, Bcl-2 expression was significantly lower in false negative lesions than in true positive lesions (P=0.046), but Cox-2 expression did not show such a difference (P>0.05). In PH lesions, the expressions of Bcl-2 and Cox- 2 did not differ significantly between false negative than true positive lesions (P>0.05). CONCLUSIONS 99mTc-MIBI SPECT/CT has a high sensitivity for HPT localization, and the T/NT ratio is positively correlated with the lesion volume. An increased expression of Bcl-2 in PA lesions and a decreased cell fat content in PH lesions can facilitate the detection of HPT glands by 99mTc-MIBI SPECT/CT.
Collapse
Affiliation(s)
- Y Zheng
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - X Chi
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Y Qi
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Y Jiang
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - K Huang
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Y He
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - S Wang
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - G Li
- Department of Nuclear Medicine, Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| |
Collapse
|
27
|
Kuo LE, Bird SH, Lubitz CC, Pandian TK, Parangi S, Stephen AE. Four-dimensional computed tomography (4D-CT) for preoperative parathyroid localization: A good study but are we using it? Am J Surg 2021; 223:694-698. [PMID: 34579935 DOI: 10.1016/j.amjsurg.2021.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 08/24/2021] [Accepted: 09/16/2021] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- Lindsay E Kuo
- Department of Surgery, Temple University Lewis Katz School of Medicine, Philadelphia, PA, USA.
| | - Sarah H Bird
- Codman Center for Clinical Effectiveness in Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Carrie C Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - T K Pandian
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Sareh Parangi
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Antonia E Stephen
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
28
|
Burkhardt SJ, Sumner JP, Mann S. Ambidirectional cohort study on the agreement of ultrasonography and surgery in the identification of parathyroid pathology, and predictors of postoperative hypocalcemia in 47 dogs undergoing parathyroidectomy due to primary hyperparathyroidism. Vet Surg 2021; 50:1379-1388. [PMID: 34365655 PMCID: PMC9290980 DOI: 10.1111/vsu.13707] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 07/17/2021] [Accepted: 07/25/2021] [Indexed: 02/01/2023]
Abstract
Objective To investigate (1a) agreement of ultrasonographic, surgical, and histopathologic findings in the diagnosis of a neoplastic etiology underlying primary hyperparathyroidism (PHPT), (1b) the ability of ultrasonographically determined parathyroid gland size to distinguish between malignant (carcinoma) and non‐malignant (hyperplasia, adenoma) pathology, and (2) variables associated with postoperative hypocalcemia in dogs undergoing surgical treatment of PHPT. Study Design Ambidirectional cohort study. Animals Forty‐seven client owned dogs with PHPT (34 retrospective; 13 prospective). Methods Data were extracted from medical records. Method agreements were explored using Cohen's Kappa statistic. A receiver operating characteristic curve (ROC) was used to determine a cut‐off separating parathyroid pathologies. Univariable and multivariable models assessed associations between postoperative hypocalcemia and potential risk factors. Results Agreement of ultrasound and surgery for number and side of affected glands was 31/47 (65.9%) and 34/47 (72.3%), respectively. In 37/47 (78.7%) cases, parathyroid tissue was correctly assessed as pathologic by the surgeon. An ultrasonographic cut‐off of ≥8.0 mm (ROC AUC = 0.82) best distinguished malignant from benign pathologies. Dogs with a preoperative serum ionized calcium (iCa) concentration ≥1.75 mEq/L had 7.5 times greater odds of becoming hypocalcemic postoperatively. Conclusion A fair agreement existed between ultrasonographic and surgical findings in dogs with PHPT. A parathyroid mass ≥8.0 mm on ultrasonographic examination was suggestive of malignancy, while dogs with a preoperative serum iCa concentration ≥1.75 mEq/L were at increased risk for postoperative hypocalcemia in this study. Clinical significance This study supports the use of bilateral cervical surgical exploration to identify abnormal parathyroid glands for the treatment of PHPT.
Collapse
Affiliation(s)
- Samuel J Burkhardt
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, United States
| | - Julia P Sumner
- Department of Clinical Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, United States
| | - Sabine Mann
- Department of Population Medicine and Diagnostic Sciences, Cornell University College of Veterinary Medicine, Ithaca, New York, United States
| |
Collapse
|
29
|
Primary Hyperparathyroidism in Pregnancy: Literature Review of the Diagnosis and Management. J Clin Med 2021; 10:jcm10132956. [PMID: 34209340 PMCID: PMC8268799 DOI: 10.3390/jcm10132956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 06/26/2021] [Accepted: 06/28/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Parathyroid disease is uncommon in pregnancy. During pregnancy, multiple changes occur in the calcium regulating hormones which may make the diagnosis of primary hyperparathyroidism more challenging. Close monitoring of serum calcium during pregnancy is necessary in order to optimize maternal and fetal outcomes. In this review, we will describe the diagnosis and management of primary hyperparathyroidism during pregnancy. Methods: We searched MEDLINE, CINAHL, EMBASE and Google scholar bases from 1 January 1990 to 31 December 2020. Case reports, case series, book chapters and clinical guidelines were included in this review. Conclusions: Medical management options for primary hyperparathyroidism during pregnancy are severely limited due to inadequate safety data with the various potential therapies available, and surgery is advised during the 2nd trimester of pregnancy in the presence of severe hypercalcemia (calcium adjusted for albumin greater than 3.0 mmol/L (12.0 mg/dL)). Hypercalcemia should be avoided during pregnancy in order to minimize maternal and fetal complications.
Collapse
|
30
|
Pediatric hyperparathyroidism: review and imaging update. Pediatr Radiol 2021; 51:1106-1120. [PMID: 33904951 DOI: 10.1007/s00247-021-05050-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/26/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
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.
Collapse
|
31
|
Aksoy SÖ, Adiyaman SC, Çevlik AD, Güray Durak M, Seçil M, Sevinç Aİ. Intra-operative parathyroid hormone evaluation is superior to frozen section analysis in parathyroid surgery. Am J Otolaryngol 2021; 42:102886. [PMID: 33460974 DOI: 10.1016/j.amjoto.2020.102886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 12/26/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Surgery is currently the only treatment option for patients with primary hyperparathyroidism (PHPT). Recently, minimally invasive parathyroidectomy (MIP) has begun to replace traditional bilateral neck exploration (BNE). OBJECTIVE The aim of this study is to compare the results of parathyroidectomies performed in our hospital over the past decade that were guided by intra-operative parathyroid hormone (IOPTH) sampling or frozen section (FS) analysis. MATERIAL AND METHODS Data on 697 patients who underwent parathyroidectomies in the Department of Endocrine Surgery, Dokuz Eylul University between January 2005 and 2018 were included in this study. Patients with malignancies other than thyroid papillary microcarcinoma and parathyroid cancer were excluded from the study. RESULTS The concomitant use of neck ultrasound (US) and technetium 99m Sestamibi (99mTc MIBI) scintigraphy successfully localized the hyperfunctioning parathyroid glands in nearly 96% of cases. As compared with the IOPTH group, the operation time was longer in the FS group (p < 0.001), and the need for postoperative calcium (Ca) supplementation was higher (p < 0.001). The duration of hospitalization (days) was significantly higher in the FS group (4.2 ± 3.4 vs. 2.6 ± 1.9) as compared with that in the IOPTH group (p < 0.001). In addition, the recurrence rate in the FS group was significantly higher than that in the IPOTH group (p = 0.002). CONCLUSION IOPTH sampling is a safe and effective method when performed by experienced surgeons and with appropriate preoperative screening. This study emphasizes that IOPTH sampling. We believe that the success in parathyroid surgery is due to three factors: correct indication, accurate localization and experienced surgeon.
Collapse
|
32
|
Filser B, Uslar V, Weyhe D, Tabriz N. Predictors of adenoma size and location in primary hyperparathyroidism. Langenbecks Arch Surg 2021; 406:1607-1614. [PMID: 33928428 PMCID: PMC8370949 DOI: 10.1007/s00423-021-02179-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/18/2021] [Indexed: 12/14/2022]
Abstract
Purpose In primary hyperparathyroidism (PHPT), intraoperative localization of the parathyroid adenoma can be challenging, especially in cases of negative preoperative imaging. Since a focused unilateral parathyroidectomy has benefits compared to a conventional bilateral neck exploration, the question arises whether adenoma size prediction can facilitate a targeted approach. We investigated whether single parathyroid adenoma size can be estimated using preoperative parathyroid hormone (PTH), calcium, and phosphate in patients with PHPT. Preoperative imaging accuracy was evaluated. Methods The data of 156 patients who underwent curative parathyroidectomy for single adenoma PHPT were analyzed retrospectively. Information obtained included laboratory data, imaging results, intraoperative data, and final pathology. Imaging accuracy was analyzed descriptively. The association between preoperative biochemical markers and adenoma dimensions was investigated using Spearman’s correlation coefficient and multivariable regression modeling. Results Cervical ultrasound correctly predicted adenoma laterality in 95.5%, sestamibi scintigraphy in 80.6%, both had lower true-positive rates for quadrant prediction. Patients with negative imaging results showed higher thyroid volumes than those with positive results. Adenoma volume was positively correlated with preoperative PTH (p < 0.001) and calcium (p < 0.001) and negatively correlated with preoperative phosphate (p = 0.001). Using these preoperative biochemical markers and patient age and BMI, adenoma volume can be significantly predicted using the multivariable regression algorithm. Conclusion Cervical ultrasound is superior to scintigraphy for predicting adenoma location and should be the first-choice imaging method, but both methods may be limited by increased thyroid volume. Large adenomas are more likely with higher PTH, higher calcium, and lower phosphate levels. In cases of undetermined adenoma location, an estimation of adenoma volume via our algorithm could corroborate sonographic volume measurements of the suspected adenoma.
Collapse
Affiliation(s)
- Barbara Filser
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany.
| | - Verena Uslar
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany
| | - Dirk Weyhe
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany
| | - Navid Tabriz
- Medical Campus University of Oldenburg, School of Medicine and Health Sciences, University Hospital for Visceral Surgery, Pius-Hospital Oldenburg, Georgstr. 12, 26121, Oldenburg, Germany
| |
Collapse
|
33
|
Tay D, Das JP, Yeh R. Preoperative Localization for Primary Hyperparathyroidism: A Clinical Review. Biomedicines 2021; 9:biomedicines9040390. [PMID: 33917470 PMCID: PMC8067482 DOI: 10.3390/biomedicines9040390] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 01/02/2023] Open
Abstract
With increasing use of minimally invasive parathyroidectomy (PTx) over traditional bilateral neck exploration in patients with primary hyperparathyroidism (PHPT), accurate preoperative localization has become more important to enable a successful surgical outcome. Traditional imaging techniques such as ultrasound (US) and sestamibi scintigraphy (MIBI) and newer techniques such as parathyroid four-dimension computed tomography (4D-CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) are available for the clinician to detect the diseased gland(s) in the preoperative workup. Invasive parathyroid venous sampling may be useful in certain circumstances such as persistent or recurrent PHPT. We review the diagnostic performance of these imaging modalities in preoperative localization and discuss the advantages and weaknesses of these techniques. US and MIBI are established techniques commonly utilized as first-line modalities. 4D-CT has excellent diagnostic performance and is increasingly performed in first-line setting and as an adjunct to US and MIBI. PET and MRI are emerging adjunct modalities when localization has been equivocal or failed. Since no evidence-based guidelines are yet available for the optimal imaging strategy, clinicians should be familiar with the range and advancement of these techniques. Choice of imaging modality should be individualized to the patient with consideration for efficacy, expertise, and availability of such techniques in clinical practice.
Collapse
Affiliation(s)
- Donovan Tay
- Department of Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore;
| | - Jeeban P. Das
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Randy Yeh
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
- Correspondence:
| |
Collapse
|
34
|
Yalon T, Neymark M, Rottenberg A, Appelbaum L, Assaf D, Kluger Y, Mazeh H, Mekel M. The Added Value of Technetium-99 m Sestamibi Scan in Patients with Primary Hyperparathyroidism and Positive Ultrasound. World J Surg 2021; 45:2148-2154. [PMID: 33738523 DOI: 10.1007/s00268-021-06066-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Neck ultrasound (US) and Technetium-99 m Sestamibi (MIBI) scan are the most commonly used imaging studies for preoperative localization of parathyroid adenomas. The aim of this study was to determine the added value of MIBI scan and its effect on the operative plan via a hypothetical model where a stepwise approach is conducted and MIBI is considered only after the ultrasound is evaluated. METHODS Patients who underwent parathyroidectomy for primary hyperparathyroidism (PHPT) between 2012 and 2019 at two tertiary centers were included. Data collected included demographic data, preoperative workup, operative findings and follow-up. The added value of MIBI scans was determined for patients with positive ultrasound. RESULTS A total of 513 patients with positive US result and a MIBI scan were included. If a stepwise approach was conducted then MIBI scan would not change the operative plan in 492 (95.9%). Among the remaining 21 patients, MIBI scan would correctly change the ultrasound-based operative plan in only 12 (2.3%) patients, while incorrectly change the plan in 9 (1.8%), resulting in unnecessary exploration of the contralateral side. In patients with sonographic appearance of a parathyroid gland larger than 1.2 cm, MIBI scan would correctly change the operative plan in only 1 of the 287 (0.35%) patients. CONCLUSIONS Our study suggests that the routine use of MIBI scans may have limited added value in patients with PHPT and a positive neck ultrasound, especially in those with adenoma size larger than 1.2 cm. Positive ultrasound alone may be sufficient for the preoperative localization of parathyroid disease.
Collapse
Affiliation(s)
- T Yalon
- Department of General and oncologic Surgery - Surgery C, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel.
| | - M Neymark
- Rambam-Health Care Campus, Haifa, Israel
| | - A Rottenberg
- Hadassah Hebrew-University Medical Center - Mount Scopus Campus, Jerusalem, Israel
| | - L Appelbaum
- Hadassah Hebrew-University Medical Center - Mount Scopus Campus, Jerusalem, Israel
| | - D Assaf
- Department of General and oncologic Surgery - Surgery C, Chaim Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Ramat Gan, Israel
| | - Y Kluger
- Rambam-Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - H Mazeh
- Hadassah Hebrew-University Medical Center - Mount Scopus Campus, Jerusalem, Israel
| | - M Mekel
- Rambam-Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| |
Collapse
|
35
|
Shah R, Gosavi V, Mahajan A, Sonawane S, Hira P, Kurki V, Bal M, Sathe P, Pai P, D'Cruz A, Uchino S, Garale MN, Patil V, Lila A, Shah N, Bandgar T. Preoperative prediction of parathyroid carcinoma in an Asian Indian cohort. Head Neck 2021; 43:2069-2080. [PMID: 33751728 DOI: 10.1002/hed.26677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 02/08/2021] [Accepted: 02/26/2021] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Ravikumar Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Vikrant Gosavi
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Abhishek Mahajan
- Department of Radiodiagnosis and Imaging, Tata Memorial Center, Mumbai, India
| | - Sushil Sonawane
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Priya Hira
- Department of Radiology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Vineeth Kurki
- Department of Radiodiagnosis and Imaging, Tata Memorial Center, Mumbai, India
| | - Munita Bal
- Department of Pathology, Tata Memorial Center, Mumbai, India
| | - Pragati Sathe
- Department of Pathology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Prathamesh Pai
- Department of Head & Neck Surgical Oncology, Tata Memorial Center, Mumbai, India
| | - Anil D'Cruz
- Department of Head & Neck Surgical Oncology, Apollo Hospital, Navi Mumbai, India
| | - Shinya Uchino
- Noguchi Thyroid Clinic and Hospital Foundation, Beppu, Oita, Japan
| | - Mahadeo Namdeo Garale
- Department of General Surgery, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Virendra Patil
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Anurag Lila
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College & KEM Hospital, Mumbai, India
| |
Collapse
|
36
|
Ferrari C, Santo G, Mammucci P, Pisani AR, Sardaro A, Rubini G. Diagnostic Value of Choline PET in the Preoperative Localization of Hyperfunctioning Parathyroid Gland(s): A Comprehensive Overview. Biomedicines 2021; 9:biomedicines9030231. [PMID: 33669104 PMCID: PMC7996619 DOI: 10.3390/biomedicines9030231] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 12/03/2022] Open
Abstract
Hyperparathyroidism is a metabolic disorder characterized by the excessive production of the parathyroid hormone. The diagnosis is based on clinical and laboratory data. In most cases the only treatment is surgery and a correct preoperatory localization of the hyperfunctioning parathyroid gland(s) is essential. Currently, ultrasonography combined with [99mTc]Tc-MIBI parathyroid scintigraphy, optionally associated with single photon emission computed tomography/computed tomography (SPECT/CT), represent the standard preoperative imaging. In recent years, a number of studies have evaluated the potential role of choline positron emission tomography (PET) in hyperparathyroidism with promising results. Most of the recent evidence underlined its higher sensitivity and diagnostic accuracy in the localization of hyperfunctioning parathyroid glands. Choline PET has a higher spatial resolution that is useful for the detection of smaller parathyroid glands and it also has shorter examination times and favorable radiation exposure. These are just a few of the aspects that support it to overcome traditional imaging. Moreover, from the preliminary data, the choline uptake mechanism seems to also have an impact on its better performance. For these reasons, if first used as second level imaging in patients with negative or inconclusive traditional imaging results, several authors have supported its use as a first line investigation. This comprehensive overview aims to provide an accurate description of the preliminary results available in the literature about the use of choline PET/CT in hyperparathyroidism and to compare these results with the performance of traditional imaging methods.
Collapse
Affiliation(s)
- Cristina Ferrari
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Giulia Santo
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Paolo Mammucci
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Antonio Rosario Pisani
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Angela Sardaro
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy
- Correspondence:
| | - Giuseppe Rubini
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| |
Collapse
|
37
|
Foster T, Dy B, Rocco R, Mckenzie T, Thompson G, Wermers R, Lyden M. Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization. Am Surg 2021; 88:254-259. [PMID: 33517698 DOI: 10.1177/0003134821991991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT. METHODS Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization. RESULTS From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings. DISCUSSION Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.
Collapse
Affiliation(s)
- Trenton Foster
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Benzon Dy
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | - Raffaele Rocco
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| | | | | | - Robert Wermers
- Department of Medicine, 6915Mayo Clinic, Rochester, MN, USA
| | - Melanie Lyden
- Department of Surgery, 6915Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
38
|
Maccora D, Caldarella C, Calcagni ML. 11C-Methionine PET/CT in patients with primary hyperparathyroidism and inconclusive pre-operative imaging work-up: diagnostic accuracy and role of semi-quantitative analysis. Ann Nucl Med 2021; 35:469-478. [PMID: 33491131 DOI: 10.1007/s12149-021-01584-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/11/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE 11C-Methionine PET/CT (C-MET) is a promising method in detecting abnormal parathyroid glands in patients with primary hyperparathyroidism (PHPT). The first aim of the study was to evaluate which is the diagnostic role of C-MET in patients with PHPT and inconclusive pre-operative imaging. Second, we aimed to investigate whether C-MET semi-quantitative parameters may reflect biochemical and histological characteristics of involved glands. METHODS Patients with PHPT, undergoing C-MET after an inconclusive pre-operative imaging and having a parathyroid surgery, were retrospectively included. C-MET visual and semi-quantitative assessment was performed. Parameters, as SUVmax, SUVpeak, SUVmean, functional lesion volume (FLV) and total lesion activity (TLA), were measured for each detected lesion; SUVmean, FLV and TLA were calculated on 40-90% thresholds of SUVmax to define SUVmean40-90, FLV40-90 and TLA40-90, respectively. Results were correlated with patients' clinical-laboratory (calcium and PTH values) and histological data (size and weight of excised glands). Mann-Whitney test was used and P value < 0.05 was considered significant. RESULTS Thirty-eight patients (36 female, age: 57.69 ± 15.13 years) were included. Pre-operative median calcium and PTH values were 11.1 mg/dl [interquartile range (IQR) 10.6-11.5] and 154.6 pg/ml (IQR 101.8-227.0), respectively. C-MET showed a parathyroid uptake in 30 out of thirty-eight patients (78.9%). Among 42 nodules excised, C-MET correctly detected the side of the neck (right/left) in 30/42 with sensitivity, specificity and accuracy of 79, 75 and 79%, respectively. C-MET correctly identified the exact position (superior/inferior) in 27/42 with sensitivity, specificity and accuracy of 75, 50 and 71%, respectively. SUVpeak, FLV50-70 and TLA40-70 were significantly (P < 0.05) higher in patients with higher PTH results. The histological size resulted significantly (P < 0.05) higher in abnormal glands with higher SUVmax, SUVpeak, FLV40-80 and TLA40-90, the weight was higher in glands with higher SUVpeak, SUVmean40-50, FLV40-80 and TLA40-90. CONCLUSIONS C-MET showed a good performance in detecting hyperfunctioning parathyroid glands in PHPT patients with inconclusive pre-operative imaging. Semi-quantitative PET-derived parameters closely correlated with PTH as well as with size and weight of the excised gland, thus reflecting some biochemical and histological characteristics of involved glands.
Collapse
Affiliation(s)
- Daria Maccora
- Istituto di Medicina Nucleare, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo Caldarella
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy.
| | - Maria Lucia Calcagni
- Istituto di Medicina Nucleare, Università Cattolica del Sacro Cuore, Rome, Italy.,UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, L.go Agostino Gemelli 8, 00168, Rome, Italy
| |
Collapse
|
39
|
Broome DT, Naples R, Bailey R, Tekin Z, Hamidi M, Bena JF, Morrison SL, Berber E, Siperstein AE, Scharpf J, Skugor M. Use of Preoperative Imaging in Primary Hyperparathyroidism. J Clin Endocrinol Metab 2021; 106:e328-e337. [PMID: 33119066 DOI: 10.1210/clinem/dgaa779] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Indexed: 12/12/2022]
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.
Collapse
Affiliation(s)
- David T Broome
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Robert Naples
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Richard Bailey
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Zehra Tekin
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| | - Moska Hamidi
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - James F Bena
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Shannon L Morrison
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH
| | - Eren Berber
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Allan E Siperstein
- Department of Endocrine Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Joseph Scharpf
- Head and Neck Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Mario Skugor
- Department of Endocrinology, Diabetes & Metabolism, Cleveland Clinic Foundation, Cleveland, OH
| |
Collapse
|
40
|
Zajíčková K, Dvořáková M, Moravcová J, Včelák J, Goltzman D. Familial hypocalciuric hypercalcemia in an index male: grey zones of the differential diagnosis from primary hyperparathyroidism in a 13-year clinical follow up. Physiol Res 2020; 69:S321-S328. [PMID: 33094630 DOI: 10.33549/physiolres.934522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Familial hypocalciuric hypercalcemia (FHH) type 1, caused by a heterozygous inactivating mutation of the gene encoding the calcium-sensing receptor (CaSR), is characterized by mild to moderate hypercalcemia, hypocalciuria and inappropriately normal or elevated parathyroid hormone (PTH). FHH must be differentiated from primary hyperparathyroidism (PHPT) because parathyroidectomy is ineffective in the former. Herein, we report a 39-year-old male patient with a 13-year history of asymptomatic PTH-dependent hypercalcemia (mean calcium of 2.88 mmol/l; reference range 2.15-2.55 mmol/l) and calcium-to-creatinine clearance ratio (Ca/Cr) ranging from 0.007 to 0.0198, which is consistent with either FHH or PHPT. Although a family history of hypercalcemia was negative, and PET-CT with fluorocholine was suggestive of a parathyroid adenoma, genetic analysis of the CaSR gene identified a heterozygous inactivating mutation NM_000388.4:c.1670G>A p. (Gly557Glu) in exon 6 and a polymorphism NM_000388.4:c.1192G>A p. (Asp398Asn) in exon 4. The G557E mutation has been previously reported in a Japanese family in which all family members with the mutation had Ca/Cr below 0.01 consistent with FHH. The biochemical profile of FHH and PHPT may overlap. Our FHH patient with a G557E CaSR mutation illustrates that the differential diagnosis can be difficult in an index case with no family history, (false) positive parathyroid imaging and higher calciuria than expected for FHH. Calcium intake, vitamin D status and bone resorption might have contributed to the Ca/Cr variations over a 13-year clinical follow up. This case thus emphasizes the irreplaceable role of genetic testing of the CaSR gene when clinical evaluation is inconclusive.
Collapse
Affiliation(s)
- K Zajíčková
- Institute of Endocrinology, Prague, Czech Republic.
| | | | | | | | | |
Collapse
|
41
|
Bunch PM, Randolph GW, Brooks JA, George V, Cannon J, Kelly HR. Parathyroid 4D CT: What the Surgeon Wants to Know. Radiographics 2020; 40:1383-1394. [PMID: 32678698 DOI: 10.1148/rg.2020190190] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
Collapse
Affiliation(s)
- Paul M Bunch
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| | - Gregory W Randolph
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| | - Jennifer A Brooks
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| | - Valerie George
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| | - Jennifer Cannon
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| | - Hillary R Kelly
- From the Departments of Radiology (P.M.B.) and General Surgery (J.C.), Wake Forest School of Medicine, Medical Center Boulevard, Winston Salem, NC 27157; Departments of Otolaryngology (G.W.R.) and Radiology (H.R.K.), Massachusetts Eye and Ear, Harvard Medical School, Boston, Mass; Department of Otolaryngology Head and Neck Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Mass (J.A.B.); West Virginia University School of Medicine, Morgantown, WVa (V.G.); and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass (H.R.K.)
| |
Collapse
|
42
|
Demir B, Binnetoglu A, Sahin A, Yavuz DG. Single Center Experience in the Surgical Management of Primary Hyperparathyroidism. Clin Exp Otorhinolaryngol 2020; 13:285-290. [PMID: 32646207 PMCID: PMC7435428 DOI: 10.21053/ceo.2019.01361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/13/2019] [Indexed: 11/22/2022] Open
Abstract
Objectives. As calcium included as a part of routine laboratory screening early diagnosis of primary hyperparathyroidism (PHPT) has been increased. Surgical resection of parathyroid adenoma or hyperplasia still is the mainstay of the treatment for most PHPT patients. The aim of this study was to evaluate of the surgical outcomes of patients with PHPT that referred to our ENT department of our University Hospital for the last 6 years. Methods. One hundred thirty-seven patients with PHPT who underwent parathyroid surgery in our clinic between October 2011 and January 2018 included in this retrospective study. Data on demographics, clinical findings, past medical history, preoperative laboratory values in 3 months, preoperative localizing imaging studies including ultrasonography (USG) and 99mTc-sestamibi (methoxyisobutyl isonitrile, [MIBI]) scan, operative findings, postoperative laboratory values, and pathology reports were recorded. MIBI scan and USG are used as the first-line modalities in our center. Single-photon emission computed tomography was used for challenging situations of re-exploration and ectopic parathyroid pathology. Four-dimensional computed tomography scanning is was preferred as the last imaging modality. Focused unilateral neck exploration (FUNE) was performed with intraoperative frozen section analysis as a routine procedure. Bilateral neck exploration (BNE) was used only in re-exploration, ectopic parathyroid, and with high suspicion of multigland disease. Results. Totally 137 patients (female:male, 3:3; mean age, 54.6±13.2 years) included in the study. Single parathyroid adenoma was found in 108 patients (78.8%). Most common adenoma localization was left inferior parathyroid gland (46.7%). FUNE was performed in 89.8% of the patients and BNE for 10.2% of the patients. Postoperative normocalcemia was reached in 132 patients and permanent hypocalcemia was observed in two patients. Persistence hypercalcemia observed in three patients. Postoperative pathology reports revealed three patients have parathyroid carcinoma. Conclusion. Preoperative imaging modalities is very important in parathyroidectomy surgery. Routine use of preoperative imaging modalities reduced the risk of complications in our clinic.
Collapse
Affiliation(s)
- Berat Demir
- Department of Otorhinolaryngology-Head and Neck Surgery, Pendik Training and Research Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Adem Binnetoglu
- Department of Otorhinolaryngology-Head and Neck Surgery, St. Elizabeth's Medical Center, Brighton, MA, USA
| | - Akın Sahin
- Department of Otorhinolaryngology-Head and Neck Surgery, Pendik Training and Research Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| | - Dilek Gogas Yavuz
- Section of Endocrinology and Metabolism, Pendik Training and Research Hospital, Marmara University Medical Faculty, Istanbul, Turkey
| |
Collapse
|
43
|
18F-Fluorocholine PET and Multiphase CT Integrated in Dual Modality PET/4D-CT for Preoperative Evaluation of Primary Hyperparathyroidism. J Clin Med 2020; 9:jcm9062005. [PMID: 32604786 PMCID: PMC7356908 DOI: 10.3390/jcm9062005] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
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.
Collapse
|
44
|
Tellam JJ, Abdulrasool G, Ciin LCH. Think twice: a rare calcium sensing receptor mutation and a new diagnosis of familial hypocalciuric hypercalcaemia. Endocrinol Diabetes Metab Case Rep 2020; 2020:EDM200004. [PMID: 32698162 PMCID: PMC7354709 DOI: 10.1530/edm-20-0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/29/2020] [Indexed: 11/22/2022] Open
Abstract
SUMMARY Distinguishing primary hyperparathyroidism (PHPT) from familial hypocalciuric hypercalcaemia (FHH) can be challenging. Currently, 24-h urinary calcium is used to differentiate between the two conditions in vitamin D replete patients, with urinary calcium creatinine clearance ratio (UCCR) <0.01 suggestive of FHH and >0.02 supportive of PHPT. A 26-year-old Caucasian gentleman presented with recurrent mild hypercalcaemia and inappropriately normal parathyroid hormone (PTH) following previous parathyroidectomy 3 years prior. He had symptoms of fatigue and light-headedness. He did not have any other symptoms of hypercalcaemia. His previous evaluation appeared to be consistent with PHPT as evidenced by hypercalcaemia with inappropriately normal PTH and UCCR of 0.0118 (borderline low using guidelines of >0.01 consistent with PHPT). He underwent parathyroidectomy and three parathyroid glands were removed. His calcium briefly normalised after surgery, but rose again to pre-surgery levels within 3 months. Subsequently, he presented to our centre and repeated investigations showed 24-h urinary calcium of 4.6 mmol/day and UCCR of 0.0081 which prompted assessment for FHH. His calcium-sensing receptor (CASR) gene was sequenced and a rare inactivating variant was detected. This variant was described once previously in the literature. His mother was also confirmed to have mild hypercalcaemia with hypocalciuria and, on further enquiry, had the same CASR variant. The CASR variant was classified as likely pathogenic and is consistent with the diagnosis of FHH. This case highlights the challenges in differentiating FHH from PHPT. Accurate diagnosis is vital to prevent unnecessary surgical intervention in the FHH population and is not always straightforward. LEARNING POINTS Distinguishing FHH from PHPT with co-existing vitamin D deficiency is difficult as this can mimic FHH. Therefore, ensure patients are vitamin D replete prior to performing 24-h urinary calcium collection. Individuals with borderline UCCR could have either FHH or PHPT. Consider performing CASR gene sequencing for UCCR between 0.01 and 0.02. Parathyroid imaging is not required for making the diagnosis of PHPT. It is performed when surgery is considered after confirming the diagnosis of PHPT.
Collapse
Affiliation(s)
- Jane J Tellam
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- University of Queensland, Herston, Queensland, Australia
| | - Ghusoon Abdulrasool
- Royal Brisbane and Women’s Hospital, Herston, Queensland, Australia
- University of Queensland, Herston, Queensland, Australia
- Pathology Queensland, Australia
| | - Louise C H Ciin
- Gold Coast University Hospital, Southport, Queensland, Australia
- Griffith University, Southport, Queensland, Australia
| |
Collapse
|
45
|
Binnetoğlu A, Demir B, Mamadlı J. Challenges in the Management of Ectopic Parathyroid Pathologies: A Case Series of Five Patients. Turk Arch Otorhinolaryngol 2020; 58:133-136. [PMID: 32783043 DOI: 10.5152/tao.2020.4782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 03/06/2020] [Indexed: 11/22/2022] Open
Abstract
In primary hyperparathyroidism (PHPT) the diagnosis and treatment of ectopic parathyroid adenomas (EPTA) is a challenging process for head and neck surgeons. We present five patients with EPTA in different locations, along with an in-depth discussion of imaging modalities. We used sestamibi scintigraphy (MIBI) and ultrasound as first line imaging tools in asymptomatic hypercalcemia and PHPT. Single photon emission computed tomography (SPECT) was combined with MIBI or computed tomography (CT) if a parathyroid pathology was not localized initially. Four-dimensional parathyroid CT (4D-CT) was the last imaging modality preferred to localize the ectopic parathyroid gland. We performed focused unilateral neck exploration (FUNE) with intraoperative frozen section analysis as a routine procedure for imaging-detected lesions. Bilateral neck exploration was performed for re-exploration cases and imaging-negative cases. Histopathology confirmed EPTA and postoperative serum calcium normalized in all cases. 4D-CT is promising for ectopic parathyroid gland localization if all other imaging modalities fail. Despite the advancements in imaging, surgical experience continues to play the central role in the management of ectopic parathyroid pathologies.
Collapse
Affiliation(s)
- Adem Binnetoğlu
- Department of Otorhinolaryngology-Head and Neck Surgery, Marmara University School of Medicine, Pendik Training and Research Hospital, İstanbul, Turkey
| | - Berat Demir
- Department of Otorhinolaryngology-Head and Neck Surgery, Marmara University School of Medicine, Pendik Training and Research Hospital, İstanbul, Turkey
| | - Javahir Mamadlı
- Department of Otorhinolaryngology-Head and Neck Surgery, Marmara University School of Medicine, Pendik Training and Research Hospital, İstanbul, Turkey
| |
Collapse
|
46
|
de Maissin C, Leclère JC, Roudaut N, Thuillier P, Monguillon P, Marianowski R, Potard G. Evaluation of the performance of ultrasonography and 99mTc-sestamibi scintigraphy for primary hyperparathyroidism surgery. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 137:365-369. [PMID: 32446647 DOI: 10.1016/j.anorl.2020.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Minimally invasive surgery has become the standard surgical attitude in primary hyperparathyroidism. It requires precise preoperative lesion localization. The aim of the present study was to evaluate the performance of ultrasonography and 99mTc-sestamibi scintigraphy in minimally invasive surgery for primary hyperparathyroidism. MATERIALS AND METHODS A retrospective study included all patients managed surgically for primary hyperparathyroidism between January 2008 and November 2017 in the University Hospital of Brest (France). Two hundred and seventy-three patients underwent ultrasonography and 99mTc-sestamibi scintigraphy. Results determined intrinsic (sensitivity and specificity) and extrinsic (positive and negative predictive values) performance on per-patient and per-gland analysis. Demographic, preoperative, interventional and cure data were compared according to ultrasonography and scintigraphy results, distinguishing 3 patient groups: concordant n=156, discordant n=99, negative n=18. RESULTS On per-gland analysis, sensitivity was 70% for ultrasound, 74% for 99mTc-sestamibi scintigraphy and 81% for associated ultrasound-scintigraphy; positive predictive values were 89%, 91% and 96%, respectively. Gland volume and concomitant thyroid pathology rates differed significantly (both p=0.003) between the 3 imaging results groups. CONCLUSION The performance of associated ultrasound-99mTc-sestamibi-scintigraphy provided a positive predictive value of 96%. Combining the two techniques reduced surgical morbidity.
Collapse
Affiliation(s)
- C de Maissin
- Service d'ORL et de Chirurgie Cervico-Faciale, CHU Brest, Brest, France
| | - J-C Leclère
- Service d'ORL et de Chirurgie Cervico-Faciale, CHU Brest, Brest, France.
| | - N Roudaut
- Service Diabétologie, Endocrinologie et Maladies Métaboliques, CHU Brest, Brest, France
| | - P Thuillier
- Service Diabétologie, Endocrinologie et Maladies Métaboliques, CHU Brest, Brest, France
| | - P Monguillon
- Endocrinologist, diabetologist, metabolic diseases specialist, in private practice, Brest, France
| | - R Marianowski
- Service d'ORL et de Chirurgie Cervico-Faciale, CHU Brest, Brest, France
| | - G Potard
- Service d'ORL et de Chirurgie Cervico-Faciale, CHU Brest, Brest, France
| |
Collapse
|
47
|
Baj J, Sitarz R, Łokaj M, Forma A, Czeczelewski M, Maani A, Garruti G. Preoperative and Intraoperative Methods of Parathyroid Gland Localization and the Diagnosis of Parathyroid Adenomas. Molecules 2020; 25:E1724. [PMID: 32283730 PMCID: PMC7181220 DOI: 10.3390/molecules25071724] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/05/2023] Open
Abstract
Accurate pre-operative determination of parathyroid glands localization is critical in the selection of minimally invasive parathyroidectomy as a surgical treatment approach in patients with primary hyperparathyroidism (PHPT). Its importance cannot be overemphasized as it helps to minimize the harmful side effects associated with damage to the parathyroid glands such as in hypocalcemia, severe hemorrhage or recurrent laryngeal nerve dysfunction. Preoperative and intraoperative methods decrease the incidence of mistakenly injuring the parathyroid glands and allow for the timely diagnosis of various abnormalities, including parathyroid adenomas. This article reviews 139 studies conducted between 1970 and 2020 (49 years). Studies that were reviewed focused on several techniques including application of carbon nanoparticles, carbon nanoparticles with technetium sestamibi (99m Tc-MIBI), Raman spectroscopy, near-infrared autofluorescence, dynamic optical contrast imaging, laser speckle contrast imaging, shear wave elastography, and indocyanine green to test their potential in providing proper parathyroid glands' localization. Apart from reviewing the aforementioned techniques, this study focused on the applications that helped in the detection of parathyroid adenomas. Results suggest that applying all the reviewed techniques significantly improves the possibility of providing proper localization of parathyroid glands, and the application of indocyanine green has proven to be the 'ideal' approach for the diagnosis of parathyroid adenomas.
Collapse
Affiliation(s)
- Jacek Baj
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Robert Sitarz
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Marek Łokaj
- Department of Surgery, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Alicja Forma
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Marcin Czeczelewski
- Chair and Department of Forensic Medicine, Medical University of Lublin, 20-950 Lublin, Poland;
| | - Amr Maani
- Chair and Department of Anatomy, Medical University of Lublin, 20-950 Lublin, Poland; (R.S.); (A.F.); (A.M.)
| | - Gabriella Garruti
- Section of Endocrinology, Andrology and Metabolic Diseases, Department of Emergency and Organ Transplantations, University of Bari “Aldo Moro” Medical School, 70124 Bari, Italy;
| |
Collapse
|
48
|
Xue Y, Li W, Xia Z, Lei C, Cao Y, Wang Z, Pang H. The role of 18F-FCH PET/CT in patients with uremic hyperparathyroidism compared with 99mTc-sestaMIBI SPECT/CT and ultrasonography. EJNMMI Res 2019; 9:118. [PMID: 31879808 PMCID: PMC6933043 DOI: 10.1186/s13550-019-0583-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 12/06/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate the diagnostic efficacy of 18F-fluorocholine (18F-FCH) PET/CT for uremic hyperparathyroidism (uHPT) compared to 99mTc-sestaMIBI SPECT/CT and ultrasonography (US). METHODS A total of 17 uHPT patients with stage 5 chronic kidney disease (CKD) were prospectively enrolled. All patients underwent US, 99mTc-sestaMIBI SPECT/CT, and 18F-FCH within 2 months and received surgical treatment. Visual and quantitative methods were used for image analyses. Intraoperative localization and postoperative histological results of the reference standard as well as the sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) of the three modalities were analyzed using Pearson's χ2 tests. In addition, the diagnostic efficacy of 18F-FCH PET/CT for uHPT was evaluated. The relationships between PET parameters and laboratory parameters were assessed using the Spearman correlation coefficient. RESULTS A total of 63 parathyroid hyperplasia lesions were resected in 17 uHPT patients, and 53 lesions were detected using 18F-FCH PET/CT with no false-positive results. The sensitivity, specificity, accuracy, PPV, and NPV were 84.13%, 100%, 86.49%, 100%, and 52.38%, respectively. In comparison, the corresponding values for 99mTc-sestaMIBI SPECT/CT and US were 63.49%, 90.91%, 67.57%, 97.56%, and 30.30% and 61.90%, 81.82%, 64.86%, 95.12%, and 27.27%, respectively. The volume of hyper-functioning parathyroid glands was significantly different between lesions positive in 18F-FCH PET/CT and negative in 18F-FCH PET/CT (mean volume 1.36 ± 0.55 cm3 vs. 0.83 ± 0.26 cm3; P = 0.019). US misidentified intrathyroidal parathyroid hyperplasia as thyroid nodules in three patients, while 18F-FCH PET correctly identified the anatomy. No significant associations were observed between PET parameters and laboratory parameters in uHPT. CONCLUSION 18F-FCH PET/CT was more sensitive and accurate for uHPT than 99mTc-sestaMIBI SPECT/CT and US, and had better preoperative diagnostic efficacy, particularly for lesions diagnosed as a thyroid nodule by US.
Collapse
Affiliation(s)
- Yu Xue
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Wenbo Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Zhu Xia
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Chengming Lei
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Yiyi Cao
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China
| | - Zhengjie Wang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China.
| | - Hua Pang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, People's Republic of China.
| |
Collapse
|
49
|
Aygün N, İşgör A, Uludağ M. The Effectiveness of Preoperative Ultrasonography and Scintigraphy in the Pathological Gland Localization in Primary Hyperparathyroidism Patients. SISLI ETFAL HASTANESI TIP BULTENI 2019; 53:379-384. [PMID: 32377112 PMCID: PMC7192300 DOI: 10.14744/semb.2019.37097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/21/2019] [Indexed: 12/26/2022]
Abstract
OBJECTIVES Primary hyperparathyroidism (pHPT) is a common disease, and its curative treatment is surgical. Nowadays, preoperative localization studies have become standard before surgical treatment, and the first stage imaging methods are ultrasonography and/or scintigraphy. With the contribution of these studies to the localization of the pathological gland, focused surgery has become the first standard of choice. In this study, we aimed to evaluate the efficacy of ultrasonography and scintigraphy in the preoperative localization of the pathologic gland or glands in patients who underwent surgical treatment and cure for pHPT. METHODS In this study; the data of the biochemically diagnosed pHPT patients, who had Tc 99m-MIBI scintigraphy and/or ultrasonography for localisation preoperatively, were evaluated retrospectively. The lesion, which was positive in USG or scintigraphy for localization, was evaluated according to the neck side or neck quadrant, and the results were compared with intraoperative localization findings. The effectiveness of both methods and combinations was evaluated with the localization rates, sensitivity and positive predictive values (PPV). The three methods were compared with the Youden index (J). RESULTS The mean age of 380 patients included in this study was 54.8±12.8 years (20-83). Three hundred eight of them were female, and 72 were male. Scintigraphy was performed in 339 patients, USG was performed in 344 patients, and both USG and scintigraphy were performed in 306 patients. One hundred twenty patients (32%) underwent bilateral neck exploration (BNE), and 260 patients (68.4%) underwent minimally invasive parathyroidectomy (MIP) (unilateral exploration or focused surgery). Single adenoma was detected in 358 (94%), double adenoma in 10 (3%) and hyperplasia in 12 (3%) patients.Localization rates of USG, scintigraphy, USG and scintigraphy combinations were 53%, 74%, 75%; their sensitivity was 56%, 85%, 89%; PPDs were 90%, 86%, 83%. The efficiency of scintigraphy is higher than USG (J: 0.743 vs 0.527). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.743 vs 0.754).The localization rates of USG, scintigraphy, USG and scintigraphy combinations were 46%, 64%, 66%; their sensitivity was 51%, 83%, 88%; PPDs were 79%, 74%, 73%. The efficiency of scintigraphy is higher than that of USG (J: 0.64 vs 0.427). The contribution of scintigraphy to USG in combination with USG was limited (J: 0.64 vs 0.66). CONCLUSION In patients with pHPT, scintigraphy is a more effective method for USG as the first step preoperative imaging and should be preferred as the first method if there is no contraindication. A combination of scintigraphy with USG may contribute minimally to the efficacy of scintigraphy. It may be advantageous for early detection of the pathologic gland in patients with incompatible two imaging and initiating surgery on the positive side of the first scintigraphy. Scintigraphy and USG methods may allow successful MRP surgery in the majority of patients with pHPT.
Collapse
Affiliation(s)
- Nurcihan Aygün
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Adnan İşgör
- Department of General Surgery, Bahcesehir University, Faculty of Medicine, Istanbul, Turkey
| | - Mehmet Uludağ
- Department of General Surgery, Health Sciences University, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| |
Collapse
|
50
|
Maccora D, Rizzo V, Fortini D, Mariani M, Giraldi L, Giordano A, Bruno I. Parathyroid scintigraphy in primary hyperparathyroidism: comparison between double-phase and subtraction techniques and possible affecting factors. J Endocrinol Invest 2019; 42:889-895. [PMID: 30600433 DOI: 10.1007/s40618-018-0996-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/18/2018] [Indexed: 11/26/2022]
Abstract
PURPOSE Parathyroid scintigraphy is superior to other imaging techniques in detecting hyperfunctioning parathyroid glands. It is mainly performed using double-phase or dual-tracer subtraction methods. Neither of the techniques is perfect and different protocols are being used. We aimed to evaluate the accuracy of double-phase and subtraction methods in detecting abnormal gland as well as the potential effects of coexisting thyroid disease and clinical-laboratory data. METHODS We considered patients with primary hyperparathyroidism who underwent parathyroid surgery, after a parathyroid scintigraphy between April 2015 and February 2017. Sixty-eight patients were included; in 45 cases (66.2%), a thyroid disease was coexistent. Diagnostic performances of the two techniques were compared. The effect of thyroid disease and clinical-pathological data on examination interpretation was considered. RESULTS Double-phase scintigraphy showed higher sensitivity and accuracy in detecting the exact abnormal gland compared to the digital subtraction (90% and 75% vs. 76% and 66%, respectively). For double-phase technique, sensitivity and accuracy were higher in cases with no thyroid disease when compared to those with thyroid disease (92% and 86% vs. 88% and 69%, respectively). Similarly, for digital subtraction, sensitivity and accuracy were higher in the absence of thyroid disease compared to their presence (84% and 79% vs. 70% and 58%, respectively). There was no significant variation in the performance of both techniques, considering clinical-laboratory data. CONCLUSIONS Double-phase scintigraphy has been more accurate than digital subtraction. The presence of thyroid disease could be a possible limit, affecting the subtraction more than the double-phase technique. Clinical data did not influence the scintigraphic outcome.
Collapse
Affiliation(s)
- D Maccora
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy.
- Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168, Rome, Italy.
| | - V Rizzo
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
- Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168, Rome, Italy
| | - D Fortini
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
| | - M Mariani
- Institute of Public Health, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168, Rome, Italy
| | - L Giraldi
- Institute of Public Health, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168, Rome, Italy
| | - A Giordano
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
- Institute of Nuclear Medicine, Università Cattolica del Sacro Cuore, L.go F. Vito 1, 00168, Rome, Italy
| | - I Bruno
- UOC di Medicina Nucleare, Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.go A. Gemelli 8, 00168, Rome, Italy
| |
Collapse
|