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Fullerton ZH, Orloff LA. Pearls of Parathyroidectomy: How to Find the Hard to Find Ones. Otolaryngol Clin North Am 2024; 57:125-137. [PMID: 37634984 DOI: 10.1016/j.otc.2023.07.004] [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] [Indexed: 08/29/2023]
Abstract
The treatment of hyperparathyroidism through parathyroidectomy requires careful and complete preoperative evaluation. There are multiple imaging modalities and methods available to clinicians today to aid in identifying a pathological lesion; however, each has limitations that the clinician must understand. A systematic approach to patient evaluation, imaging, and surgical exploration is necessary to ensure accurate diagnosis and maximize the chances of minimally invasive and successful surgical removal.
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Affiliation(s)
- Zoe H Fullerton
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA 94305, USA
| | - Lisa A Orloff
- Department of Otolaryngology-Head and Neck Surgery, Stanford University, 801 Welch Road, Stanford, CA 94305, USA.
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Ilgan S, Aydoğan Bİ, Emer Ö, Anıl C, Gürsoy A, Cesur M, Bilezikçi B. Sonographic Features of Atypical and Initially Missed Parathyroid Adenomas: Lessons Learned From a Single-Center Cohort. J Clin Endocrinol Metab 2024; 109:439-448. [PMID: 37668359 DOI: 10.1210/clinem/dgad527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/01/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
CONTEXT Awareness of typical and atypical ultrasonographic (US) features of parathyroid adenomas (PAs) is crucial since US is the most widely used first-line imaging modality. OBJECTIVE The purpose of this study was to describe the atypical features of PAs on US and other possible factors leading to a false negative examination in a large single-center cohort. MATERIALS AND METHODS The US records of 457 PAs in 445 patients with biochemically proven primary hyperparathyroidism (PHPT) were evaluated in a prospectively maintained database. Atypical size, composition, shape, echogenicity, location, and vascular pattern on US were noted. For patients who previously had at least one negative US examination in referring centers, the main possible reason was defined accordingly. RESULTS The study group included 359 female and 86 male patients with PHPT. Typical sonographic features were observed in 231 PAs (51%), whereas 226 (49%) had at least one atypical US feature. The most common atypical features were atypical size (29%), followed by atypical echogenicity (19%), shape (8%), location (7%), and composition (7%), respectively. There were 122 initially missed PAs in all groups. The most frequent main atypical US features leading to false negative examinations were atypical size (22.1%) and atypical location (18.8%). Inexperience was third most common reason (16.3%) for false negative US examinations. CONCLUSIONS Almost half of PAs have at least one atypical feature on US. Awareness of the high prevalence of atypical US features could increase the accuracy of US examination and potentially decrease demand for more expensive second-line imaging modalities.
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Affiliation(s)
- Seyfettin Ilgan
- Department of Nuclear Medicine, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Berna İmge Aydoğan
- Department of Endocrinology and Metabolism, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Özdeş Emer
- Department of Nuclear Medicine, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Cüneyd Anıl
- Department of Endocrinology and Metabolism, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Alptekin Gürsoy
- Department of Endocrinology and Metabolism, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Mustafa Cesur
- Department of Endocrinology and Metabolism, Ankara Güven Hospital, 06680 Ankara, Turkey
| | - Banu Bilezikçi
- Department of Pathology, Ankara Güven Hospital, 06680 Ankara, Turkey
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4DCT Scanning Technique for Primary Hyperparathyroidism: A Scoping Review. Radiol Res Pract 2021; 2021:6614406. [PMID: 34094599 PMCID: PMC8163538 DOI: 10.1155/2021/6614406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/11/2021] [Accepted: 05/13/2021] [Indexed: 12/27/2022] Open
Abstract
Objective 4DCT for the detection of (an) enlarged parathyroid(s) is a commonly performed examination in the management of primary hyperparathyroidism. Protocols are often institution-specific; this review aims to summarize the different protocols and explore the reported sensitivity and specificity of different 4DCT protocols as well as the associated dose. Materials and Methods A literature study was independently conducted by two radiologists from April 2020 until May 2020 using the Medical Literature Analysis and Retrieval System Online (MEDLINE) database. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize different parameters of the scanning protocol and observed diagnostic attributes. Results A total of 51 articles were included and 56 scanning protocols were identified. Most protocols use three (n = 25) or four different phases (n = 23). Almost all authors include noncontrast enhanced imaging and an arterial phase. Arterial images are usually obtained 25–30 s after administration of contrast, and less agreement exists concerning the timing of the venous phase(s). A mean contrast bolus of 100 mL is administered at 3-4 mL/s. Bolus tracking is not often used (n = 3). A wide range of effective doses are reported, up to 28 mSv. A mean sensitivity of 81.5% and a mean specificity of 86% are reported. Conclusion Many different 4DCT scanning protocols for the detection of parathyroid adenomas exist in the literature. The number of phases does not appear to affect sensitivity or specificity. A triphasic approach, however, seems preferable, as three patterns of enhancement of parathyroid adenomas are described. Bolus tracking could help to reduce the variability of enhancement. Sensitivity and specificity also do not appear to be affected by other scan parameters like tube voltage or tube current. To keep the effective dose within limits, scanning at a lower fixed tube current seems preferable. Lowering tube voltage from 120 kV to 100 kV may yield similar image contrast but would also help lower the dose.
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Detection of parathyroid adenomas with multiphase 4DCT: towards a true four-dimensional technique. BMC Med Imaging 2021; 21:64. [PMID: 33827463 PMCID: PMC8028189 DOI: 10.1186/s12880-021-00597-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
Background Four-dimensional computed tomography (4DCT) is a commonly performed examination in the management of primary hyperparathyroidism, combining three-dimensional imaging with enhancement over time as the fourth dimension. We propose a novel technique consisting of 16 different contrast phases instead of three or four different phases. The main aim of this study was to ascertain whether this protocol allows the detection of parathyroid adenomas within dose limits. Our secondary aim was to examine the enhancement of parathyroid lesions over time. Methods For this prospective study, we included 15 patients with primary hyperparathyroidism and a positive ultrasound prior to surgery. We performed 4DCT with 16 different phases: an unenhanced phase followed by 11 consecutive arterial phases and 4 venous phases. Continuous axial scanning centered on the thyroid was performed over a fixed 8 cm or 16 cm coverage volume after the start of contrast administration. Results In all patients, an enlarged parathyroid lesion was demonstrated, and the mean lesion size was 13.6 mm. The mean peak arterial enhancement for parathyroid lesions was 384 Hounsfield units (HU) compared to 333 HU for the normal thyroid. No significant difference could be found. The time to peak (TTP) was significantly earlier for parathyroid adenomas than for normal thyroid tissue: 30.8 s versus 32.3 s (p value 0.008). The mean slope of increase (MSI) of the enhancement curve was significantly steeper than that of normal thyroid tissue: 29.8% versus 22.2% (p value 0.012). The mean dose length product was 890.7 mGy cm with a calculated effective dose of 6.7 mSv. Conclusion Our 4DCT protocol may allow better visualization of the pattern of enhancement of parathyroid lesions, as enhancement over time curves can be drawn. In this way, wash-in and wash-out of contrast in suspected lesions can be readily demonstrated. Motion artifacts are less problematic as multiple phases are available. Exposure to our proposed 4DCT technique is comparable to that for classic helical 4DCT. Careful selection of parameters (lowering kV and SNR) can help to further reduce the dose.
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Abstract
Primary hyperparathyroidism (PHPT) is a common endocrine abnormality, caused in most cases by a single parathyroid adenoma. Surgery remains the first-line curative therapy in PHPT. Imaging plays a vital role in presurgical localization of parathyroid adenomas. Ultrasound provides a safe and quick imaging modality free of ionizing radiation, but is operator dependent. Sestamibi scan offers comparable sensitivity to ultrasound, improved with concurrent tomographic imaging. 4DCT remains a problem-solving technique in challenging cases and after failed neck exploration. We present an overview of various parathyroid imaging modalities, including protocols and findings, in addition to relevant pearls and pitfalls.
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Affiliation(s)
- Malak Itani
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, St Louis, MO 63110, USA.
| | - William D Middleton
- Mallinckrodt Institute of Radiology, Washington University in St. Louis School of Medicine, 510 South Kingshighway Boulevard, Campus Box 8131, St Louis, MO 63110, USA
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Liu R, Xia Y, Chen C, Ye T, Huang X, Ma L, Hu Y, Jiang Y. Ultrasound combined with biochemical parameters can predict parathyroid carcinoma in patients with primary hyperparathyroidism. Endocrine 2019; 66:673-681. [PMID: 31489590 DOI: 10.1007/s12020-019-02069-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 08/21/2019] [Indexed: 01/03/2023]
Abstract
PURPOSES Parathyroid cancer (PC) is rare, but fatal condition. Preoperative prediction of PC remains challenging but meaningful. The aim of this study was to determine an effective model to predict PC in patients with parathyroid lesions >1.5 cm. METHODS In this retrospective case-control study, we enrolled 30 patients with PC matched to 60 patients with parathyroid adenoma or hyperplasia by admission year. All patients were diagnosed with primary hyperparathyroidism (pHPT) and had parathyroid lesions >1.5 cm. Ultrasonic features of the two patient groups, as well as demographic, clinical, and biochemical characteristics were retrospectively compared. Best subset selection and multivariate logistic regression analysis were conducted to identify the independent risk factors of PC. ROC curve and decision curve analysis were developed to evaluate the applicability of the new model. RESULTS The best subset selection method and multiple logistic regression analysis showed that ultrasonic features of DR (two diameters' ratio of the lesion) and tumor infiltration in conjunction with intact parathyroid hormone (iPTH) level (collective model) were independent predictors of malignancy. Meanwhile, DR, shape, and tumor infiltration (ultrasound model) were found to be risk factors when only ultrasonic features were included in the multivariate analysis. The decision curve analysis showed that collective model outperforms ultrasound model with a better net benefit and a wider range of threshold probabilities. CONCLUSIONS Ultrasonic features in combination with iPTH level may be an applicable model for predicting PC and has a better potential to facilitate decision-making preoperatively.
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Affiliation(s)
- Ruifeng Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Yu Xia
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Cheng Chen
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Tiantian Ye
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Xuepei Huang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Li Ma
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China
| | - Ya Hu
- Department of General Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China.
| | - Yuxin Jiang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Shuaifuyuan 1#, Dongcheng District, 100730, Beijing, China.
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Henegan J, McGrath S, Shah K, Bendinelli C. On the use of autofluorescence for detection of intrathyroidal parathyroid adenoma. ANZ J Surg 2019; 90:916-917. [PMID: 31522459 DOI: 10.1111/ans.15425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 07/25/2019] [Accepted: 07/28/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica Henegan
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Shaun McGrath
- Department of Endocrinology, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Kalpesh Shah
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Cino Bendinelli
- Department of Surgery, John Hunter Hospital, Newcastle, New South Wales, Australia.,Faculty of Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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Triggiani V, Castellana M, Basile P, Renzulli G, Giagulli VA. Parathyroid Carcinoma Causing Mild Hyperparathyroidism in Neurofibromatosis Type 1: A Case Report and Systematic Review. Endocr Metab Immune Disord Drug Targets 2019; 19:382-388. [PMID: 30198445 PMCID: PMC7360910 DOI: 10.2174/1871530318666180910123316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/20/2018] [Accepted: 07/20/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Neurofibromatosis type 1 is an autosomal dominant disorder characterized by an increased incidence of tumors, including endocrine ones. Primary hyperparathyroidism can be rarely caused by a parathyroid carcinoma; these patients are generally characterized by severe symptoms, large neck lesions and high levels of PTH and calcium. We report a case of hyperparathyroidism due to parathyroid carcinoma in a patient affected by neurofibromatosis type 1. A systematic review of the literature was also conducted. PATIENT FINDINGS A 56-year-old woman was referred for a 13 mm-nodular lesion of the neck incidentally discovered on ultrasound examination and mild hyperparathyroidism. A 99mTctetrofosmin/ pertechnetate subtraction scintigraphy was negative for parathyroid disease. Given the absence of suspicious ultrasound finding, a fine-needle aspiration cytology was performed with iPTH determination in the aspirate, confirming the parathyroid origin of the lesion. The patient underwent left inferior parathyroidectomy with intraoperative monitoring of iPTH and became normocalcemic. On histopathological examination, parathyroid carcinoma presenting at the resection margin was diagnosed, thus a surgery revision was requested. CONCLUSION Even if literature does not support a syndromic association between neurofibromatosis type 1 and primary hyperparathyroidism, the benefit of precociously diagnosing and treating this condition may outweigh costs associated with screening. This case report moreover demonstrates that sometimes clinical, laboratory and imaging aspects suspicious for cancer may be missing. A prompt referral to a high-volume center is crucial for the management of those cases of incidental histopathological diagnosis.
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Affiliation(s)
- Vincenzo Triggiani
- Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, Interdisciplinary Department of Medicine, University of Bari, School of Medicine, Policlinico, Bari, Italy
| | | | | | | | - Vito Angelo Giagulli
- Section of Internal Medicine, Geriatrics, Endocrinology and Rare Diseases, Interdisciplinary Department of Medicine, University of Bari, School of Medicine, Policlinico, Bari, Italy
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Minisola S, Cipriani C, Diacinti D, Tartaglia F, Scillitani A, Pepe J, Scott-Coombes D. Imaging of the parathyroid glands in primary hyperparathyroidism. Eur J Endocrinol 2016; 174:D1-8. [PMID: 26340967 DOI: 10.1530/eje-15-0565] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 09/03/2015] [Indexed: 01/21/2023]
Abstract
Primary hyperparathyroidism (PHPT) is one of the most frequent endocrine diseases worldwide. Surgery is the only potentially curable option for patients with this disorder, even though in asymptomatic patients 50 years of age or older without end organ complications, a conservative treatment may be a possible alternative. Bilateral neck exploration under general anaesthesia has been the standard for the definitive treatment. However, significant improvements in preoperative imaging, together with the implementation of rapid parathyroid hormone determination, have determined an increased implementation of focused, minimally invasive surgical approach. Surgeons prefer to have a localization study before an operation (both in the classical scenario and in the minimally invasive procedure). They are not satisfied by having been referred a patient with just a biochemical diagnosis of PHPT. Imaging studies must not be utilized to make the diagnosis of PHPT. They should be obtained to both assist in determining disease etiology and to guide operative procedures together with the nuclear medicine doctor and, most importantly, with the surgeon. On the contrary, apart from minimally invasive procedures in which localization procedures are an obligate choice, some surgeons believe that literature on parathyroidectomy over the past two decades reveals a bias towards localization. Therefore, surgical expertise is more important than the search for abnormal parathyroid glands.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Cristiana Cipriani
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Daniele Diacinti
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Francesco Tartaglia
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Alfredo Scillitani
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - Jessica Pepe
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
| | - David Scott-Coombes
- Department of Internal Medicine and Medical DisciplinesDepartment of Radiological SciencesOncology and PathologyDepartment of Surgical Sciences"Sapienza" Rome University, Via del Policlinico 155, 00161 Rome, ItalyUnit of Endocrinology"Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo, Foggia, ItalyDepartment of SurgeryUniversity Hospital of Wales, Heath Park, Cardiff, Wales, UK
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