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Lawrence E, Johri G, Dave R, Li R, Gandhi A. A contemporary analysis of the pre- and intraoperative recognition of multigland parathyroid disease. Langenbecks Arch Surg 2023; 408:389. [PMID: 37806985 PMCID: PMC10560634 DOI: 10.1007/s00423-023-03087-w] [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: 06/05/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Despite advances in biochemical and radiological identification of parathyroid gland enlargement, primary hyperparathyroidism (PHPT) due to sporadic multigland parathyroid disease (MGPD) remains a perioperative diagnostic dilemma. Failure to recognise MGPD pre- or intraoperatively may negatively impact surgical cure rates and result in persistent PHPT and ongoing patient morbidity. METHODS We have conducted a comprehensive review of published literature in attempt to determine factors that could aid in reliably diagnosing sporadic MGPD pre- or intraoperatively. We discuss preoperative clinical features and examine pre- and intraoperative biochemical and imaging findings concentrating on those areas that give practicing surgeons and the wider multi-disciplinary endocrine team indications that a patient has MGDP. This could alter surgical strategy. CONCLUSION Biochemistry can provide diagnosis of PHPT but cannot reliably discriminate parathyroid pathology. Histopathology can aid diagnosis between MGPD and adenoma, but histological appearance can overlap. Multiple negative imaging modalities indicate that MGPD may be more likely than a single parathyroid adenoma, but the gold standard for diagnosis is still intraoperative identification during BNE. MGPD remains a difficult disease to both diagnose and treat.
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Affiliation(s)
- E Lawrence
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - G Johri
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - R Dave
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - R Li
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK
| | - A Gandhi
- Wythenshawe Hospital and Nightingale Breast Cancer Centre, Manchester University Foundation Trust, Southmoor Road, Manchester, M23 9LT, UK.
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oglesby Cancer Research Building, M20 4GJ, Manchester, UK.
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Zenno A, Ramamoorthy B, Hammoud DA, Quezado M, Zeiger MA, Jha S. Case Report: Nine-year-old with parathyroid adenoma within the piriform sinus. Front Endocrinol (Lausanne) 2023; 14:1171052. [PMID: 37288292 PMCID: PMC10242159 DOI: 10.3389/fendo.2023.1171052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/04/2023] [Indexed: 06/09/2023] Open
Abstract
We present the case of a 9-year-old girl who presented with symptomatic hypercalcemia from primary hyperparathyroidism (PHPT). Laboratory results revealed elevated serum calcium 12.1 mg/dl (ref: 9.1-10.4), elevated ionized calcium 6.8 (ref: 4.5-5.6) mg/dl, phosphorus 3.8 (ref: 3.3-5.1) mg/dl, 25-OH vitamin D 20.1 (30-100) ng/ml, and elevated intact PTH 70 (15-65) pg/ml, consistent with the diagnosis of PHPT. She had persistent hyperparathyroidism after bilateral neck exploration, left thyroid lobectomy, and transcervical thymectomy. Neither inferior gland was identified. No parathyroid tissue was seen on histology. Repeat preoperative imaging identified a 7-mm × 5-mm adenoma on 4DCT not seen on 99Tc-sestamibi parathyroid scan. The patient then underwent a successful redo parathyroidectomy with removal of a submucosal left parathyroid adenoma at the superior aspect of the thyroid cartilage in the piriform sinus. Her biochemical work-up remains consistent with surgical cure 6 months after surgery. Herein, we also review common locations for ectopic parathyroid adenomas. Clinical Trial Registration NCT04969926.
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Affiliation(s)
- Anna Zenno
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, MD, United States
| | - Bhavishya Ramamoorthy
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Dima A. Hammoud
- Center for Infectious Disease Imaging, Radiology and Imaging Sciences, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, United States
| | - Martha Quezado
- National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Martha A. Zeiger
- Surgical Oncology Program, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Smita Jha
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, United States
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Relative Perfusion Differences between Parathyroid Adenomas and the Thyroid on Multiphase 4DCT. Int J Biomed Imaging 2022; 2022:2984789. [PMID: 35646108 PMCID: PMC9142320 DOI: 10.1155/2022/2984789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 03/14/2022] [Accepted: 05/10/2022] [Indexed: 02/07/2023] Open
Abstract
A multiphase 4DCT technique can be useful for the detection of parathyroid adenomas. Up to 16 different phases can be obtained without significant increase of exposure dose using wide beam axial scanning. This technique also allows for the calculation of perfusion parameters in suspected lesions. We present data on 19 patients with histologically proven parathyroid adenomas. We find a strong correlation between 2 perfusion parameters when comparing parathyroid adenomas and thyroid tissue: parathyroid adenomas show a 55% increase in blood flow (BF) (p < 0.001) and a 50% increase in blood volume (BV) (p < 0.001) as compared to normal thyroid tissue. The analysis of the ROC curve for the different perfusion parameters demonstrates a significantly high area under the curve for BF and BV, confirming these two perfusion parameters to be a possible discriminating tool to discern between parathyroid adenomas and thyroid tissue. These findings can help to discern parathyroid from thyroid tissue and may aid in the detection of parathyroid adenomas.
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Sonawane S, Jadhav SS, Goroshi M, Krishnappa B, Sharma A, Hira P, Garle MN, Gosavi V, Memon S, Patil VA, Lila AR, Shah N, Bandgar T. Percentage arterial enhancement on 2D CT in the diagnosis of primary hyperparathyroidism: A prospective validation study and potential pitfalls. Head Neck 2022; 44:1849-1856. [PMID: 35638259 DOI: 10.1002/hed.27108] [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: 12/25/2021] [Revised: 04/10/2022] [Accepted: 05/11/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Parathyroid lesions are identified by subjective enhancement and washout patterns on computed tomography (CT). We have previously proposed "percentage arterial enhancement" (PAE) as an objective index and now aim to validate its performance prospectively. METHODS Dual-phase CT was performed in 40 consecutive primary hyperparathyroidism patients. PAE was calculated as [{arterial phase Hounsfield unit (HU)-unenhanced phase HU}/unenhanced phase HU] × 100. PAE > 128.9% was considered parathyroid. RESULTS PAE had 94.2% sensitivity, 100% positive predictive value (PPV) in lateralization, and sensitivity and PPV of 93.9% in quadrant localization of single-gland disease. PAE failed to identify two lesions: an intrathyroidal parathyroid carcinoma in the background of multinodular goiter and another lower enhancing cystic parathyroid adenoma. PAE had 60% sensitivity, and 100% PPV to identify multigland disease. The mean effective dose was 2.74 mSV. CONCLUSIONS PAE is a specific CT index for parathyroid lesions with less radiation exposure. Areas of caution include intrathyroidal and cystic lesions.
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Affiliation(s)
- Sushil Sonawane
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Swati S Jadhav
- Department of Endocrinology, Sapthagiri Institute of Medical Sciences and Research Centre, Bangalore, India
| | - Manjunath Goroshi
- Department of Endocrinology, Jawaharlal Nehru Medical College, Belagavi, India
| | - Brijesh Krishnappa
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Anima Sharma
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Priya Hira
- Department of Radiodiagnosis, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Mahadev N Garle
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Vikrant Gosavi
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Saba Memon
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Virendra A Patil
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Anurag R Lila
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Nalini Shah
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
| | - Tushar Bandgar
- Department of Endocrinology, Seth GS Medical College and KEM Hospital, Mumbai, India
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Raeymaeckers S, De Brucker Y, Tosi M, Buls N, De Mey J. High-frequency Multiphase 4DCT for the Detection of Parathyroid Adenomas: A Pictorial Essay. J Endocr Soc 2021; 5:bvab132. [PMID: 34458658 PMCID: PMC8389182 DOI: 10.1210/jendso/bvab132] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Indexed: 11/19/2022] Open
Abstract
4-Dimensional computed tomography (4DCT) for the detection of (an) enlarged parathyroid(s) is a commonly performed examination in the management of primary hyperparathyroidism. In our center, we introduced a high-frequency multiphase 4DCT protocol obtaining 16 phases, including 11 different arterial phases. Exposure to this multiphase 4DCT technique is similar to that for classic helical 4DCT. In this pictorial essay we reconstructed our multiphase 4DCT series in the manner of a classic helical 4DCT and compare both techniques. We illustrate how multiphase 4DCT may aid in the detection of parathyroid adenomas. We found 17 out of 19 lesions demonstrating a type A pattern of enhancement, therefore suggesting this pattern could be more prevalent than previously thought. Some parathyroid adenomas may be mistaken for enlarged lymph nodes using classic 4DCT whereas high-frequency multiphase 4DCT can detect a temporary rise in enhancement, thus suggesting the lesions in question to be of parathyroid origin. Smaller lesions may prove more obvious as the difference in enhancement between parathyroid and thyroid can become more prominent.
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Affiliation(s)
- Steven Raeymaeckers
- Department of Radiology, Universitair ziekenhuis Brussel, Laarbeeklaan, Jette, Belgium
| | - Yannick De Brucker
- Department of Radiology, Universitair ziekenhuis Brussel, Laarbeeklaan, Jette, Belgium
| | - Maurizio Tosi
- Department of Anesthesiology, Universitair ziekenhuis Brussel, Laarbeeklaan, Jette, Belgium
| | - Nico Buls
- Department of Radiology, Universitair ziekenhuis Brussel, Laarbeeklaan, Jette, Belgium
| | - Johan De Mey
- Department of Anesthesiology, Universitair ziekenhuis Brussel, Laarbeeklaan, Jette, Belgium
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