Localization Of Abnormal Parathyroid Glands Research Articles

Preoperative diagnosis of parathyroid gland pathology in patients with persistent or recurrent primary hyperparathyroidism: a retrospective study

INTRODUCTION: Localization of abnormal parathyroid glands in persistent or relapsed patients with primary hyperparathyroidism presents problems for surgeons before repeated surgery. There is no clear standard for the choice of diagnostic modality for localization of PG in this group of patients.OBJECTIVE: To search for the optimal diagnostic protocol of the parathyroid pathology preoperative diagnosis in patients with primary hyperparathyroidism with persistent or recurrent disease.MATERIALS AND METHODS: 55 patients diagnosed with persistence or recurrence of PHPT who underwent repeated surgical treatment were included in the study. Before surgical intervention all patients underwent laboratory and instrumental investigations in the volume of: blood tests for PTH, TTH, ionized calcium, 25(OH)D, creatinine, phosphorus, neck ultrasound, parathyroid scintigraphy by washout method, dual-isotope subtractive scintigraphy of parathyroid glands (early and delayed phases), SPECT of parathyroid glands (with uptake correction), computed tomography of the neck with intravenous bolus contrast.RESULTS: CT and planar subtraction dual-isotope scintigraphy showed the highest DA in the overall group (persistence and recurrence) (78% and 78%), with the DA of these methods differing slightly (88% and 92%) and overall accuracy being higher for CT (90% and 87%). Neck ultrasound showed the lowest rates among all methods (DA — 46%, DS — 80%, OA — 67%). Planar scintigraphy (washout) and SPECT were comparable in their informativeness: DA — 67% and 65%, DS — 96% and 98%, OA — 85% and 86%.DISCUSSION: The most commonly used current diagnostic search algorithm before reoperation is visualization of the thyroid gland by two modalities: Neck ultrasound and parathyroid scintigraphy (washout/subtraction) or SPECT-CT. In doubtful cases, the second step is computed tomography of the neck with contrast or PET/CT. It is extremely difficult to choose one optimal diagnostic method, as none of them has 100% diagnostic accuracy. In addition, each study has limitations, and the availability of some modalities is limited. In our study, the location of pathologically altered thyroid was correctly recognized in 90% of cases by CT with contrast and in 87% of cases by planar subtraction dual-isotope scintigraphy. The informativeness of neck ultrasound showed the lowest values of all modalities. SPECT and planar washout scintigraphy took an intermediate position in terms of diagnostic accuracy.CONCLUSION: Isolated ultrasonography of the neck has low diagnostic accuracy in patients with primary hyperparathyroidism with persistent or recurrent disease. We recommend the combination of US with contrast-enhanced computed tomography of the neck or US with dual isotope subtraction scintigraphy of the parathyroid glands, which have the same diagnostic accuracy. SPECT and planar washout scintigraphy can be used for the diagnosis of abnormal parathyroid glands in persistent or recurrent patients with primary hyperparathyroidism when more informative techniques are unavailable. When the techniques were combined, the combination of ultrasound/CT with contrast and ultrasound/planar subtraction dual isotope scintigraphy showed the best results with DA of 85% and 86%.

Evaluation of Imaging Findings in Patients with Pretransplant and Posttransplant Tertiary Hyperparathyroidism.

Tertiary hyperparathyroidism, characterized by autonomous overproduction of parathyroid hormone, can be seen in patients with long-standing secondary hyperparathyroidism (pretransplant) or after renal transplant (posttransplant). Parathyroid scintigraphy and ultrasonography are the most commonly used imaging procedures for the preoperative localization of abnormal parathyroid glands. We aimed to evaluate imaging findings in pretransplant and posttransplant tertiary hyperparathyroidism. This study included 32 patients with pretransplant tertiary hyperparathyroidism and 20 patients with posttransplant tertiary hyperparathyroidism. On parathyroid scintigraphy with technetium-99m sestamibi, early-phase and latephase images were acquired. Images were evaluated for the presence and the number of active foci and the degree of uptake on the late-phase image. The existence of an autonomous gland was based on latephase retention and was scored from 0 to 2 (retention score). On ultrasonography, the criteria threshold for autonomy was the maximum length of the largest gland ≥10 mm (ultrasonography score). On parathyroid scintigraphy, the most commonly observed pattern in the pretransplant group was positivity in ≥3 glands, and in the posttransplant group the most commonly observed pattern was positivity in 1 to 2 glands. In pretransplant and posttransplant groups, the criteria threshold for the presence of an autonomous parathyroid gland on parathyroid scintigraphy (grade 2 retention) was met in 26 (81%) and 9 (45%) patients and on ultrasonography in 25 (78%) and 10 (50%) patients, respectively. In the whole group of patients (n = 52), correlation existed between ultrasonography score and retention score. Glandular weight was correlated with both retention score and ultrasonography score. Higher numbers of detectable glands and the presence of parathyroid autonomy were more common in the pretransplant group. This might be explained by parathyroid gland involution after transplant. The results may also suggest that factors other than autonomy are responsible for posttransplant tertiary hyperparathyroidism.

FRI688 Efficacy Of 4D CT Scan And Tc-99m-MIBI-SPECT/CT For The Preoperative Localization Of Abnormal Parathyroid Glands In Patients With Primary Hyperparathyroidism

Abstract Disclosure: E. Zareva: None. V. Rivera-Hernandez: None. S. Salpekar: None. J. Moyo: None. M. Bilbatua: None. Z. Lauer: None. A. Zare: None. P. Kaur: None. M. Deshmukh: None. Background: Primary hyperparathyroidism is a common endocrine disorder that often requires surgical intervention for a cure. Accurate localization of abnormal parathyroid glands is critical for successful surgical treatment. NM Parathyroid scan with single-photon emission computed tomography(Tc99m-MIBI-SPECT/CT) is considered the gold standard, but other options like ultrasound, CT, MRI, and PET have been used. Accurate preoperative imaging has become even more critical with the development of focused surgical approaches. This study aims to evaluate the accuracy of Tc99m-MIBI-SPECT/CT and 4D CT scan in localizing abnormal parathyroid glands in our institution. Objectives: To evaluate and compare the efficacy of 4D CT scan and Tc99m-MIBI-SPECT/CT for the preoperative localization of abnormal parathyroid glands in patients with primary hyperparathyroidism in a single health network. Methods and Design: We collected data on 100 patients with biochemically confirmed primary hyperparathyroidism regarding age, sex, image modalities such asTc99m-MIBI-SPECT/CT and 4D CT before surgery, and the surgical pathology results. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated for both imaging modalities. Results: A total of 100 patient charts were reviewed, including 77 females and 23 males (3.35:1 female to male ratio),with an average age of 65.9 years (standard deviation 12.59). 90 patients had undergone surgical resection. 54 (60%) of them were diagnosed as parathyroid adenoma; 30 (33.3%) as parathyroid hyperplasia; 1 (1.1%) malignant parathyroid carcinoma; 5 (5.5%) were normal. 84 patients underwent Tc99m-MIBI-SPECT/CT and97 patients - 4D CT. 4D CT scan had a sensitivity of 90.36% (95% CI,81.89%-95.75%) and specificity of 50.00% (95% CI, 6.76%-93.24%) and outperformed Tc99m-MIBI-SPECT/CT which had a sensitivity of 45.71% (95% CI,33.74%-58.06%) and specificity of 80.00% (95% CI, 28.36%-99.49%). 4D CT had a positive predictive value (PPV) of 97.40% (95% CI, 90.93%-99.68%) and a negative predictive value (NPV) of 20.01% (95% CI, 2.52%-55.62%) compared toTc99m-MIBI-SPECT/CT which had PPV of 96.95% (95% CI, 84.22%-99.92%) and NPV of9.57% (95% CI, 2.68%-22.68%). 4D CT also had higher accuracy (85.5%; 95% CI,79.87%-94.35%) compared to Tc99m-MIBI scan (48.01%; 95% CI,36.32%-59.86%). Conclusion: Diagnostic imaging plays a crucial role in the management of primary hyperparathyroidism. Among the patients who had Tc99m-MIBI-SPECT/CT, less than half had positive scans suggestive of abnormal parathyroid tissue. This highlights the need for additional imaging methods for patients with negative scans. 4D CT is widely used in our institution and is more effective than Tc99m-MIBI-SPECT/CT in the preoperative localization of abnormal parathyroid glands. Presentation: Friday, June 16, 2023

Comparative Effectiveness of MRI, 4D-CT and Ultrasonography in Patients with Secondary Hyperparathyroidism.

Accurate preoperative localization of abnormal parathyroid glands is crucial for successful surgical management of secondary hyperparathyroidism (SHPT). This study was conducted to compare the effectiveness of preoperative MRI, 4D-CT, and ultrasonography (US) in localizing parathyroid lesions in patients with SHPT. We performed a retrospective review of prospectively collected data from a tertiary-care hospital and identified 52 patients who received preoperative MRI and/or 4D-CT and/or US and/or 99mTc-MIBI and subsequently underwent surgery for SHPT between May 2013 and March 2020. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each imaging modality to accurately detect enlarged parathyroid glands were determined using histopathology as the criterion standard with confirmation using the postoperative biochemical response. A total of 198 lesions were identified intraoperatively among the 52 patients included in this investigation. MRI outperformed 4D-CT and US in terms of sensitivity (P < 0.01), specificity (P = 0.455), PPV (P = 0.753), and NPV (P = 0.185). The sensitivity and specificity for MRI, 4D-CT, and US were 90.91%, 88.95%, and 66.23% and 58.33%, 63.64%, and 50.00%, respectively. The PPV of combined MRI and 4D-CT (96.52%) was the highest among the combined 2 modalities. The smallest diameterof the parathyroid gland precisely localized by MRI was 8×3 mm, 5×5 mm by 4D-CT, and 5×3 mm by US. MRI has superior diagnostic performance compared with other modalities as a first-line imaging study for patients undergoing renal hyperparathyroidism, especially for ectopic or small parathyroid lesions. We suggest performing US first for diagnosis and then MRI to make a precise localization, and MRI proved to be very helpful in achieving a high success rate in the surgical treatment of renal hyperparathyroidism in our own experience.

ODP111 PERSISTENT TERTIARY HYPERPARATHYROIDISM AFTER TOTAL PARATHYROIDECTOMY AND KIDNEY TRANSPLANTATION: THE CASE OF THE SUPERNUMERARY GLANDS

Abstract Secondary hyperparathyroidism in patients with kidney failure and hemodialysis usually resolves after total parathyroidectomy or kidney transplantation. Case report We report a case of a 53 year-old women polycystic kidney disease diagnosed at the age of 32, with end-stage renal disease and hemodialysis between 45-51 yrs. At the age of 50 she developed hypercalcemia (10.4-10.8 mg/dl) with very high PTH levels of 1100 pg/ml, and was referred forparathyroidectomy. Intraoperatively the four parathyroid glands were identified in canonical sites and a total parathyroidectomy was performed; postoperative total serum Calcium 8.9-9.6 mg/dl, PTH 510-680 pg/ml, suggesting the presence of a functional remnant parathyroid tissue. One year later she underwent kidney transplantation, immediate preoperative serum Calcium 10.4 mg/dl. 2 yrs later, she was referred to our clinic for hypercalcemia (11.8-12.5 mg/dl; increasing 5 mo post-transplant), high serum PTH 229-316 pg/ml) and low bone mass (lumbar spine T-score = -4.4 DS, femoral neck T-score = - 2.6 DS). She was asymptomatic and the biochemistries were: total serum calcium 12.8 mg/dl (11.8 mg/dl after hydration), serum PTH 228 pg/ml, hypophosphatemia 1.9 mg/dl, Alkaline Phosphatase 102 U/l, creatinine 1.13 mg/dl (0.85 mg/dl after hydration). 99m Tc-sestamibi SPECT-CT imaging revealed an ectopic hyperfunctional parathyroid gland above pulmonary artery bifurcation. Waiting for surgical decision, the patient was treated with denosumab 60 mg, lowering serum Calcium at 11 mg/dl at 1 mo, 11.5 mg/dl at 3 mo, PTH 511 pg/ml. Conclusion This case illustrates the needfor more accurate preoperative localization of abnormal parathyroid glands in patients with tertiary hyperparathyroidism besides the standard 4-gland exploration. Presentation: No date and time listed

Role of preoperative visualization in the choice of surgery for primary hyperparathyroidism

Precise localization of abnormal parathyroid glands is important for a successful surgery for primary hyperparathyroidism (PHPT). While a large number of patients can be successfully treated with the focused parathyroidectomy, there is a considerable rate of the persistent PHPT mostly because of undetected multiglandular disease (MGD). The aim of the study was to evaluate the meaning of preoperative visualization data for planning the surgery for patients with PHPT. The study was conducted at SPBU Hospital in 2017-2018. 810 patients who underwent a primary surgery for PHPT were included in the study. Preoperative imaging results were investigated and multivariative logistic regressions were calculated to assess the predictive values of preoperative data. The rate of cases with persistent disease and cases with MGD were compared between patients with different results of preoperative data. Age, sex, body mass index, negative results of preoperative US, MIBI and 4D CT were not independently associated with the higher risk of multiglandular disease. The larger number of performed preoperative visualization studies were associated with the higher risk of persistence. 37% cases of MGD were not identified preoperatively. There were 7 cases with previously unsuspected second adenomas found only due to bilateral neck exploration. Any combination of preoperative visualization modalities was not able to rule out the MGD reliably. Efficacy of surgical treatment was not associated with the higher number of preoperative studies. Bilateral neck exploration may decrease the rate of the persistent hyperparathyroidism improving the identification of multiglandular disease.

Parathyroid Imaging Practices for Primary Hyperparathyroidism Without Previous Operations Among Endocrine Surgery Program Directors.

Attempts at preoperative localization of abnormal parathyroid gland(s) in primary hyperparathyroidism (pHPT) can be performed with a variety of modalities. Study utilization is surgeon-specific with highly variable opinions in parathyroid surgery. As more people are diagnosed with pHPT, the complexity of the disease has given rise to variation in management. This heterogeneity raises the question of the true clinical practice of imaging among individual endocrine surgeons. To better understand the preoperative parathyroid imaging practices of endocrine surgeons, an email-based survey was disseminated to the program directors of 22 American Association of Endocrine Surgeons fellowship programs querying them on their initial diagnostic test of choice for pHPT. Clinical support team members from each respective program were subsequently contacted and answers were compared. Sixty-eight percent (15/22) of clinical team members recommended either an additional (12/15) or different imaging test (3/15) than what was recommended by their institution's endocrine surgeon. The most common initial imaging test that was repeated by both the endocrine surgeon and clinical team member was neck ultrasound; 33% of clinical team members (7/22) responded concordantly to their surgeon with ultrasound as the initial recommendation. Significant variability exists in the preoperative approach to patients with hyperparathyroidism. Here, we demonstrate that inconsistency in preoperative imaging recommendations even extends to within an individual surgeon's practice based on the impact of the clinical support team, highlighting the role for improved clinical protocols within an institution's clinical team.

Three-phase four-dimensional computed tomography as a first-line investigation in primary hyperparathyroidism.

Parathyroid computed tomography using multiple phases (four-dimensional computed tomography (4DCT) for parathyroid localization was first described in 2006. Since its inception, there has been variable uptake of this technique due to inconsistency of results between institutions and perceived higher radiation dose than technetium-99 sestamibi scans (MIBI). 4DCT has been the primary imaging modality for parathyroid localization at our institution since 2013. A retrospective study of surgically managed patients with primary hyperparathyroidism who had preoperative localization with 4DCT from 2013-2018 was performed. A total of 353 patients were included for analysis. The positive predictive value (PPV) of our three-phase 4DCT protocol was 93.3%, sensitivity (localized) 85.2% with a 5.8% false-positive rate and 13.9% false-negative (non-localizing) rate when reported by a head and neck radiologist (HNR). Calculated effective dose varied from 4.5 to 8.9mSV. On multivariable logistic regression, reporting by an experienced HNR (P< 0.001) and gland weight > 200 mg (P= 0.002) were significant for higher accuracy, lower false positives and false negatives. A first-line three-phase 4DCT protocol for primary hyperparathyroidism is an accurate technique providing precise anatomical localization of abnormal parathyroid glands, particularly when performed by a specialist HNR. In our practise, it provides the best rate of detection and superior anatomical localization needed for minimally invasive parathyroid surgery, compared to other commonly used localization techniques. It also avoids the need for four gland exploration in the majority of patients with primary hyperparathyroidism.

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization.

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. 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. From January 2018 to September 2019, there were 423 patients (mean, 61years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8cm. 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 1-2cm 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. 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.

Sestamibi Single-Positron Emission Computed Tomography/Diagnostic-quality Computed Tomography for the localization of abnormal parathyroid glands in patients with primary hyperparathyroidism: What clinicopathologic factors affect its accuracy?

Sestamibi Single-Positron Emission Computed Tomography/Diagnostic-quality Computed Tomography (MIBI-SPECT/CT) is a common technology used for primary hyperparathyroidism (PHPT) localization in clinical practice. However, the clinicopathologic factors affecting the accuracy of MIBI-SPECT/CT and the potential limitations remain unclear. Retrospectively enrolled PHPT patients (n = 280) were analyzed from August 2017 to December 2019. Of 96 patients with PHPT (mean age, 54years; 63 females), 17 had discordance between MIBI-SPECT/CT and intraoperative findings. Among the 17 patients with discordance, 58.8% had major discordance, which occurred in most patients with multigland disease (MGD). Compared with concordant patients, discordant patients exhibited increased frequencies of autoimmune thyroid disease (29.4% vs 10.1%, p = 0.035), MDG (41.2% vs 3.8%, p = 0.035), higher PTH (296pg/mL vs 146pg/mL; p = 0.012),and lower phosphorus levels (0.77mmol/L vs 0.90mmol/L; p = 0.024). MDG (odds ratio [OR], 16.95; 95% CI 2.10-142.86), parathyroid lesion size of 12mm or less (OR, 6.93; 95% CI 1.41-34.10), and a PTH level higher than 192.5pg/mL (OR, 12.66; 95% CI 2.17-71.43) were independently associated with discordant MIBI-SPECT/CT results. MGD was most strongly associated with discordance between MIBI-SPECT/CT and intraoperative findings followed by a PTH level higher than 192.5pg/mL and parathyroid lesion size of 12mm or less. Surgeons should recognize these potential limitations, which may improve the preoperative procedure by encouraging further localization imaging and promptly facilitate intraoperative troubleshooting.

Primary Hyperparathyroidism: To Evaluate Benefit of Ultrasound and Tc99m-SESTAMIBI Scan in Localizing Abnormal Parathyroid Gland Before Surgery, in a Secondary Care Hospital.

IntroductionPrimary hyperparathyroidism is a common endocrine condition requiring parathyroidectomy for curative management. Localization of parathyroid gland by ultrasound and Tc99m-SESTAMIBI is important to opt for less invasive and comparatively lower complication risk surgery minimal invasive parathyroidectomy (MIP) instead of four-gland exploration surgery.AimTo evaluate ultrasound and Tc99m-SESTAMIBI in localization of abnormal parathyroid gland before surgery.Method and materialsAll patients of primary hyperparathyroidism (PHPT) that presented to a secondary care hospital (endocrinology department) from 2015-2019 were recruited retrospectively from electronic fusion system of hospital. Results of ultrasound parathyroid and Tc99m-SESTAMIBI done for localization of abnormal parathyroid gland were analyzed.ResultsTotal PHPT patients recruited were 59, mean age 64.2 years, male 11 (18.64%) and female 48 (81.3%). Ultrasound parathyroid was done in 44 patients, Tc 99m-SESTAMIBI was done in 31, both tests were done in 31 patients. Combined concordant adenoma in both tests was seen in 11 (35%) cases which can opt for minimal invasive parathyroidectomy (MIP) with confidence whereas 65% of cases would require either four-gland exploration or further testing like single-photon emission computed tomography-computed tomography (SPECT-CT) or intraoperative parathyroid hormone measurement to opt for MIP.ConclusionCombined ultrasound parathyroid and Tc 99m-SESTAMIBI scan was useful in localization of parathyroid adenoma in 11 (35%) patients that can opt for MIP which is a lower complication risk surgery whereas 20 (65%) patients would need further investigation with SPECT-CT or intraoperative parathyroid hormone measurement or four-gland exploration surgery.RecommendationThird modality of investigation such as SPECT-CT or intraoperative parathyroid hormone measurement needs evaluation so that more patients can benefit from MIP instead of four-gland exploration surgery.

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

The success of minimally invasive parathyroidectomy (MIP) relies on accurate localization of the abnormal parathyroid glands. Concordant findings on ultrasound (US) and 99mTc-scintigraphy (sestamibi) are currently considered the 'gold standard'. Computed tomography (CT) has also recently been used in preoperative planning. We sought to assess the accuracy of CT for localization of abnormal parathyroid glands in such patients. An audit of 75 patients with primary hyperparathyroidism (PHPT) who underwent neck US and CT between 2017 and 2019 at our center as their first-line imaging. All 75 patients underwent US and CT and 54 (72.0%) also had sestamibi. CT alone identified a potential target in all patients, of which the location was correct in 63 (84.0%). The overall combined sensitivity of US and CT was 88% (95% CI 78-94) and was higher than the combined sensitivity of US and sestamibi (65% [95% CI 53-76]; p < 0.001). Twenty-one patients (28.0%) had an ectopic gland, and the sensitivity of US and CT was 86% (95% CI 64-96) versus US and sestamibi (57% [95% CI 34-77]; p = 0.016). For adenomas < 1.0g (n = 36; 48%), the accuracy of CT was 81% (95% CI 64-91) compared with 62% (95% CI 44-77) for US and sestamibi (p = 0.04). The correct preoperative diagnosis of multiglandular disease (n = 9; 12%) seemed to be the most difficult, with similar accuracy for US and sestamibi (40% [95% CI 14-73]) and US and CT (50% [95% CI 20-80]) (p > 0.99). The combination of US and CT was able to correctly identify the location of the abnormal parathyroid in 88% of patients and, in comparison with US and sestamibi, had better diagnostic accuracy, especially for smaller and ectopic adenomas. This finding suggests that US and CT could be considered as a first-line imaging modality in patients with PHPT considered for MIP.

Discordant findings on preoperative imaging for primary hyperparathyroidism and thyroid disease: Choosing the path to follow

BackgroundPreoperative localization of abnormal parathyroid glands in primary hyperparathyroidism is often obtained by sestamibi, and ultrasonography. We aimed to identify which modality is most accurate when laterality of abnormal glands on preoperative imaging is discordant. MethodsA single institution retrospective review identified 112 consecutive patients with primary hyperparathyroidism who underwent successful parathyroidectomy and sestamibi with pertechnetate. ResultsSestamibi with pertechnetate had a sensitivity of 72% and positive predictive value of 90%; ultrasonography had sensitivity of 50% and positive predictive value 80%. Patients with thyroiditis had lesser sensitivity and positive predictive value on sestamibi with pertechnetate (53% and 77%, respectively), in contrast to ultrasonography (54%, 88%, respectively). The sensitivity and positive predictive value of sestamibi with pertechnetate and ultrasonography did not differ in patients with thyroid nodules. Seventeen patients (15%) had discordant laterality on preoperative imaging. In discordant cases, sestamibi with pertechnetate was correct in 53% overall but in only 17% of those with thyroiditis (P = .01), whereas ultrasonography was correct in 26% overall but in 50% of those with thyroiditis (P = .01). ConclusionThyroiditis decreased the sensitivity and positive predictive value of sestamibi with pertechnetate in primary hyperparathyroidism. In patients with discordant laterality on preoperative imaging, sestamibi with pertechnetate is the more accurate choice to guide operative planning, although ultrasonography may be a better guide in those with thyroiditis.

Association of Histological Findings with Tc-99m Sestamibi Parathyroid Imaging in Hyperfunctional Parathyroid Gland

Background: Hyperthyroidism is a relatively common disorder that results from increased production of parathormone. Tc-99m sestamibi (MIBI) scanning is used for localization of abnormal parathyroid gland, with high reported sensitivities. However, there exists a group of patients in whom MIBI scan is either equivocal or negative. Objectives: The aim of this study was to see association of the histological features of pathologic parathyroid gland with MIBI scan in hyperfunctional parathyroid gland. Methodology: This retrospective study was conducted with primary hyperthyroidism who underwent MIBI scan. The data were collected from the record from January 2012 to December 2014 for a period of two years. All patients underwent parathyroid surgery followed by histopathological examination. According to oxyphil cell distribution patients are divided in three groups. Group I comprised of &gt;25.0% oxyphil cell; group II included the 25 to 75% oxyphil cell and group III included &gt;75% of oxyphil cell. Result: A total 56 patients with hypercalcaemia and high serum parathyroid hormone (PTH) level were studied. Mean age was 41.3(±19.8) years with a range of 21 to 63 years. MIBI scan was true positive in 34(60.7%) cases and false negative in 22(39.3%) cases. In group I MIBI scan was true positive in 4(36.3%) cases and false negative in 7(63.7%) cases. In group II MIBI scan showed positive in 17(62.9%) cases and negative in 10(37.1%) cases. In group III out of 18 patients 13(72.2%) showed MIBI scan positive whereas, 5(27.8%) showed negative scan. The sensitivity was 36.3% in group I whereas, 62.9% and 72.2% in group II and group III respectively. Conclusion: Based on these findings, it could be say that Tc–99m setamibi uptake correlate with parathyroid oxyphil cell content, and false negative scan can occur with parathyroid glands containing predominantly clear cell.Journal of National Institute of Neurosciences Bangladesh, 2016;2(1):14-18

Sensitivity of 3-Dimensional Sonography in Preoperative Evaluation of Parathyroid Glands in Patients With Primary Hyperparathyroidism.

Preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism facilitates targeted surgery. We assessed the sensitivity of 3-dimensional (3D) sonography for preoperative localization of abnormal parathyroid glands. We conducted a retrospective review of patients who underwent parathyroidectomy for primary hyperparathyroidism at a single site at our institution. We compared preoperative 2-dimensional (2D) sonography, 3D sonography, and sestamibi scans with final gland localization at surgery. Two readers reviewed the sonograms to assess inter-reader variability. From January 2010 through April 2015, 52 patients underwent parathyroidectomy after preoperative 2D sonography, 3D sonography, and sestamibi scans. Three-dimensional sonography had sensitivity of 88-92% compared with 69-71% for 2D sonography for gland localization. In patients in whom sonography and sestamibi scans localized abnormalities to the same side, the sensitivities were 100% (43 of 43) for 3D sonography and 96% (48 of 50) for 2D sonography. Three-dimensional sonography had significantly higher sensitivity for localization of glands smaller than 500 mg compared with 2D sonography (88% versus 58%; P = .012). There was better inter-reader agreement between the radiologists when using 3D sonography (κ = 0.65) compared with 2D sonography (κ = 0.41). We found a significantly higher sensitivity and better inter-reader agreement for 3D sonography compared with 2D sonography for preoperative identification of abnormal parathyroid glands, especially among smaller glands.

Sestamibi Positive Vs Negative Scan In Primary Hyperparathyroidism; A Clinical Dilemma

Objectives: In primary hyperthyroidism Tc-99m Sestamibi (MIBI) scanning is commonly used for localization of abnormal parathyroid gland and the reported sensitivity is very high. However, false negative scan remain a problem. We examined whether serum calcium and parathormone (PTH) level have any impact in the sensitivity of MIBI scan.Study design: A retrospective review of 55 patients with primary hyperparathyroidism who underwent MIBI scan from January 2012 to December 2014 were included in this study. All patients underwent parathyroid surgery followed by histopathological confirmation.Results: In total, 55 patients were studied. Mean age was 41.3 ± 19.8 years (range 21-63 years). MIBI scan was true positive in 37 cases and false negative in 18 cases. The sensitivity of MIBI scan was 67.2 %. Mean serum calcium level was 12.3 mg/ dL. More than 62.2 % of patients with calcium level greater than 12.3 mg/dL had a positive scan as compared with 37.8% of those with lesser value (P&lt;0.05). Similarly a serum PTH level greater than 316 ± 139 pg/mL correlated with positive scans in 78.4 % as opposed to 21.6 % in those with lower levels (P&lt; 0 .01).Conclusion: Lower calcium and PTH level significantly correlate with reduced sensitivity of MIBI scan. Although we did not find the best cut-off level of serum calcium and PTH level that can predict a positive scan.Bangladesh J. Nuclear Med. 17(2): 142-145, July 2014

Computed Tomography and Magnetic Resonance Imaging of the Thyroid and Parathyroid Glands.

Computed tomography (CT) and magnetic resonance imaging (MRI) are advanced imaging modalities that are not typically utilized as part of the initial evaluation of thyroid and parathyroid pathology. However, both modalities have applications in complex cases, particularly in the reoperative setting and in operative planning for initial or recurrent carcinomas. As part of a multimodal approach, CT and MRI can increase the successful preoperative localization of abnormal parathyroid glands. Newer imaging modalities, such as PET-CT and SPECT-CT in thyroid imaging, and 4D-CT in parathyroid imaging, can provide information on the anatomy as well as the function of pathologic tissues. Both modalities provide excellent assessment of the extent of disease, local invasion and distant metastases. Drawbacks include cost and availability, and these should be weighed against benefits in the context of the management of thyroid and parathyroid disease.

Successful Localization of Abnormal Parathyroid Gland Using Ultrasound-Guided Methylene Blue Dye Injection in the Reoperative Neck.

Persistent or recurrent hyperparathyroidism is a challenging problem for endocrine surgeons. The aim of this study was to review our experience using ultrasound-guided (US-G) methylene blue dye injection for the localization and removal of abnormal parathyroid glands in patients having primary hyperparathyroidism and previous neck surgery. Between January 2012 and May 2013, six consecutive patients with primary hyperparathyroidism (PHPT) and previous neck surgery underwent focused parathyroidectomy with the use of US-G methylene blue dye injections to localize the presumed parathyroid adenoma were included in the study. We analyzed the data of six patients who underwent reoperative parathyroid surgery using US-G methylene blue dye injection retrospectively. The dye injection was performed just prior to surgery. All patients were successfully treated for their hyperparathyroidism which was confirmed by at least 50% drop in intraoperative parathormone level 10min after resection. There were no complications related with US-G dye injection or with surgery. US-G methylene blue dye injection is a cheap, safe, and effective method for localization of diseased parathyroid glands and guiding surgery in the reoperative neck.

Four‐dimensional computed tomography for parathyroid localization: a new imaging modality

Four-dimensional computed tomography (4DCT) is a new parathyroid localization technique not previously reported in Australia. It provides both functional and anatomical imaging in a single test, with superior sensitivity compared with sestamibi scintigraphy (SeS). This study examines the utility of 4DCT in defined clinical situations. This is a retrospective cohort study in a tertiary referral hospital setting. One hundred consecutive operative cases of primary hyperparathyroidism (99 patients) undergoing both preoperative 4DCT and SeS. Localization studies were correlated with operative findings, histopathology and clinical outcomes. The utility of 4DCT was analysed in three common clinical settings: primary cases with positive SeS (Group A, n = 68), primary cases with negative SeS (Group B, n = 21) and re-operative cases (Group C, n = 11). The overall sensitivity of 4DCT was 92% compared with 70% for SeS. The sensitivity of 4DCT was superior to SeS in Groups B and C (76% versus 0% and 91% versus 46%, respectively). The overall cure rate was 98%, with 94% of cases completed as minimally invasive procedures. Up to 62% of Group B cases potentially avoided a bilateral neck exploration owing to a positive 4DCT. 4DCT is an accurate technique providing both functional and anatomical localization of abnormal parathyroid glands. However, the advantage of speed and simplicity in image acquisition needs to be balanced against the small risk of increased radiation exposure in the younger patient group.

4D-CT for Preoperative Localization of Abnormal Parathyroid Glands in Patients with Hyperparathyroidism: Accuracy and Ability to Stratify Patients by Unilateral versus Bilateral Disease in Surgery-Naïve and Re-Exploration Patients

4D-CT is an emerging technique that uses high-resolution images, multiplanar reformats, and perfusion characteristics to identify abnormal parathyroid glands in patients with hyperparathyroidism. This study evaluates the accuracy of 4D-CT for localization and lateralization of abnormal parathyroid glands in preoperative planning for minimally invasive parathyroidectomy vs bilateral neck exploration at a tertiary referral center. Radiology, pathology, and operative reports were retrospectively reviewed for 208 patients with hyperparathyroidism who underwent 4D-CT and parathyroid surgery between May 2008 and January 2012. 4D-CT performance in localizing side and site was determined by use of surgical and pathologic findings as a reference. Of 208 patients, 155 underwent initial surgery and 53 underwent re-exploration parathyroid surgery. No lesions were found in 8 patients (3.8%). A total of 284 lesions were found in 200 patients; 233 were correctly localized by 4D-CT (82.0%). Of the 200 patients with parathyroid lesions, 146 underwent unilateral and 54 bilateral neck exploration. 4D-CT correctly identified unilateral vs bilateral disease in 179 (89.5%) of 200. 4D-CT correctly localized parathyroid lesions in 126 of the unilateral cases (86.3%). In the re-exploration cohort, 4D-CT correctly identified unilateral vs bilateral disease in 46 (95.8%) of 48. There was no statistically significant difference in subgroups stratified by surgery type (primary or subsequent) and number of scan phases (3 or 4) (P > .56). 4D-CT leverages modern high-resolution CT scanning and dynamic contrast enhancement to localize abnormal parathyroid glands in patients with hyperparathyroidism of any cause and can be used for planning minimally invasive parathyroidectomy vs bilateral neck exploration.