Localization Of Parathyroid Adenomas Research Articles

Impact of Histological Subtypes on Preoperative Localization of Parathyroid Adenomas

Introduction: Parathyroid scintigraphy and ultrasonography are the primary imaging methods used for localizing parathyroid adenomas. However, there remains a risk of missed or failed localization. This study aims to investigate the relationship between clinical and pathological findings in patients with parathyroid adenoma, focusing on the causes behind missed adenomas and localization failures. Patients and Methods: We analyzed the demographic, clinical, laboratory, and radiological data of patients who underwent surgery for primary hyperparathyroidism due to adenomas. Additionally, we reassessed the adenomas' pathologic characteristics, including size, weight, dominant cell type, and the percentage of oxyphilic cells. Results: A total of 115 patients were studied, with dominant cell types distributed as follows: 83 (71.6%) conventional chief cells, 15 (12.9%) water-clear cells, and 17 (14.7%) oxyphilic cells. The average percentage of oxyphilic cells was 21.15%. The localization rate via ultrasonography was significantly lower in the water-clear cell group (p < 0.05). While not statistically significant, the localization success using scintigraphy was lower in the oxyphilic cell group compared to others (58.8% vs. 80.7% and 86.7%). Our findings suggest that histological subtypes of parathyroid adenomas, particularly dominant cell content, may affect preoperative localization success. Conclusion: Missed parathyroid adenomas may be attributed to their histological subtypes and dominant cell composition. These factors could influence the accuracy of preoperative localization with ultrasonography and scintigraphy.

Bone Mineral Density and First Line Imaging with [18F]fluorocholine PET/CT in Normocalcemic and Hypercalcemic Primary Hyperparathyroidism: Results from a Single Center.

Objectives: Primary hyperparathyroidism (PHPT) is associated with normal or elevated calcium levels and affects bone mineral density. The proportion of cases predisposed to metabolic bone disease is unknown in patients with PHPT. The aim of this study was to assess bone mineral density and bone quality in patients with normo- or hypercalcemic primary hyperparathyroidism undergoing baseline parathyroid gland assessment with [18F]fluorocholine PET/CT imaging. Methods: A total of 140 consecutive patients were enrolled in this observational study. All patients with normo- or hypercalcemic primary hyperparathyroidism underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS). [18F]fluorocholine PET/CT was performed in all patients for the detection and localization of parathyroid adenoma. Hyper- and normocalcemic patients were compared with regard to the proportion of osteoporosis and osteopenia, T-Score, TBS, serum calcium, phosphorus and parathyroid hormone levels, the maximum standardized uptake value (SUVmax) in PET/CT imaging, and laboratory results. Results: The majority of patients was female (88.57%) and had a pathologic bone mineral density (52.86%). Overall, 33 patients had osteoporosis and 41 osteopenia. The mean lumbar T-Score was -1.48 (SD 1.37) and the T-Score of the femoral neck was -1.21 (SD 0.92). Mean TBS was also decreased (-2.13). No difference was found between normo- or hypercalcemic patients regarding bone metabolism and imaging parameters. Conclusions: More than half of patients with normo- or hypercalcemic PHPT showed abnormal BMD. First-line [18F]fluorocholine PET/CT identified parathyroid adenoma in a high proportion of patients, even in patients with normocalcemic PHPT. The early evaluation of metabolic bone disease seems desirable in clinical management of females with PHPT.

Primary hyperparathyroidism with intrathyroidal location of parathyroid adenoma

Primary hyperparathyroidism is a common endocrine disease with high morbidity and mortality from all causes. The disease can be asymptomatic and for a long time remain undiagnosed, which leads to untimely surgical treatment, increases the risks of development and progression of severe disabling complications and worsens patients prognosis. In clinical practice there are certain difficulties in diagnosing this pathology. One of the urgent problems is the search for the source of parathyroid hormone hyperproduction, especially in case of atypical location of paraаdenoma. The most common atypical locations of altered parathyroid glands are thymus, retroor paraesophageal space, retropharyngeal space, mediastinum and thyroid gland. The frequency of intrathyroidal masses of parathyroid glands, in the thyroid parenchyma or under its capsule, ranges on average from 2 to 3%, but according to some authors can reach 18–22%. With such localization of paraadenomas there is a need for their differential diagnosis, first of all, with nodular formations of the thyroid gland. In addition, the absence of additional laboratory studies parathormone and calcium blood levels does not allow timely suspicion of the disease, and cytologic examination of the material obtained by fine-needle aspiration puncture biopsy does not allow reliable differentiation of the altered parathyroid gland. This article presents a clinical case of a patient with primary hyperparathyroidism with intrathyroidally located parathyroid adenoma, for a long time long identified as a “nodular goiter,” and provides a brief review of the methods that identify an intrathyroidally located parathyroma. Despite the abundance of diagnostic methods in visualization of intrathyroidal parathyroid glands, today the most appropriate seems to be expert ultrasound examination with assessment of the parathyroid hormone level in a washout after fine-needle aspiration, supplemented, if necessary, by scintigraphy and single-photon emission computed tomography combined with computed tomography or multispiral computed tomography.

Surgeon Review of 4D CT for Identification of Parathyroid Adenomas.

Preoperative localization of parathyroid adenomas aids surgical planning for patients with hyperparathyroidism. This study explores the diagnostic accuracy of surgeon-reviewed 4D computed tomography (4D CT) scans for localization of parathyroid adenomas. A retrospective review of 95 patients with hyperparathyroidism who underwent parathyroidectomy at a tertiary care center was performed. The sensitivity, specificity, positive and negative predictive values, accuracy of identifying abnormal glands by surgeon, and interrater reliability between two head and neck surgeons was assessed. The sensitivity of surgeon localization of all glands was 71% (95% CI, 63%-78%), improving to 76% when combined with radiology reads. The specificity was 98% (95% CI, 95%-99%), the positive predictive value was 95% (95% CI, 90%-99%), and the negative predictive value was 84% (95% CI, 79%-88%) for all abnormal glands. Interrater reliability between surgeons was κ = 0.771. The diagnostic accuracy of surgeon localization of abnormal glands on the 4D CT scan was substantial. Improvement with radiology report integration highlights the benefits of multidisciplinary collaboration. Interrater reliability between two fellowship-trained surgeons was moderate. These findings support the importance of surgeons developing proficiency in reading 4D CT scans to engage in interdisciplinary communication and improve patient outcomes.

Diagnostic accuracy of ultrasonography and 99m-Technetium Sestamibi scintigraphy for the preoperative localization of Parathyroid Adenoma keeping histopathological findings as reference standard.

To determine the diagnostic accuracy of Ultrasound (US) and 99m-Tc Sestamibi scan in patients with primary hyperparathyroidism (PHPT) for the localization of parathyroid adenoma before surgery keeping Parathyroid histopathology as reference standard. This three years retrospective study was performed in the Department of Endocrinology, Hayatabad Medical Complex, Peshawar. Patients with PHPT who underwent parathyroidectomy from July 2019 to June 2022 were included in the study. Information relating to localization studies prior to surgical management like US and 99m-Tc Sestamibi scan was documented. These imaging findings were subsequently compared with the findings of parathyroid surgery and histopathology results which were taken as reference standard. The sensitivity, positive predictive value (PPV) and overall accuracy of US for the preoperative localization of parathyroid adenoma was 77%, 95.7% and 75%, respectively. Whereas the sensitivity, PPV and accuracy of 99m-Tc Sestamibi scintigraphy was 89.5%, 95% and 86% respectively. Ultrasound despite its cost effectiveness has a lower sensitivity compared to 99m-Tc Sestamibi scintigraphy. Similarly, the sensitivity and overall accuracy of US and 99m-Tc Sestamibi scan when taken in combination is higher compared to either modality. It is thus recommended that the combination of these modalities should be employed to localize the adenomas accurately for surgery of the parathyroid gland for a better outcome.

Evaluation of the relationship between thyroid cancer and the concurrent detection of thyroid nodules on the background of primary hyperparathyroidism

Introduction: Primary Hyperparathyroidism (PHPT) is commonly caused by a benign parathyroid adenoma that results in overactivity of the gland and subsequent hypercalcemia due to elevated parathyroid hormone (PTH). This endocrine pathology is associated with thyroid cancer, specifically Papillary Thyroid Cancer (PTC). However, the explanation for their synchronous presentation is unknown. Moreover, it causes diagnostic and treatment challenges that impact patient outcomes. Aims and Objectives: To critically analyze published research to address the relationship between PHPT and thyroid cancer, the role of ultrasound imaging in detecting sinister thyroid nodules in PHPT patients and the features of PHPT that predispose the risk of thyroid malignancy. Study Design: Literature Review Methodology: Electronic database searches of PubMed and CINAHL Plus through EBSCOhost were conducted using the keywords "primary hyperparathyroidism", "thyroid nodules" and "thyroid cancer". Following application of filters and removal of duplicates, 627 relevant results remained. Articles were screened for eligibility based on predetermined selection criteria. Following a review of titles and abstracts, 10 peer-reviewed articles were chosen for further analysis. The studies included were critically appraised using the EBL Critical Appraisal Checklist. Results: 10 articles were examined, 2 were prospective cohort studies and 8 were retrospective cohort studies. All studies involved exhaustive medical chart reviews of patients with PHPT, to investigate the concomitance of thyroid malignancy. Six studies established cervical ultrasound as the optimal method of recognition and preoperative localization of thyroid and parathyroid lesions. Overall, the incidence of thyroid cancer among PHPT patients ranged between 2.9% to 32.9%. Four studies established age, gender and PTH levels as risk factors. Conclusion: The existing literature is consistent with previous studies and purports that individuals with a background fo PHPT are at an increased risk of thyroid cancer. Furthermore the highest likelihood of identifying thyroid cancer is through preoperative localization of parathyroid adenomas by cervical ultrasound, in female patients over the age of 50. Key Findings: Further research is needed to understand the underlying pathogenesis and genetic mechanisms that encompass the relationship between PHPT and thyroid cancer.

8402 The Usefulness of the Contrast-Enhanced Ultrasound (CEUS) in Preoperative Localization of Parathyroid Gland Adenomas

Abstract Disclosure: A. Żyłka: None. K. Dobruch-Sobczak: None. H. Piotrzkowska-Wróblewska: None. P. Góralski: None. J. Gałczyński: None. E. Bakuła-Zalewska: None. M. Dedecjus: None. Objectives: Preoperative localization of parathyroid gland adenomas in patients diagnosed with primary hyperparathyroidism (pHPT) is challenging process. The aim of the study was to assessed the usefulness of contrast-enhanced ultrasound (CEUS) as complimentary diagnostic modality to conventional ultrasonography for detection of hyperfunctioning parathyroid gland lesions. Methods: Between the years 2021 and 2022, 36 adult patients (33 women and 3 men, aged 37-76) diagnosed with pHPT, underwent high-resolution ultrasound (US) and CEUS of parathyroid gland adenomas, suspected after fine-needle aspiration biopsy with positive parathormone (PTH) wash-out results and/or avid in 99mTechnetium -sestamibi scintigraphy. During CEUS examination 1.5 ml of SonoVue contrast has been injected and followed by analysing of qualitative CEUS enhancement features. All patients were qualified to surgical treatment according to clinical symptoms, laboratory and imaging findings and underwent parathyroidectomy with histopathologic results confirming parathyroid gland adenomas. Analysis of the B-mode features and visual CEUS enhancement patterns was performed retrospectively. Ten CEUS qualitative parameters of lesions were assessed including: homo- or heterogenous enhancement; hyper- or hypoenhancement; distribution of contrast in wash-in phase as: centripetal, centrifugal or combined and in wash-out phase as: centrally, peripherally or combined. Then the model was extended using the results based on US B-mode imaging which involved size, echogenicity, calcifications, cystic components and vascularity patterns assessed in Color Doppler (CD) and superb microvascular imaging (SMI). Results: Histopathologic results included 36 parathyroid adenomas (in 33 women and 3 men), the medium size 18.8mm (±11.1) and volume 3.7mm3 (±8.2). In B-mode US examination the majority of lesions were assessed as hypoechoic (n=36; 100%) with dominant inhomogenous echostructure (n=20; 55.5%), mixed vascularity (n=24; 66.6%) and polar vessel observed in 14 lesions (38.8%). There were no adenomas with calcifications, cystic components were observed only in 4 nodules (11.1%). In the CEUS study, dominated qualitative features were homogenous (n=22; 61,1%) and hyperenhancement (n=27; 75%), with centripetal distribution of contrast in wash-in phase (n=24; 66,6%) and dominant centrally wash-out of the contrast (n=20; 55,5%). Conclusions: Preliminary results indicate ultrasonographic patterns characteristic for parathyroid gland adenomas in multiparametric ultrasound involved CEUS examination, which seemed to be valuable tool for localization hyperfunctional parathyroid glands. Further multicenter studies should be performed to standardize qualitative CEUS features in order to diagnose primary hyperparathyroidism preoperatively. Presentation: 6/1/2024

8402 The Usefulness Of The Contrast-Enhanced Ultrasound (CEUS) In Preoperative Localization Of Parathyroid Gland Adenomas

Abstract Disclosure: A. Żyłka: None. K. Dobruch-Sobczak: None. H. Piotrzkowska-Wróblewska: None. P. Góralski: None. J. Gałczyński: None. E. Bakuła-Zalewska: None. M. Dedecjus: None. Objectives: Preoperative localization of parathyroid gland adenomas in patients diagnosed with primary hyperparathyroidism (pHPT) is challenging process. The aim of the study was to assessed the usefulness of contrast-enhanced ultrasound (CEUS) as complimentary diagnostic modality to conventional ultrasonography for detection of hyperfunctioning parathyroid gland lesions. Methods: Between the years 2021 and 2022, 36 adult patients (33 women and 3 men, aged 37-76) diagnosed with pHPT, underwent high-resolution ultrasound (US) and CEUS of parathyroid gland adenomas, suspected after fine-needle aspiration biopsy with positive parathormone (PTH) wash-out results and/or avid in 99mTechnetium -sestamibi scintigraphy. During CEUS examination 1.5 ml of SonoVue contrast has been injected and followed by analysing of qualitative CEUS enhancement features. All patients were qualified to surgical treatment according to clinical symptoms, laboratory and imaging findings and underwent parathyroidectomy with histopathologic results confirming parathyroid gland adenomas. Analysis of the B-mode features and visual CEUS enhancement patterns was performed retrospectively. Ten CEUS qualitative parameters of lesions were assessed including: homo- or heterogenous enhancement; hyper- or hypoenhancement; distribution of contrast in wash-in phase as: centripetal, centrifugal or combined and in wash-out phase as: centrally, peripherally or combined. Then the model was extended using the results based on US B-mode imaging which involved size, echogenicity, calcifications, cystic components and vascularity patterns assessed in Color Doppler (CD) and superb microvascular imaging (SMI). Results: Histopathologic results included 36 parathyroid adenomas (in 33 women and 3 men), the medium size 18.8mm (±11.1) and volume 3.7mm3 (±8.2). In B-mode US examination the majority of lesions were assessed as hypoechoic (n=36; 100%) with dominant inhomogenous echostructure (n=20; 55.5%), mixed vascularity (n=24; 66.6%) and polar vessel observed in 14 lesions (38.8%). There were no adenomas with calcifications, cystic components were observed only in 4 nodules (11.1%). In the CEUS study, dominated qualitative features were homogenous (n=22; 61,1%) and hyperenhancement (n=27; 75%), with centripetal distribution of contrast in wash-in phase (n=24; 66,6%) and dominant centrally wash-out of the contrast (n=20; 55,5%). Conclusions: Preliminary results indicate ultrasonographic patterns characteristic for parathyroid gland adenomas in multiparametric ultrasound involved CEUS examination, which seemed to be valuable tool for localization hyperfunctional parathyroid glands. Further multicenter studies should be performed to standardize qualitative CEUS features in order to diagnose primary hyperparathyroidism preoperatively. Presentation: 6/1/2024

8385 Coexistence of Parathyroid Adenoma & Papillary Thyroid Cancer: A Rare Case Report

Abstract Disclosure: K. Dash: None. S. Verma: None. U. Ayyagari: None. M. Roy: None. S. Rathore: None. Prevalence of primary hyperparathyroidism (pHPT) ranges from 0.1- 0.4% in general population. Nodular thyroid disease is an increasingly common incidental diagnosis due to widespread use of ultrasound. Papillary thyroid cancer (PTC) is the most common cancer of thyroid gland. Here we report a 53 year old post-menopausal woman presented with weight loss, generalised body aches, arthralgia, myalgia, and proximal muscle weakness. She was hypertensive and clinically euthyroid. Physical examination revealed generalized tenderness all over the body but no thyroid or parathyroid nodules on palpation. Biochemical evaluation showed hypercalcemia 12.1mg/dl (8.4-10.2mg/dl), PTH>2000pg/ml (14-72pg/ml), ALP-1855 U/L (40–125 U/L), decreased phosphorous of 2.4mg/dl (25-4.6 mg/dl), and vitamin-D of 46 nmol/L ( 75-250 nmol/L). USG neck revealed a heterogeneous lesion at the lower pole of right lobe of thyroid gland & two small hypoechoic nodules seen in the right lobe of thyroid gland. FNAC from nodules was inconclusive. USG abdomen revealed nephrocalcinosis. DEXA scan showed severe osteoporosis. Tc99mSestamibi SPECT-CT showed uptake at lower pole of right lobe of thyroid. On exploration, two nodules were palpated in the right lobe of the thyroid and simultaneous right hemi-thyroidectomy was performed. Histopathologic report confirmed parathyroid adenoma (figure 1) as well as presence of carcinoma in the two nodules: one was a papillary thyroid cancer (Classic variant) and the other a follicular variant of papillary thyroid carcinoma (figure 2). Margins were negative for malignancy. She was treated with levothyroxine to maintain TSH <0.1U/L and followed up with annual ultrasound screening. At 2 year follow up, patient was symptom free with improved T score on DEXA scan and no nodule over residual thyroid gland. Discussion: Co-existence of pHPT and PTC ranges from 2.3-4.3%. The use of ultrasound neck as a routine imaging modality for localisation of parathyroid adenoma allows detection of thyroid nodules. Benign and/or malignant thyroid nodules are commonly seen in patients with pHPT and this can range from 2-15%. Women have higher risk for co-existence. The relationship between the two diseases is thought to be incidental. Some authors have suggested possible role of shared genes, embryological factors, transcription factors, vitamin-D deficiency and hyperparathyroidism that could lead to activation of angiogenic factors and carcinogenesis. Fig. 1. Parathyroid adenoma. (a)Tc99m sestamibi scan showing right inferior parathyroid adenoma (b) Parathyroid adenoma (400x high power) comprising predominantly of Chief cells with mild pleomorphism. Fig. 2. Histopathology of PTC. (a)Papillary Carcinoma thyroid. 10xPhotomicrograph showing areas of calcification. (b) Papillary Carcinoma thyroid. Photomicrograph showing thyroid with papillary pattern with areas of infiltration. Presentation: 6/1/2024

6634 Dual-Mediated PTH And Osteolytic Hypercalcemia In Metastatic Endometrial Carcinoma

Abstract Disclosure: C.K. Persaud: None. D.J. Beckman: None. Background: Hypercalcemia of malignancy occurs in 20-30% of advanced stage cancer patients. Etiologies include parathyroid hormone-related peptides (PTHrP)-mediated, osteolytic metastases-mediated, overproduction of 1,25-dihydroxycholecalciferol, and rarely parathyroid hormone (PTH)-mediated. PTH-mediated hypercalcemia of malignancy is rare and occurs through ectopic PTH production or primary hyperparathyroidism. We report a rare case of both PTH-mediated and osteolytic-mediated hypercalcemia in the setting of malignancy. Clinical Case: A 57-year-old female with history of endometrial cancer and multiple solid organ metastasis, presented with two weeks of progressive poor oral intake, nausea, emesis, and right flank pain. On hospital admission, she had a serum calcium of >20.1 mg/dL (8.6-10.2), PTH of 203 pg/mL (15.0-65.0), and creatinine of 1.7 mg/dL (0.7-1.2, baseline 1.3). Non-contrasted CT chest/abdomen/pelvis noted increased size of known right adrenal metastasis, new left adrenal metastasis, periaortic lymphadenopathy, and scattered nodules in the subcutaneous tissues of the abdomen and chest, however bone metastasis were not noted. Patient’s hypercalcemia was treated with zoledronic acid, calcitonin, cinacalcet, and eventually denosumab due to difficulty controlling hypercalcemia. Additional labs obtained during evaluation included ionized calcium >2.5 nmol/L (1.12-1.32), PTHrP <2.0 pmol/L (<2.0), 1,25-dihydroxycholecalciferol <10 pg/mL (21-65). Patient’s right adrenal metastasis biopsy one month prior to admission was subsequently stained for PTH and was negative. Technetium-99m sestamibi scan was obtained for localization of parathyroid adenoma or carcinoma. The scan did not localize, however did show numerous new lytic lesions in the skull, spine, sternum, rib cage, and right humerus. Patient’s hospital course was complicated by progressively worsening renal function, anemia, and thrombocytopenia. Patient was discharged to a long-term acute rehab facility off hypercalcemia treatment with a corrected calcium of 10.0 mg/dL. Conclusion: PTH-mediated hypercalcemia is a rare cause of hypercalcemia of malignancy. PTH levels are typically low or low-normal in osteolytic mediated hypercalcemia. Generally, if PTH is elevated in hypercalcemia, an alternate etiology is not evaluated. This case highlights a rare dual-mediated hypercalcemia of malignancy. The patient’s PTH level elevation was discordant with her high degree of hypercalcemia and prolonged treatment course. She was subsequently found to have widespread bone metastases contributing to hypercalcemia. While multiple etiologies of hypercalcemia can be rare, it is important to evaluate for all contributing causes, especially with additional clinical conditions, such as malignancy. Presentation: 6/3/2024

Incidental synchronous intrathyroidal parathyroid carcinomas and papillary thyroid microcarcinoma with compressive neck mass and primary hyperparathyroidism: case report and literature review

BackgroundParathyroid carcinoma (PC) is a rare malignancy, often diagnosed incidentally through postoperative pathological examination. The occurrence of nodular goiter, intrathyroidal parathyroid carcinoma, contralateral parathyroid adenoma (PA), and papillary thyroid microcarcinoma (PTMC) is extremely uncommon, which prompted us to report our case experience.Case presentationWe describe a 67-year-old male who presented with a cervical mass causing tracheal compression, which prompted him to seek medical advice. Based on preoperative auxiliary examination results from color Doppler ultrasound, SPECT parathyroid imaging, and blood tests, he was initially diagnosed with a suspected parathyroid adenoma and nodular goiter. Excision of the right lobe and isthmus of the thyroid, and left superior parathyroid gland was conducted, which were sent to intraoperative frozen pathological examination. During intraoperative observation, adhesion around the right thyroid lobe was discovered. Consequently, right central area lymph node dissection was performed due to suspicion of an aggressive malignant tumor. Histology and immunohistochemistry analysis revealed incidental intrathyroidal parathyroid carcinoma, contralateral parathyroid adenoma, classical papillary thyroid microcarcinoma, and nodular goiter.ConclusionParathyroid carcinoma should be highly suspected when extremely high levels of PTH and severe hypercalcemia are present, which cannot be simply explained by a preoperatively localized parathyroid adenoma, especially when suspicious malignant adhesion is found during intraoperative exploration. In cases where multifocal thyroid nodules are associated with increased uptake of 99Tc-sestamibi, the possibility of coexisting carcinomas should be considered, not only for thyroid malignancy but also for the potential presence of intrathyroidal parathyroid carcinoma.

434 Determining the Utility of Early Phase [99mTc]Tc-MIBI Single-Photon Emission Computed Tomography with Contrast Enhanced Computerised tomography(SPECT/CECT) in Localisation of Parathyroid Adenomas for Surgical Planning

434 Determining the Utility of Early Phase [99mTc]Tc-MIBI Single-Photon Emission Computed Tomography with Contrast Enhanced Computerised tomography(SPECT/CECT) in Localisation of Parathyroid Adenomas for Surgical Planning

Dual-tracer subtraction scintigraphy combined with SPECT/CT in preoperative patients with primary hyperparathyroidism.

Abstract.

F18-Choline PET/CT or MIBI SPECT/CT in the Surgical Management of Primary Hyperparathyroidism

Whether F18-choline (FCH) positron emission tomographic (PET)/computed tomographic (CT) scan can replace Tc99m-sestaMIBI (MIBI) single-photon emission (SPE)CT/CT as a first-line imaging technique for preoperative localization of parathyroid adenomas (PTA) in patients with primary hyperparathyroidism (PHPT) is unclear. To compare first-line FCH PET/CT vs MIBI SPECT/CT for optimal care in patients with PHPT needing parathyroidectomy and to compare the proportions of patients in whom the first-line imaging method resulted in successful minimally invasive parathyroidectomy (MIP) and normalization of calcemia 1 month after surgery. A French multicenter randomized open diagnostic intervention phase 3 trial was conducted. Patients were enrolled from November 2019 to May 2022 and participated up to 6 months after surgery. The study included adults with PHPT and an indication for surgical treatment. Patients with previous parathyroid surgery or multiple endocrine neoplasia type 1 (MEN1) were ineligible. Patients were assigned in a 1:1 ratio to receive first-line FCH PET/CT (FCH1) or MIBI SPECT/CT (MIBI1). In the event of negative or inconclusive first-line imaging, they received second-line FCH PET/CT (FCH2) after MIBI1 or MIBI SPECT/CT (MIBI2) after FCH1. All patients underwent surgery under general anesthesia within 12 weeks following the last imaging. Clinical and biologic (serum calcemia and parathyroid hormone levels) assessments were performed 1 and 6 months after surgery. The primary outcome was a true-positive first-line imaging-guided MIP combined with uncorrected serum calcium levels of 2.55 mmol/l or less 1 month after surgery, corresponding to the local upper limit of normality. Overall, 57 patients received FCH1 (n = 29) or MIBI1 (n = 28). The mean (SD) age of patients was 62.8 (12.5) years with 15 male (26%) and 42 female (74%) patients. Baseline patient characteristics were similar between groups. Normocalcemia at 1 month after positive first-line imaging-guided MIP was observed in 23 of 27 patients (85%) in the FCH1 group and 14 of 25 patients (56%) in the MIBI1 group. Sensitivity was 82% (95% CI, 62%-93%) and 63% (95% CI, 42%-80%) for FCH1 and MIBI1, respectively. Follow-up at 6 months with biochemical measures was available in 43 patients, confirming that all patients with normocalcemia at 1 month after surgery still had it at 6 months. No adverse events related to imaging and 4 adverse events related to surgery were reported. This randomized clinical trial found that first-line FCH PET/CT is a suitable and safe replacement for MIBI SPECT/CT. FCH PET/CT leads more patients with PHPT to correct imaging-guided MIP and normocalcemia than MIBI SPECT/CT thanks to its superior sensitivity. ClinicalTrials.gov Identifier: NCT04040946.

Papillary Thyroid Cancer, Small Cell Lung Cancer, and Parathyroid Adenoma Synchronously Visualized on 99m Tc-MIBI SPECT/CT in a Patient With Hyperparathyroidism : Comparison With 18 F-FDG PET/CT.

99m Tc-MIBI scintigraphy is a nuclear medicine imaging modality commonly used for the preoperative localization of parathyroid adenomas in patients with hyperparathyroidism. In addition, 99m Tc-MIBI can also be used for imaging various tumors due to its unique mechanism of intracellular accumulation. Here, we introduced a case of a single 99m Tc-MIBI SPECT/CT simultaneously visualized two different malignant tumors, such as papillary thyroid cancer and small cell lung cancer, along with a parathyroid adenoma in a patient with hyperparathyroidism. The clinical usefulness of 99m Tc-MIBI SPECT/CT was also explored by comparing it with 18 F-FDG PET/CT among the three tumors.

The utility of contrast-enhanced ultrasound (CEUS) in the preoperative localization of parathyroid gland adenomas

The utility of contrast-enhanced ultrasound (CEUS) in the preoperative localization of parathyroid gland adenomas

AB130. SOH24AB_066. Evaluating the combined approach of three intra-operative adjuncts in localizing parathyroid adenomas during minimally invasive radio-guided parathyroidectomy: a single center retrospective analysis

AB130. SOH24AB_066. Evaluating the combined approach of three intra-operative adjuncts in localizing parathyroid adenomas during minimally invasive radio-guided parathyroidectomy: a single center retrospective analysis

Parathyroid fine needle aspiration with PTH washout: Can it lead to parathyroid cell seeding in primary hyperparathyroidism?

Although parathyroid fine-needle aspiration (P-FNA) with parathyroid hormone (PTH) washout is effective in detecting preoperative parathyroid lesions, it also presents risks such as fibrosis, hematoma, and, in rare cases, tumor seeding. This study aimed to investigate whether P-FNA with PTH washout leads to the seeding of parathyroid cells along the path of the needle. A retrospective analysis was conducted on patients undergoing minimally invasive parathyroidectomy guided by preoperative PTH washout. Permanent pathology reports, imaging data, and postoperative serum parathyroid hormone and calcium levels were assessed to determine the effectiveness and safety of the procedure. Complications following P-FNA with PTH washout were also reviewed using data from the patient registration system of Bulent Ecevit University. The procedure accurately localized parathyroid adenomas in 87 patients who underwent ultrasound-guided parathyroidectomy following preoperative P-FNA and PTH washout. Postoperatively, 75 patients showed normal parathyroid hormone and calcium levels. Two patients required secondary surgery for contralateral adenomas. Critically, there was no evidence of P-FNA with PTH washout-induced parathyromatosis or seeding during the follow-up. Effective adenoma localization is crucial for successful minimally invasive surgery of hyperparathyroidism. Our study indicates that combining preoperative P-FNAB with PTH washout and imaging enhances adenoma detection, especially when intraoperative PTH measurements are not available, thus improving surgical outcomes. Notably, we found no evidence of cell implantation after P-FNA, suggesting the safety and efficacy of this method for preventing parathyroid cell seeding.

Preoperative Lateralization and Diagnostic Value of Selective Bilateral Internal Jugular Venous Sampling in Primary Hyperparathyroidism: Single-Center Experience.

Background and Objectives: Primary hyperparathyroidism (pHPT) is a common endocrine disorder caused by excessive production of parathyroid hormone (PTH) leading to elevated calcium levels. Diagnosis is primarily based on biochemical evaluation, and surgery is the curative treatment. Imaging techniques like ultrasound and Tc-99m Sestamibi scintigraphy are used for localization, but selective Internal Jugular Venous (SVS) becomes valuable in cases of inconclusive or conflicting results. This study evaluated the diagnostic efficacy of SVS for localizing parathyroid adenomas in cases where non-invasive radiological diagnostic methods yielded inconclusive results or negative findings despite clinical symptoms suggestive of pHPT. Materials and Methods: In this retrospective study, a total of 28 patients diagnosed with pHPT underwent SVS at a tertiary center known for receiving referrals from 2017 to 2022. The diagnoses were confirmed through biochemical analysis. The SVS results in 22 patients were compared with non-invasive imaging methods, including ultrasound, scintigraphy, and computed tomography with/without contrast material. SVS was indicated when at least two non-invasive diagnostic procedures failed to clearly localize the parathyroid glands or provided ambiguous results. Results: SVS demonstrated higher sensitivity for localizing parathyroid adenomas compared to non-invasive imaging methods, accurately lateralizing the adenoma in 68.18% of cases. Among the SVS findings, 31.8% of patients had negative results, with 9.1% not having clinically proven parathyroid adenoma, while 22.7% had false negative SVS findings but were later confirmed to have adenoma during surgery. Ultrasound correctly identified the location in 45.45% of cases, CT in 27.27%, and scintigraphy in 40.9%. Conclusions: SVS is a valuable diagnostic tool for accurately localizing parathyroid adenomas in patients with inconclusive non-invasive imaging results. It aids in targeted surgical interventions, contributing to improved management and treatment outcomes in primary hyperparathyroidism.

Four-Dimensional Computed Tomography for Parathyroid Adenoma Localization: A Pre-Operative Imaging Protocol.

Primary hyperparathyroidism (PHPT) affects approximately 0.86% of the population, with surgical resection as the treatment of choice. A 4D computed tomography (CT) is a highly effective tool in localizing parathyroid adenomas; however, there is currently no defined role for 4D CT when stratified against ultrasonography (USG) and nuclear medicine Technetium Sestamibi SPECT/CT (SES) imaging. Retrospective Study. University Hospital. All patients who underwent parathyroidectomy for PHPT between 2014 and 2019 at a single institution were reviewed. Patients who had a 4D CT were included. We compared outcomes of 4D CT as a second line imaging modality to those of USG and SES as first line modalities. An imaging algorithm was proposed based on these findings. There were 84 patients identified who had a 4D CT after unsuccessful first line imaging. A 4D CT localized parathyroid adenoma to the correct quadrant in 64% of cases, and to the correct laterality in 75% of cases. Obese patients had significantly lower rates of adenoma localization with USG (33.4%), compared to non-obese patients (67.5%; P = .006). In determining multigland disease the sensitivity of 4D CT was 86%, while the specificity was 87%. A 4D CT has impressive rates of accurate localization of parathyroid adenomas; however due to the radiation exposure involved, it should remain a second line imaging modality. PHPT patients should first be evaluated with USG, with 4D CT used if this is unsuccessful and patients are greater than 40 years old, have a high BMI, or are having revision surgery.