Parathyroid Glands In Primary Hyperparathyroidism Research Articles

Correlation Between Near-Infrared Autofluorescence Properties and Sestamibi Uptakes of Parathyroid Glands in Primary Hyperparathyroidism.

Near-infrared autofluorescence (NIRAF) characteristics of parathyroid glands in primary hyperparathyroidism (pHPT) vary, with unclarity regarding the underlying mechanism. Similarly, 99mTc-sestamibi uptake in diseased parathyroid glands is variable. There is a suggestion that oxyphilic cell content may influence both imaging modalities. This study aims to analyze the relationship between NIRAF imaging characteristics, 99mTc-sestamibi uptake, and cellular composition in pHPT. Retrospective analysis of an Institutional Review Board-monitored prospective database. Single tertiary referral center. NIRAF characteristics of parathyroid glands of patients with pHPT between 2019 and 2024 were compared with 99mTc-sestamibi scan findings from a prospective database. Using third-party software, brightness intensity and heterogeneity index (HI) of the glands were calculated. A subgroup of parathyroid glands obtained from consecutive patients with pHPT in 2020 to 2021 underwent histological analysis. A total of 428 patients with 638 diseased parathyroid glands were analyzed. Forty-seven percent of the glands showed an uptake on 99mTc-sestamibi scans. The brightness intensity of the NIRAF signals from parathyroid glands that were seen versus not seen on sestamibi was 2.1 versus 2.3 (P = .002) and HI 0.18 versus 0.17 (P = .35), respectively. On multivariate analysis, low autofluorescence intensity, high gland volume, and single adenoma were associated with detectability on 99mTc-sestamibi scan (P < .0001). Intraglandular adipose tissue content was lower in diseased glands that were detected on 99mTc-sestamibi scans (0% vs 5%, P < .0001). Our findings indicate an inverse relationship between autofluorescence intensity and detectability on 99mTc-sestamibi scans and a lack of correlation between different cell types and autofluorescence properties.

Near-Infrared Autofluorescence Signature: A New Parameter for Intraoperative Assessment of Parathyroid Glands in Primary Hyperparathyroidism.

The success of parathyroidectomy in primary hyperparathyroidism depends on the intraoperative differentiation of diseased from normal glands. Deep learning can potentially be applied to digitalize this subjective interpretation process that relies heavily on surgeon expertise. In this study, we aimed to investigate whether diseased versus normal parathyroid glands have different near-infrared autofluorescence (NIRAF) signatures and whether related deep learning models can predict normal versus diseased parathyroid glands based on intraoperative in-vivo images. This prospective study included patients who underwent parathyroidectomy for primary hyperparathyroidism or thyroidectomy using intraoperative NIRAF imaging at a single tertiary referral center from November 2019 to March 2024. Autofluorescence intensity and heterogeneity index of normal versus diseased parathyroid glands were compared, and a deep learning model was developed. NIRAF images of a total of 1,506 normal and 597 diseased parathyroid glands from 797 patients were analyzed. Normal versus diseased glands exhibited a higher median normalized NIRAF intensity [2.68 (2.19-3.23) vs 2.09 (1.68-2.56) pixels, p<.0001] and lower heterogeneity index [0.11 (0.08-0.15) vs 0.18 (0.13-0.23), p<.0001]. On receiver operating characteristics analysis, optimal thresholds to predict a diseased gland were 2.22 in pixel intensity and 0.14 in heterogeneity index. On deep learning, precision and recall of the model were 83.3% each, and area under the precision-recall curve (AUPRC) was 0.908. Normal and diseased parathyroid glands in primary hyperparathyroidism have different intraoperative NIRAF patterns that could be quantified with intensity and heterogeneity analyses. Visual deep learning models relying on these NIRAF signatures could be built to assist surgeons in differentiating normal from diseased parathyroid glands.

The usefulness of 18F-choline PET/CT in patients with negative findings on 99mTc-sestamibi SPECT/CT in Locating Hyperfunctioning Parathyroid Glands in Primary Hyperparathyroidism

The usefulness of 18F-choline PET/CT in patients with negative findings on 99mTc-sestamibi SPECT/CT in Locating Hyperfunctioning Parathyroid Glands in Primary Hyperparathyroidism

Evaluation of Surgeon-Performed Ultrasonography With or Without Contrast Enhancement vs Scintigraphy in Patients With Primary Hyperparathyroidism

Scintigraphy and ultrasonography are common imaging modalities for the preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism. When comparing the 2 modalities, the benefits of ultrasonography in terms of convenience, patient comfort, duration, cost, and lack of radiation should be taken into account. To investigate whether surgeon-performed ultrasonography, with or without contrast-enhanced ultrasonography (CEUS), is noninferior to scintigraphy for localizing pathological parathyroid glands in patients with primary hyperparathyroidism. Prospective, paired, noninferiority cohort study performed at a high-volume tertiary referral center for parathyroidectomy with blinded examiners and a 6-month follow-up. Participants were adults (age ≥18 years) referred for parathyroidectomy due to primary hyperparathyroidism. Of 207 eligible patients, 35 were excluded, leaving 172 enrolled in the study. Inclusion lasted from September 2019 until February 2021. Follow-up ended in December 2021. 99mTechnetium-pertechnetate/99mtechnetium-sestamibi subtraction scintigraphy with 99mtechnetium-sestamibi single-photon emission computed tomography/computed tomography, followed by surgeon-performed ultrasonography and CEUS. The sensitivity of each imaging modality in localizing pathological parathyroid glands, calculated on a per-quadrant and a per-patient basis, respectively. The a priori noninferiority margin was a lower 95% confidence limit for the difference in sensitivity not falling below -10%. Out of 172 participants, 139 (80.8%) were women, the median (range) age was 65 (24-87) years, and the median (IQR) follow-up was 200.5 (181-280.25) days. Quadrant sensitivity (95% CI) was 70.9% (63.2%-78.5%) for ultrasonography, 68.4% (60.4%-76.5%) for ultrasonography plus CEUS, and 67.0% (60.0%-74.0%) for scintigraphy. The sensitivity difference (95% CI) compared with scintigraphy was 3.9% (-4.1% to 11.8%) for ultrasonography and 1.5% (-6.4% to 9.3%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. Per-patient sensitivity was 81.4% (74.8%-86.9%) for ultrasonography and 79.1% (72.2%-84.9%) for both scintigraphy and ultrasonography plus CEUS. The sensitivity difference compared with scintigraphy was 2.3% (-6.8% to 11.4%) for ultrasonography and 0.0% (-9.1% to 9.1%) for ultrasonography plus CEUS, establishing noninferiority for both modalities. In this cohort study, conventional ultrasonography by an experienced parathyroid surgeon-sonographer was noninferior to scintigraphy and may constitute a valid first-line imaging modality in patients with primary hyperparathyroidism, even without the addition of CEUS. Further imaging should be reserved for cases that are equivocal or nonlocalizing on ultrasonography.

Smaller parathyroids have higher near-infrared autofluorescence intensity in hyperparathyroidism

BackgroundIntraoperative parathyroid gland identification can be challenging. Parathyroid glands have an intrinsic autofluorescence when excited by wavelengths in the near-infrared region. Studies using near-infrared cameras to detect parathyroid gland near-infrared autofluorescence have suggested improved identification. The pathologic parathyroid glands in primary hyperparathyroidism have variable near-infrared autofluorescence intensity, but how this correlates with different characteristics of hyperparathyroidism is unknown. Our objective was to correlate the fluorescent intensity of excited glands with clinical variables to enhance a surgeon’s ability to identify parathyroid glands. MethodsThe data on patients undergoing surgery for primary hyperparathyroidism were collected. The images were collected intraoperatively with a handheld near-infrared device and analyzed. The data consisted of the ratio of mean parathyroid gland near-infrared autofluorescence over background (white gauze) near-infrared autofluorescence. The variables assessed for correlation with autofluorescence intensity were gland volume and weight, preoperative serum calcium and parathyroid hormone, age, body mass index, and sex. The images were quantified by Image J software (National Institutes of Health, Bethesda, MD). The lasso regression was analyzed by R version 4.1.3 to calculate adjusted P values (R Foundation for Statistical Computing, Vienna, Austria). ResultsFrom 2017 to 2021, 131 patients with primary hyperparathyroidism underwent parathyroidectomies of 151 parathyroid glands. The mean near-infrared autofluorescence intensity of parathyroid glands had a negative correlation with weight with lighter glands fluorescing more (P = .019) and a positive correlation with age with glands from older patients fluorescing more (P = .013). There were no significant correlations with preoperative serum calcium and parathyroid hormone, body mass index, and sex (P > .05). ConclusionIn patients with primary hyperparathyroidism, we found that autofluorescence intensity correlated with parathyroid gland weight and patient age. This suggested that near-infrared camera use may be particularly helpful in identifying smaller adenomas and in older patients.

Invited Commentary: Can Imaging Alone Predict the Number of Abnormal Parathyroid Glands in Primary Hyperparathyroidism?

Journal of the American College of Surgeons: August 2022 - Volume 235 - Issue 2 - p 340-341 doi: 10.1097/XCS.0000000000000237

C-11 methionine positron emission tomography scans improve the preoperative localization of pathologic parathyroid glands in primary hyperparathyroidism.

Preoperative localization of pathologic parathyroid glands is essential in the preparation of a parathyroidectomy. We evaluated the use of a C-11 methionine positron emission tomography/computed tomography scan in a 7-year period in selected patients with primary hyperparathyroidism. The indications to perform a C-11 methionine positron emission tomography/computed tomography were either persistent primary hyperparathyroidism after parathyroidectomy or inconclusive preoperative localization on ultrasound and sestaMIBI. A group of 36 patients was referred for a C-11 methionine positron emission tomography/computed tomography. Biochemical data, pathology, and results of sestaMIBI were collected retrospectively. The primary hyperparathyroidism patients were divided into two groups. In group 1 (N = 17), the C-11 methionine positron emission tomography/computed tomography was performed before parathyroidectomy. In group 2 (N = 19), the C-11 methionine positron emission tomography/computed tomography was performed after unsuccessful parathyroidectomy and before a reoperation. Overall, in 30 of the 36 patients (83%), C-11 methionine positron emission tomography/computed tomography identified a true-positive pathologic parathyroid gland confirmed by an experienced pathologist, consistent with a positive predictive value of 91%. In group 1, 94% of the patients (N = 16) had pathologic parathyroid tissue identified by C-11 methionine positron emission tomography/computed tomography. This resulted in a clinical benefit in 13 patients (76%). In group 2, the benefit was slightly lower, as 74% of the patients (N = 14) had a true-positive C-11 methionine positron emission tomography/computed tomography scan resulting in a clinical benefit in nine patients (47%). In two selected groups of patients planned for an initial operation or reoperation of primary hyperparathyroidism and inconclusive conventional imaging, we found C-11 methionine positron emission tomography/computed tomography to give parathyroid surgeons a clinical benefit in the majority of cases, electing the patients for unilateral surgery.

Locating hyperfunctioning parathyroid glands using 11C-Choline PET/CT: an inter- and intra-observer variation study

BackgroundUse of 11C-Choline PET/CT is gaining ground in detecting hyperfunctioning parathyroid glands in primary hyperparathyroidism. The purpose of this study was to evaluate the robustness of 11C-Choline PET/CT by assessing intra- and inter-observer agreement to determine whether the method was reader sensitive and therefore should only be performed at highly specialised sites with a high number of cases.PET/CT images of 40 patients diagnosed with primary hyperparathyroidism were anonymised and evaluated three times by three readers: an expert reader and two non-experts (non-experts were experienced in PET/CT imaging, but not in 11C-Choline PET/CT in the setting of primary hyperparathyroidism). Number of hyperfunctioning parathyroid glands, location relative to the thyroid gland and confidence of each assessment (low, moderate or high) were noted, and intra- and inter-observer agreement calculated using Fleiss’ kappa method. Sensitivities and specificities of the non-experts were calculated using the expert reader as gold standard.ResultsIntra-observer agreement was ‘good’ to ‘near perfect’ for all readers. Inter-observer agreement was good between non-experts and the expert, with kappa values ≥ 0.74. Sensitivities between non-experts and the expert were high, > 81%, when assessing which side and 75% when assessing thyroid quadrant. All specificities were > 94%. Reader certainties were ‘high’ in > 80% of cases for the expert and > 70% and > 65%, respectively for the two non-experts.Conclusion11C-Choline PET/CT is not reader sensitive for the localisation of hyperfunctioning parathyroid glands and may therefore be safely implemented at sites that have a moderate number of cases. Access to a cyclotron laboratory is, however, a necessity for the production of 11C-Choline.The study was conducted in accordance with the Helsinki 2 declaration and The International Council for Harmonisation Guideline for Good Clinical Practice (ICH_GCP) clinical trial, approved by the Research Ethics Committee of the Capital Region of Denmark (Journal-nr.:H-18012490, date of approval: 18 June 2018) and the Danish Medicines Agency (EudraCT no. 2018-000726-63, date of approval: 6 June 2018). The GCP unit in Eastern Denmark has carried out regular monitoring of the trial according to GCP (ID: 2018-1050).

Pediatric hyperparathyroidism: review and imaging update

Hyperparathyroidism, due to increased secretion of parathyroid hormones, may be primary, secondary or tertiary. Most pediatric patients with sporadic primary hyperparathyroidism will be symptomatic, presenting with either end-organ damage or nonspecific symptoms. In younger patients with primary hyperparathyroidism, there is a higher prevalence of familial hyperparathyroidism including germline inactivating mutations of the calcium-sensing receptor genes that result in either neonatal severe hyperparathyroidism or familial hypocalciuric hypercalcemia. Parathyroid scintigraphy and ultrasound are complementary, first-line imaging modalities for localizing hyperfunctioning parathyroid glands. Second-line imaging modalities are multiphase computed tomography (CT) and magnetic resonance imaging. In pediatrics, multiphase CT protocols should be adjusted to optimize radiation dose. Although, the role of these imaging modalities is better established in preoperative localization of hyperfunctioning parathyroid glands in primary hyperparathyroidism, the same principles apply in secondary and tertiary hyperparathyroidism. In this manuscript, we will review the embryology, anatomy, pathophysiology and preoperative localization of parathyroid glands as well as several subtypes of primary familial hyperparathyroidism. While most of the recent imaging literature centers on adults, we will focus on the issues that are pertinent and applicable to pediatrics.

The EANM practice guidelines for parathyroid imaging

IntroductionNuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration.MethodsOver a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT.ConclusionThese guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.

Development of an algorithm for intraoperative autofluorescence assessment of parathyroid glands in primary hyperparathyroidism using artificial intelligence

BackgroundPrevious work showed that normal and abnormal parathyroid glands exhibit different patterns of autofluorescence, with the former appearing brighter and more homogenous. However, an objective algorithm based on quantified measurements was not provided. The aim of this study is to develop objective algorithms for intraoperative autofluorescence assessment of parathyroid glands in primary hyperparathyroidism using artificial intelligence. MethodsThe utility of near-infrared fluorescence imaging in parathyroidectomy procedures was evaluated in a study approved by the institutional review board. Autofluorescence patterns of parathyroid glands were measured intraoperatively. Comparisons were performed between normal and abnormal glands, as well as between different pathologies. Using machine learning, decision trees were created. ResultsNormal parathyroid glands were brighter (higher normalized autofluorescence pixel intensity) and more homogenous (lower heterogeneity index) compared to abnormal glands. Optimal cutoffs to differentiate normal from abnormal parathyroid glands were >2.0 for normalized autofluorescence intensity (sensitivity 73%, specificity 70%, area under the curve 0.756) and <0.12 for parathyroid heterogeneity index (sensitivity 75%, specificity 81%, area under the curve 0.839). Decision trees created by machine learning using normalized autofluorescence intensity, heterogeneity index, and gland volume were 95% accurate in predicting normal versus abnormal glands and 84% accurate in predicting subclasses of parathyroid pathologies. ConclusionTo our knowledge, this is the first study to date reporting objective algorithms using quantified autofluorescence data to intraoperatively assess parathyroid glands in primary hyperparathyroidism. These results suggest that objective data can be obtained from autofluorescence signals to help differentiate abnormal parathyroid glands from normal glands.

11C-Choline PET/CT vs. 99mTc-MIBI/123Iodide Subtraction SPECT/CT for Preoperative Detection of Abnormal Parathyroid Glands in Primary Hyperparathyroidism: A Prospective, Single-Centre Clinical Trial in 60 Patients

Background: In patients with primary hyperparathyroidism (PHPT) locating hyperfunctioning glands (HPGs) is crucial when planning minimally invasive surgery. Dual-isotope subtraction scintigraphy with 99mTc-MIBI/123Iodide using SPECT/CT and planar pinhole imaging (Method A) has previously shown a sensitivity >93%. However, the method is costly and time consuming and entails a high radiation dose. 11C-Choline PET/CT (Method B) is an appealing candidate method unencumbered by these disadvantages. Methods: Sixty patients with newly diagnosed PHPT participated and were scanned using both methods prior to parathyroidectomy. We investigated whether sensitivities of Method A and Method B are similar in a method-to-method comparison when using surgical findings as the true location. Results: At the patient level, sensitivities were (A) 0.98 (95% CI: 0.90–1.00) and (B) 1.00 (95% CI: 0.93–1.00). At the gland level, sensitivities were (A) 0.88 (95% CI: 0.78–0.94) and (B) 0.87 (95% CI: 0.76–0.92). With a non-inferiority margin of ∆ = −0.1, we found a 1-sided p-value < 0.001. Conclusion: Our methods comparison study found that sensitivity of Method B was not inferior to Method A. We suggest that 11C-Choline PET/CT is a clinically relevant first-choice candidate for preoperative imaging of PHPT and that Method B can likely replace Method A in the near future.

Imaging methods of the parathyroid glands in primary hyperparathyroidism. Literature review

Primary hyperparathyroidism (PHPT) is a common endocrine disease that occurs with multiple profiles in which no classical manifestation. Diagnosis revolves around routine measurement of serum calcium and parathyroid hormone more than in half cases. The understanding of clinical presentation, epidemiology and management tactics of patients with hyperparathyroidism has significantly changed by virtue of the use of biochemical calcium screening.&#x0D; The successful diagnosis and treatment are possible with the cooperation of a multidisciplinary team of endocrinologist, endocrine surgeon, radiologist, nuclear medicine physician and pathomorphologist.&#x0D; The only radical method of treatment is the surgical removal of abnormal parathyroid glands. In this regard, there is necessary to improve the parathyroid glands imaging algorithms.&#x0D; Early treatment of hyperparathyroidism allows to avoid severe damage to the bones, kidneys, heart, other organs, improving the quality of life and reducing the incidence of disability.&#x0D; For a systematic literature review, more than 100 articles published from 2000 to the present time were used, on following resources: PubMed, Embase, SciSearch, Scopus, Cochrane Databases, Research Gate, Google Scholar. Including recommendations from the American Association of Endocrinologists and Endocrine Surgeons (AACE/AAES), European Society of Nuclear Medicine (EANM), European Society ofEndocrinologists (ESE), Russian Association of Endocrinologists (RAE) and several other organizations.&#x0D; The main goal of this review is to summarize and present relevant information and a new look on preoperative imaging techniques, methods of intraoperative navigation, surgery, control quality of treatment in patients with primary hyperparathyroidism.

The Significance of Histologically "Large Normal" Parathyroid Glands in Primary Hyperparathyroidism.

We investigated outcomes in a cohort of patients with a biochemical diagnosis of primary hyperparathyroidism (pHPT) undergoing surgery for asymptomatic disease or target organ damage, where a focussed or four-gland operation was undertaken and the histopathology only reported a "large normal" parathyroid gland (LNP). Patients subjected to a parathyroidectomy for pHPT between 2012 and 2018 with a pathology of LNP were included. Patients with fat depletion or additional histological features of adenoma or hyperplasia in any of the resected glands were excluded. A control group was formed from 50 consecutive patients with the histological finding of adenoma or hyperplasia during the same study period. The primary outcome was biochemical normalisation of pHPT at 1-2weeks and after 6 months post-operatively. Forty-eight LNP patients (2% of all parathyroidectomies) were included in the study group with 50 matched controls. LNP patients had a lower biochemical cure rate (81% vs. 98% P < 0.05) and a higher risk of recurrence (10% vs. 0%, P = 0.06). LNP patients had a milder form of pHPT (Ca2+ 2.63 vs. 2.68 P < 0.05) with a smaller PTH and Ca2+ drop post-operatively. For LNP patients with failure, a definite additional cause of pHPT was found in only two patients. This study highlights a controversial area in pHPT and reports LNP as a cause of pHPT. The biochemical analysis of this LNP group supports a benefit in resection in the setting of pHPT, although the risk of failure (persistence/recurrence) is higher than those with adenoma or hyperplasia. Stricter post-operative follow-up of LNP patients should be considered.

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.

PETC/CT with 18F-Choline localizes hyperfunctioning parathyroid adenomas equally well in normocalcemic hyperparathyroidism as in overt hyperparathyroidism.

Identification of pathologic parathyroid glands in primary hyperparathyroidism, traditionally based on neck ultrasound (US) and/or 99mTc-Sestamibi scintigraphy, can be challenging. PET/CT with 18F-Fluorocholine (18F-FCH) might improve the detection of pathologic parathyroid glands. We aimed at comparing the diagnostic performance of 18F-FCH-PET/CT with that of dual-phase dual-isotope parathyroid scintigraphy and neck US. Thirty-four consecutive patients with primary hyperparathyroidism were prospectively enrolled, 7 had normocalcemic hyperparathyroidism, and 27 had classic hypercalcemic hyperparathyroidism. All patients underwent high-resolution neck US, dual-phase dual-isotope 99mTc-Pertechnetate/99mTc-Sestamibi scintigraphy, and 18F-FCH-PET/CT. In the whole patients' group, the detection rates of the abnormal parathyroid gland were 68% for neck US, 71% for 18F-FCH-PET/CT, and only 15% for 99mTc-Sestamibi scintigraphy. The corresponding figures in normocalcemic and hypercalcemic hyperparathyroidism were 57 and 70% for neck US, 70 and 71% for 18F-FCH-PET/CT, and 0 and 18% for 99mTc-Sestamibi scintigraphy, respectively. In the 17 patients in whom the abnormal parathyroid gland was identified, either at surgery or at fine needle aspiration cytology/biochemistry, the correct detection rate was 82% for neck US, 89% for 18F-FCH-PET/CT, and only 17% for 99mTc-Sestamibi scintigraphy. 18F-FCH-PET/CT can be considered a first-line imaging technique for the identification of pathologic parathyroid glands in patients with normocalcemic and hypercalcemic hyperparathyroidism, even when the parathyroid volume is small.

Challenging pre-surgical localization of hyperfunctioning parathyroid glands in primary hyperparathyroidism: the added value of 18F-Fluorocholine PET/CT.

To evaluate the added value of 18F-Fluorocholine (18F-FCH) PET/CT in presurgical imaging of patients with primary hyperparathyroidism (HPT) and challenging localization of the hyper-functioning parathyroid glands. We included 27 consecutive patients with primary HPT (19 F; median age: 58 years), with either (i) non-conclusive pre-surgical localization with 99mTc-sestaMIBI scintigraphy and neck ultrasonography (US), (ii) recurrence of previously operated HPT, or (iii) familiar HPT with a suspicion of multiple gland disease. Histological findings and resolution of HPT were considered as the gold standard. 18F-FCH PET/CT was positive in 24/27 patients. Twenty-one patients underwent surgery with 27 resected lesions (14 adenomas, 11 hyperplastic glands, two hyper-functioning histologically normal glands), with resolution of HPT in 19/21 patients (90%). 18F-FCH PET/CT localized 22 lesions in 17/21 patients (per patient: sensitivity 81%, positive predictive value (PPV) 94%; per gland: sensitivity 76%, PPV 85%, specificity 91%, negative predictive value (NPV) 86%). 18F-FCH PET/CT found eight lesions which were undetectable on both 99mTc-sestaMIBI scintigraphy and US. In patients with a familial HPT and/or a multiple gland disease, sensitivity was 100 and 79% on a per-patient and a per-gland analysis respectively, while NPV was 63%. In six patients with a persistence or recurrence of previously treated HPT, 18F-FCH PET/CT localized all lesions, both in sporadic and familiar disease. 18F-FCH PET/CT is a promising modality in challenging pre-surgical localization of hyper-functioning parathyroid glands, such as inconclusive standard imaging, recurrence after surgery, or suspected multiple gland disease.

Surgical treatment of giant adenomas of parathyroid glands in primary hyperparathyroidism

Первичный гиперпаратиреоз (ПГПТ) является тяжелым инвалидизирующим заболеванием. Отсутствие скрининга гиперкальциемии в РФ – серьезная преграда для своевременного оказания специализированной хирургической помощи пациентам с данной патологией. Выявление ПГПТ на ранних этапах и оперативное удаление аденом околощитовидных желез позволяют предупредить развитие осложнений как со стороны почек, так и со стороны других органов и систем. Представлены два клинических наблюдения хирургического лечения больных ПГПТ с гигантскими аденомами околощитовидных желез: 5,8 × 3,5 × 1,5 см, весом 16,5 г и 6,0 × 3,5 × 2,5 см, весом 40 г. В обоих случаях отмечали высокие уровни паратгормона и общего кальция: 586,7 пг/мл; 3,12 ммоль/л и 876 пг/мл; 3,55 ммоль/л соответственно. В обоих случаях выявляется позднее обнаружение аденом околощитовидных желез и несвоевременное направление пациентов на лечение к хирургу-эндокринологу.&#x0D; Оба пациента прооперированы. Послеоперационный период без осложнений. Удаление аденом выполняли под визуальным контролем возвратных нервов. В раннем послеоперационном периоде отмечалось резкое снижение паратгормона и ионизированного кальция, что подтверждало адекватность проведенного лечения. Больные выписаны в удовлетворительном состоянии под наблюдение хирурга и эндокринолога поликлиники.

Role of Imaging Tests for Preoperative Location of Pathologic Parathyroid Tissue in Patients with Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) can be cured by parathyroidectomy, and the preoperative location of enlarged pathologic parathyroid glands is determined by imaging studies, especially cervical ultrasonography and scintigraphy scanning. The aim of this retrospective study was to evaluate the use of preoperative cervical ultrasonography and/or parathyroid scintigraphy in locating pathologic parathyroid tissue in a group of patients with PHPT followed in the same endocrine center. We examined the records of 61 patients who had undergone parathyroidectomy for PHPT following (99m)Tc-sestamibi scintigraphy scan and/or cervical ultrasonography. Scintigraphic and ultrasonographic findings were compared to histopathologic results of the surgical specimens. Ultrasonography detected enlarged parathyroid glands in 87% (48/55) of patients with PHPT and (99m)Tc-sestamibi scintigraphy in 79% (37/47) of the cases. Ultrasonography was able to correctly predict the surgical findings in 75% (41/55) of patients and scintigraphy in 72% (34/47). Of 7 patients who had negative ultrasonography, scintigraphy correctly predicted the surgical results in 2 (29%). Of 10 patients who had negative scintigraphy, ultrasonography correctly predicted the surgical results in 4 (40%). When we analyzed only patients with solitary eutopic parathyroid adenomas, the predictive positive values of ultrasonography and scintigraphy were 90% and 86%, respectively. Cervical ultrasonography had a higher likelihood of a correct positive test and a greater predictive positive value for solitary adenoma compared to (99m)Tc-sestamibi and should be used as the first diagnostic tool for preoperative localization of affected parathyroid glands in PHPT. Ca = calcium IEDE = Instituto Estadual de Diabetes e Endocrinologia Luiz Capriglione PHPT = primary hyperparathyroidism PTH = parathyroid hormone.

Incidentalomas during imaging for primary hyperparathyroidism--incidence and clinical outcomes.

BackgroundImaging for pre-operative localisation of parathyroid glands in primary hyperparathyroidism is now routine. This has led to the detection of incidental lesions (incidentalomas) in other organs, the nature of which is not well characterised.The aim of this study was to determine the incidence, characteristics and outcomes in patients who had incidental findings on parathyroid imaging.MethodsRecords of patients who underwent imaging for primary hyperparathyroidism over 2 years were reviewed to identify incidental lesions detected on parathyroid imaging. Patients with persistent or renal hyperparathyroidism were excluded. Details on the management of detected incidentalomas were obtained from patient records.ResultsIncidentalomas were identified in 17 of 170 patients (10 %) undergoing parathyroid imaging. Incidentalomas included thyroid (n = 11), breast (n = 3), lateral compartment of the neck (n = 1), lung (n = 1) and clavicle (n = 1). However, no disease of clinical significance needing treatment was detected on further investigation.ConclusionsAlthough a significant proportion of patients undergoing parathyroid imaging had incidental lesions detected, these seem to be of little clinical significance. The morbidity and cost of further interventions on these incidentalomas need to be weighed against the benefits of routine imaging in improving outcomes of first-time surgery in patients with primary hyperparathyroidism.