Parathyroid Ultrasonography Research Articles

Accuracy of Four-Dimensional Computed Tomography and Different Imaging Modalities in Primary Hyperparathyroidism.

Background This study aimed to compare the accuracy of different imaging modalities in the preoperative localization of parathyroid pathology in primary hyperparathyroidism. Methodology This prospective study enrolled 70 patients who were biochemically diagnosed with primary hyperparathyroidism between 2021 and 2022 at our center. Patients underwent scanning using three imaging modalities, namely, Tc99m sestamibi scan (sestamibi), parathyroid ultrasonography, and four-dimensional computed tomography (4DCT). A descriptive analysis was performed to determine and compare the respective localizing sensitivities. Results The most common site of parathyroid adenoma (PA) was the left inferior parathyroid gland, seen in 28 (40%) patients. Three patients had false-positive imaging studies with no parathyroid pathology identified surgically or on histological examination. The median levels of parathyroid hormone decreased significantly (p < 0.001) after the surgery, with a median of 24.3 (1.90-121). Furthermore, 4DCT accomplished a sensitivity of 97.14% for diagnosing the side and 94.03% for overall localization of PA. This sensitivity was superior to the sensitivity of ultrasonography and sestamibi scan to detect the side and quadrant of the adenoma. 4DCT was significantly higher in sensitivity when compared to the combination of ultrasound and sestamibi (p < 0.001). Conclusions 4DCT yielded the highest sensitivity in localizing parathyroid pathology from the imaging modalities studied with the lowest false-negative rate. Using ultrasound with 4DCT could be the most cost-effective combination for detecting primary hyperparathyroidism.

Effects of Cinacalcet on Post-transplantation Hypercalcemia and Hyperparathyroidism in Adult Kidney Transplant Patients: A Single-Center Experience.

Secondary hyperparathyroidism may manifest as hypercalcemia in the post-transplant period. The classical treatment method is parathyroidectomy and the alternative is oral cinacalcet, a calcimimetic agent therapy. We retrospectively investigated the effect of cinacalcet therapy on kidney and patient survival in these patients. In our single-center, retrospective, observational study, files of 934 patients who underwent renal transplantation in our unit between 2008 and 2022 were reviewed. A total of 23 patients were started on cinacalcet for the treatment of hypercalcemia (calcium > 10.3 mg/dl) and parathyroid hormone (PTH) elevation (>65 pg/ml). Patients with calcium < 10.3 mg/dl and PTH > 700 pg/ml at any time in the follow-up after renal transplantation were included in the study. In addition, the demographic data of the patients,baseline creatine, calcium, phosphorus, and PTH levels at the time of hypercalcemia, parathyroid ultrasonography, parathyroid scintigraphy, creatinine, calcium, phosphorus,and PTH levels in the last controls, and survival status were evaluated. The mean age of 23 patients included in the study was 52.7 ± 11 years (minimum: 32; maximum: 66). Of the patients, 16 (69.6%) were male, and 15 (65.2%) were transplanted from a living donor. Parathyroid scintigraphic revealed adenoma in three (13%) patients, hyperplasia in five patients (21.7%), and no involvement in 15 patients (65.2%). Cinacalcet treatment was initiated at a median of 33 months (interquartile range (IQR) = 13-96) after the kidney transplant operation. There was no graft loss in the patients during the follow-up period. Twenty-two patients (95.7%) were alive, and one patient died. The calcium level of the patients decreased from 11.3 ± 0.64 mg/dl to 9.98 ± 0.78 mg/dl (p = 0.001) after cinacalcet treatment. Phosphorus values increased from 2.7 ± 0.65 mg/dl to 3.10 ± 0.65 mg/dl (p = 0.004). On the other hand, there was no significant difference in PTH levels between the initial and final controls (285 (IQR = 150-573) vs. 260 pg/ml (IQR = 175-411), p = 0.650). Also, creatinine levels were similar (1.2 ± 0.38 vs. 1.24 ± 0.48 mg/dl, p = 0.43). Despite cinacalcet treatment, calcium levels did not decrease in eight patients. Complications such as renal dysfunction and pathological fracture did not develop in these patients. It seems that cinacalcet treatment is a suitable option for patients with hypercalcemia and/or hyperparathyroidism with low drug interactions and good biochemical control after renal transplantation.

A patient with femoral osteitis fibrosa cystica mimicking bone neoplasm: a case report

BackgroundOsteitis fibrosa cystica is a rare, benign and osteolytic lesion attributed to hyperparathyroidism. The high level of parathyroid hormone cause rapid bone loss.Case presentationThe patient is a 50-year-old male complaining of severe and persistent pain in the right knee joint. Imaging studies were suspicious for a benign tumor in the right distal femur. Biopsy under CT guidance showed numerous osteoclast aggregation and hemosiderin deposition around the bone trabeculae. Blood tests disclosed significantly elevated parathyroid hormone, serum calcium, serum alkaline phosphatase. Parathyroid ultrasonography and CT scan showed a solid mass in front of the trachea at the thoracic entrance plane. After resection of the mass, the clinical symptoms were relieved and the radiological results were significantly improved, which further confirmed the diagnosis.ConclusionsMetabolic diseases-associated bone lesions require a comprehensive diagnosis of multiple inspection items. An interprofessional team approach to the diagnosis and treatment of osteitis fibrosa cystica will provide the best outcome.

Multidisciplinary team efforts to improve the pregnancy outcome of pregnancy complicated with primary hyperparathyroidism: case series from a single hospital

BackgroundThere is no consensus or management algorithm for primary hyperparathyroidism (PHPT) in pregnancy.MethodsThis study comprises a retrospective case series. From August 2014 to December 2020, 9 cases of PHPT in pregnancy were diagnosed by a multidisciplinary team (MDT) consultation center of obstetrics in our hospital. Their clinical manifestations, treatment strategies, and maternal and infant outcomes were analyzed.ResultsThe median onset age of the patients was 32 (25 ~ 38) years. PHPT was diagnosed in two cases before pregnancy, in six cases during pregnancy and in one case postpartum. The main clinical manifestations were nausea, vomiting, and other nonspecific symptoms, with anemia as the most common maternal complication. Hypercalcemia crisis was developed in one case. The median levels of preoperative serum calcium and parathyroid hormone (PTH) were 3.08 (2.77 ~ 4.21) mmol/L and 300.40 (108.80 ~ 2603.60) pg/ml, respectively. The parathyroid ultrasonography tests were positive in eight cases and negative in one patient who had an ectopic lesion localized by 99mTc-MIBI. Parathyroidectomy was conducted in 7 cases during the 2nd trimester, including 2 patients diagnosed before pregnancy who refused surgery, 1 patient during the 1st trimester, and 1 patient postpartum, with a significant reduction in serum concentrations of calcium and PTH. A management algorithm was developed.ConclusionThis case series suggests that pregnant women with PHPT should be managed by MDT according to the algorithm. If PHPT is confirmed in fertile women before pregnancy, parathyroidectomy should be strongly suggested and performed. If PHPT is diagnosed during pregnancy, even in its mild form, surgical treatment, optimally during the 2nd trimester, is effective and safe for pregnancy and neonatal outcome.

P-PN020. Acute flaccid paralysis: Guillain-Barré Syndrome mimics

Introduction . Guillain-Barré syndrome (GBS) is the commonest cause of acute flaccid paralysis. However, clinicians should not miss the other causes of acute flaccid paralysis which may mimic GBS. Results . We present 3 cases of flaccid areflexic paralysis which presented acute/subacutely resembling GBS. Case 1: A 29-year-old lady presented with 2-week history of bilateral lower limb weakness with left hip pain for 3 years. Investigations revealed hypercalcaemia, hypophosphataemia, elevated ALP, vitamin D deficiency, hyperparathyroidism with right parathyroid adenoma from parathyroid ultrasonography and scintigraphy. She had plasma exchange for presumed GBS, but her lower limb weakness worsened and progressed to involve upper limbs and facial muscles. Her weakness improved after parathyroidectomy and the diagnosis was revised to hyperparathyroidism-related polyneuropathy. Case 2: A 28-year- old lady with underlying epilepsy and intellectual disability presented with progressive weakness of extremities over 3 weeks after prolonged fasting. Her weakness did not improve after treatment with immunoglobulin for GBS. Investigations showed positive urine porphobilinogen and raised urine delta-aminolaevulinic acid. A diagnosis of acute intermittent porphyria was considered most likely and her weakness improved after continuous glucose loading. Case 3: A 52-year-old lady who had bariatric surgery presented with bilateral lower limb weakness over 4 weeks after recurrent bouts of vomiting and excessive weight loss. Investigations revealed vitamin D deficiency, hypoalbuminaemia, hyperhomocysteinemia, low folate and low normal serum thiamine. As her weakness continued to progress, a diagnosis of acute nutritional neuropathy was considered more likely. Her weakness improved following multivitamins replacement. All 3 patients had normal CSF analysis except Case 1 who showed cyto-albuminologic dissociation. Sensorimotor axonal polyneuropathy was the electrodiagnosis demonstrated in all the cases. Conclusion . Clinicians should have high index of suspicion when treating acute flaccid paralysis with progressive disease and null response to immunotherapy as the neurology is reversible with treatment of the underlying cause.

A Retrospective Study of Ultrasonography in the Investigation of Primary Hyperparathyroidism: A New Perspective for Ultrasound Echogenicity Features of Parathyroid Nodules

ObjectiveTo identify and understand parathyroid lesions of patients with primary hyperparathyroidism (PHPT) more accurately under ultrasound. MethodsThis retrospective study involved 423 adult patients with PHPT with a single parathyroid nodule and positive parathyroid ultrasonography between 2018 and 2019. The clinical characteristics of the study patients and histopathologic sections were reviewed. ResultsAccording to the main grayscale echogenicity features of parathyroid nodules, 423 cases were divided into groups: iso-hyperechogenicity solid (61/423), hypoechogenicity solid (304/423), and mixed-echogenicity cyst-solid (58/423) groups. Comparison among the 3 groups showed that the iso-hyperechogenicity group included more asymptomatic patients with PHPT and fewer patients with severe symptoms like bone fractures (P < .05). The mixed-echogenicity group showed higher median serum parathyroid hormone (PTH) and serum calcium levels and larger lesion sizes (P < .05), and the iso-hyperechogenicity group showed the lowest median serum PTH level. No difference in lesion size was noted between the 2 solid groups, but the median serum PTH level in the hypoechogenicity group was higher than that in the iso-hyperechogenicity group (P < .05). According to histopathology, the hypoechogenic area of the samples may contain more functional components (chief cells), whereas the iso-hyperechogenic area has more nonfunctional components (eg, lipocytes and connective tissues). ConclusionThe PHPT nodules distinguished by ultrasound echogenicity features showed different histopathologic components, reflected by different clinical characteristics of the patients with PHPT.

18F-fluorocholine PET/CT in MEN1 Patients with Primary Hyperparathyroidism.

Primary hyperparathyroidism (HPT1) is the most frequent endocrinopathy in multiple endocrine neoplasia type 1 (MEN1). Its surgical management is challenging. We aimed to describe and compare the imaging findings of parathyroid ultrasound (US), sestaMIBI scintigraphy (sestaMIBI), and 18F-fluorocholine (FCH) PET/CT in a series of MEN1 patients with HPT1. Retrospective analysis of a cohort of MEN1 patients with HPT1 assessed by parathyroid US, sestaMIBI scintigraphy and SPECT/CT, and FCH-PET/CT for potential surgery between 2015 and 2019. Twenty-two patients with a confirmed diagnosis of MEN1 who presented with HPT1 and were assessed by the 3 imaging modalities were included. After imaging workups, 11 patients were operated on for the first time, 4 underwent a redo surgery, and 7 did not undergo an operation. The overall patient-based positivity rate of imaging was 91% (20 of 22) for parathyroid US and 96% (21 of 22) for both sestaMIBI and FCH-PET/CT. The 3 imaging modalities demonstrated negative findings in 1/22 patient who did not undergo surgery. Overall, 3 pathologic glands were not detected by any imaging technique. SestaMIBI and FCH-PET/CT both resulted in the same 3 false-positive results in ectopic areas with a significant uptake on two thymic carcinoid tumors and one inflammatory lymph node. FCH-PET/CT provided more surgically relevant data than sestaMIBI in 4/11 patients with initial surgery and in 1/4 patient who underwent redo surgery. Compared to sestaMIBI scintigraphy, FCH-PET/CT provides additional information regarding the number of pathologic parathyroid glands and their localization in MEN1 patients with HPT1.

SAT-390 Preoperative Parathyroid Ultrasound Imaging - Pitfalls and Ways to Improve Diagnostic Accuracy

Introduction: Parathyroid ultrasound (US) is commonly used for pre-operative imaging to facilitate focused parathyroid surgery. It provides point-of-care imaging without ionizing radiation and is less expensive compared to nuclear scintigraphy or computed tomography (CT). Parathyroid US is, however, operator skill and experience dependent. Methods: The charts of all patient who underwent parathyroid surgery between 2016 and 2018 were reviewed. Investigators reviewed the pre-operative US images and correlated these findings with pathology reports, operative notes and with results of CT and nuclear scintigraphy imaging. The US characteristics of parathyroid lesions were described. Results: In total 146 patients underwent parathyroid surgery during the three-year study period. The average age of the cohort was 55.1 +/- 15.1 years and the male to female ratio was 1:2.6. The average pre-operative serum calcium and PTH levels were 11.6 +/- 0.9 mg/dL and 310.9 +/-305 pg/ml, respectively. 134 out of 138 patients with preoperative PTH US had images available for review by investigators. Compared to the pre-operative read that identified 106 lesions, 19 additional parathyroid lesions were identified: seven (36.8%) were easily identifiable lesions with typical US features, 3 (15.8%) were easily identifiable lesions with atypical US features, 5 (26.3%) were lesions adherent to the thyroid gland and 9 (47.4%) were small lesions that were likely only identified by the investigators due to knowledge of the final pathology and intraoperative findings. Forty-seven parathyroid lesions could not be identified by investigators and one or more of the following reasons were determined as possible explanations: lesion was small in size (14.9%), presence of a large thyroid gland (27.7%), location of the lesion deep in the neck or at an ectopic location (21.3%). The quality of stored images was inadequate in 31.9% of these cases. After review, 67.1% (compared to the actual detection rate of 61.3%) of parathyroid lesions should have been identified on preoperative US. Sixty percent of parathyroid lesions were left sided and 66.9% were inferior in location. The shapes observed were oval (48.8%), conforming (50.4%) or elongated (<1%) and echogenicity was hypoechoic (86.8%) or isoechoic (13.2%). Only a small percentage had a target sign (6.6%) or were partially cystic (7.4%). 74.8% demonstrated a feeding vessel and 33.6% had vascular arborization or scattered vascularity. Conclusions: While parathyroid lesions with typical US feature and locations are easily identified, the common reasons for failure to identify a lesion include atypical features, small size, slender configuration and adherence to the thyroid gland. Being aware of these possibilities can improve detection rate. Parathyroid lesions are also less likely to be identified when present deep in the neck or at an ectopic location outside of the neck.

Occult Primary Hyperparathyroidism: A Case Report and Review of Parathyroid Ultrasonography

To discuss the diagnosis and management of occult primary hyperparathyroidism. We present the biochemical and radiologic evaluation, treatment, and outcome of a woman with occult primary hyperparathyroidism which presented as an unusual neck mass on ultrasound. We also present a relevant literature review. A 52-year-old female presented with Hashimoto thyroiditis and a 1.2-cm, hypoechoic oval nodule in the left upper lateral portion of the thyroid. She returned a decade later with a 2.2-cm, hypervascular mass on ultrasound. Parathyroid hormone was mildly elevated at 90 pg/mL (reference range is 15 to 65 pg/mL), but she had persistently normal levels of total serum calcium at 9.9 mg/dL (reference range is 8.7 to 10.3 mg/dL), phosphorus at 3.5 mg/dL (reference range is 2.1 to 4.5 mg/dL), and albumin at 4.4 g/dL (reference range is 3.6 to 4.8 g/dL). She had elevated ionized calcium of 5.9 mg/dL (reference range is 4.5 to 5.6 mg/dL). Computed tomography with contrast of the neck revealed an enhancing oval lesion abutting the superior pole of the left thyroid with attenuation characteristics similar though slightly different from the thyroid. 99mTc-Sestamibi scan showed increased uptake posterior to the superior aspect of the left thyroid. Bone densitometry showed osteoporosis of the left distal radius and osteopenia of the left femoral neck. Minimally invasive radio-guided parathyroidectomy was performed with normalization of parathyroid hormone. Pathology confirmed a 1.715-g parathyroid adenoma. Despite normal total calcium levels, clinically significant primary hyperparathyroidism may present as a large adenoma which could appear as a hypervascular neck mass on ultrasound. A high index of suspicion based on ultrasound features and measurement of ionized calcium may be helpful in diagnosing occult, but clinically relevant primary hyperparathyroidism.

SUN-513 Parathyromatosis: A Case of Stubborn Hypercalcemia Treated with Denosumab

Background: Parathyromatosis is a rare cause of recurrent or persistent hyperparathyroidism (HPT). Two proposed pathogenic mechanisms involve spillage and seeding of parathyroid tissue during parathyroid surgery and hyperplasia of embryologic rests of parathyroid tissue. Treatment of parathyromatosis remains a challenge as neither surgical nor pharmacological treatment has been successful in controlling the deleterious consequences of long-standing untreated HPT. We present a case of persistent parathyromatosis successfully treated with denosumab. Clinical Case: A 78 year old female with a history parathyromatosis was admitted to our teaching hospital with anorexia and acute renal failure after a cinacalcet dose increase. She had persistent hyperparathyroidism despite 7 operations including a right hemithyroidectomy and mediastinal split. Complications from her persistent hypercalcemia have included recurrent nephrolithiasis requiring 13 lithotripsies and osteoporosis treated with multiple doses of intravenous bisphosphonate over 26 years. She had known remnant parathyroid tissue within the neck and refused further surgeries, her most recent medical regimen included cinacalcet 180 mg/day and vitamin D analogues. Labs on admission included a serum calcium of 11.0 mg/dl (8.6 - 10.2 mg/dl), ionized calcium of 5.3 mg/dL (normal 4.8 - 5.2 mg/dL), PTH of 230.8 ng/l (normal 15.0 - 65.0 pg/mL), 250H-vitamin D of 39 ng/mL (normal 30 - 60 ng/mL), serum creatinine of 4.05 mg/dL (normal 0.51 - 0.95 mg/dL) and a 24-hour urine calcium of 242 mg (normal 100 - 240 mg/24hr). Imaging studies included a renal ultrasound (US) that showed bilateral nephrolithiasis without hydronephrosis, a parathyroid US and a technetium Tc 99m-sestamibi scan that showed known remnant parathyroid tissue within the thyroid bed. Because of her modest response to lower doses of cinacalcet and failure to tolerate higher doses; inability to use bisphosphonates due to ARF, denosumab at a dose of 60 mg was initiated. The use of denosumab in combination with a lower dose of cinacalcet resulted in successful control of hypercalcemia. Conclusion: Parathyromatosis remains a rare etiology of recurrent or persistent HPT. Successful treatment and control of parathyromatosis remains a challenge. Surgery remains the mainstay of therapy, but attempts at surgical cure are commonly unsuccessful, and medical therapy with calcimimetics and bisphosphonates appear to be of limited value. The addition of Denosumab, a monoclonal receptor activator of nuclear factor κB ligand (RANKL) antibody proved to be effective and appears to be a safe alternative for the management of refractory hypercalcemia.

The Effects of Lithium on Calcium and Parathormone Levels: A Cross-sectional Study with Healthy Controls

Despite lithium associated hyperparathyroidism (LAH) can lead to many complications, little notice has been paid to this sideeffect. The aim of this study was to investigate the effects of lithium on calcium and parathyroid hormone levels and the relation between lithium use and thyroid diseases. This cross-sectional study was carried out with 87 lithiumtreated patients and 65 volunteers who had a similar age and gender distribution with the lithium group. Serum levels of corrected calcium, intact parathormone, phosphorus, magnesium, alkaline phosphatase, free thyroxine, thyroid stimulating hormone, thyroid autoantibodies and creatinine were assessed, and also, thyroid and parathyroid ultrasonography was conducted. Further detailed investigations were made depending on the elevation of the initially measured calcium and/ or parathormone levels. Median values of serum levels of the corrected calcium and the intact parathormone were significantly higher in the lithium group. Calcium levels had a mild correlation with the duration of lithium treatment. In the first assessment, while all control individuals had values within the normal reference range, 11 lithium-treated patients had corrected calcium and/or intact parathormone levels above the normal reference levels. All of the five patients, who were diagnosed with LAH after further investigation, were also diagnosed with a thyroid disorder. These results demonstrate that lithium treatment has a relationship with calcium and parathormone levels. The 5.7% prevalence of LAH and potential life-threatening conditions associated with LAH necessitates the use of available low-cost METHODS to monitor blood calcium levels of lithium-treated patients for early diagnosis.

Pregnancy with primary hyperparathyroidism: analysis of five cases

Objective To study the clinical presentations, diagnosis and managements of primary hyperparathyroidism (pHPT) in pregnancy. Methods A total of five cases of pHPT in pregnancy were enrolled from January 2005 to December 2014 in Peking Union Medical College Hospital. Their clinical presentations, managements, maternal-fetal complications and pregnancy outcomes were retrospectively analyzed. Results The median age was 32 (29, 41) years. Of the five cases, three were diagnosed in the second trimester, one was before pregnancy and one was after delivery. Most of the clinical symptoms were nonspecific to pHPT, such as nausea, vomiting and loss of appetite. Frequent urination and nocturia occurred in one; unconsciousness and manifestations of acute pancreatitis and eclampsia relevant symptoms were complained of by one. The common maternal complications were nephrolithiasis and hydronephrosis (3/5), osteoporosis (2/5), anemia (2/5) and kaliopenia (2/5), while the severe complications were hypercalcemic crisis (2/5), acute pancreatitis (1/5), eclampsia (1/5), HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome (1/5), disseminated intravascular coagulation (DIC) (1/5), cerebral infarction (1/5) and intrauterine fetal death of one twin (1/5). The median level of calcium in serum samples was 3.70 (2.78, 4.50) mmol/L; the median level of parathyroid hormone (PTH) in serum samples was 294 (151, 634) pg/ml. All of the five cases were positive for parathyroid ultrasonography. Four cases received parathyroid radionuclide imaging and had positive results. One asymptomatic patient received no specific treatment, whereas the neonate presented with hypocalcemia after birth. Two cases received surgical resections in the second trimester; one of them had a live birth without fetal complication, while the other had induced abortion. Two cases received postpartum surgery; one asymptomatic patient had a live birth without fetal complication, while the other with twin pregnancy suffered stillbirths (one intrauterine fetal death and one neonatal death). Pathologic diagnosis were solitary parathyroid adenomas in four cases who received surgery. Their operations were effective except that one case, which was improved after treatment, was complicated with secondary hypoparathyroidism. Conclusions The symptoms of pHPT in pregnancy are often nonspecific, but it can cause maternal and fetal morbidity and mortality. Early diagnosis of pHPT, followed by appropriate managements, has been shown to significantly reduce the complications. Surgical management should be a safe and effective choice. Key words: Hyperparathyroidism, primary; Pregnancy complications

The effects of cinacalcet treatment on bone mineral metabolism, anemia parameters, left ventricular mass index and parathyroid gland volume in hemodialysis patients with severe secondary hyperparathyroidism.

The aim of this study was to investigate the effects of cinacalcet therapy on anemia parameters, bone mineral metabolism, left ventricular mass index (LVMI) and parathyroid gland volume in hemodialysis (HD) patients with secondary hyperparathyroidism. Twenty-five HD patients (M/F: 11/14, mean age: 45.2±17.9 years, mean HD duration: 96.4±32.7 months) were included in this prospective pilot study. The indication to start calcimimetic therapy was persistent serum levels of parathyroid hormone (PTH)>1000 pg/mL, refractory to intravenous (i.v.) vitamin D and phosphate-binding therapy. The initial and one-year results of adjusted serum calcium (Ca+2), phosphate (P), Ca×P product, PTH, hemoglobin (Hb) and ferritin levels, transferrin saturation index (TSAT), median weekly erythropoietin (EPO) dose, LVMI, and parathyroid volume by parathyroid ultrasonography were determined. There were no differences between pre- and post-treatment levels of serum Ca+2 (P=0.853), P (P=0.447), Ca×P product (P=0.587), PTH (P=0.273), ferritin (P=0.153) and TSAT (P=0.104). After 1 year of calcimimetic therapy, the Hb levels were significantly higher than the initial levels (P=0.048). The weekly dose of EPO decreased with no statistical significance. The dose of cinacalcet was increased from 32.4±12.0 to 60.0±24.4 mg/day (P=0.01). There were no differences between the pre- and post-treatment results regarding weekly vitamin D dose, parenteral iron dose, LVMI and parathyroid volume. The results of our study suggest that cinacalcet therapy might have an additional benefit in the control anemia in HD patients.

Parathyroid ultrasonography and bone metabolic profile of patients on dialysis with hyperparathyroidism.

To evaluate the parathyroid ultrasonography and define parameters that can predict poor response to treatment in patients with secondary hyperparathyroidism due to renal failure. This cohort study evaluated 85 patients with chronic kidney disease stage V with parathyroid hormone levels above 800 pg/mL. All patients underwent ultrasonography of the parathyroids and the following parameters were analyzed: Demographic characteristics (etiology of chronic kidney disease, gender, age, dialysis vintage, vascular access, use of vitamin D), laboratory (calcium, phosphorus, parathyroid hormone, alkaline phosphatase, bone alkaline phosphatase), and the occurrence of bone changes, cardiovascular events and death. The χ(2) test were used to compare proportions or the Fisher exact test for small sample frequencies. Student t-test was used to detect differences between the two groups regarding continuous variables. Fifty-three patients (66.4%) had parathyroid nodules with higher levels of parathyroid hormone, calcium and phosphorus. Sixteen patients underwent parathyroidectomy and had higher levels of phosphorus and calcium × phosphorus product (P = 0.03 and P = 0.006, respectively). They also had lower mortality (32% vs 68%, P = 0.01) and lower incidence of cardiovascular or cerebrovascular events (27% vs 73%, P = 0.02). Calcium × phosphorus product above 55 mg(2)/dL(2) [RR 1.48 (1.06, 2.08), P = 0.03], presence of vascular calcification [1.33 (1.01, 1.76), P = 0.015] and previous occurrence of vascular events [RR 2.25 (1.27, 3.98), P < 0.001] were risk factors for mortality in this population. There was no association between the occurrence of nodules and mortality. The identification of nodules at ultrasonography strengthens the indication for parathyroidectomy in patients with secondary hyperparathyroidism due to renal failure.

Parathyroid ultrasonography: the evolving role of the radiologist.

Previously, radiologists played a limited role in the treatment of parathyroid disease, primary focusing on the preoperative localization of parathyroid lesions responsible for hyperparathyroidism. But, the widespread use of high-resolution ultrasound has lead to the increasing detection of parathyroid incidentalomas (PTIs). Consequently, radiologists may be required to differentiate PTIs from thyroid lesions, which is most reliably accomplished through the fine needle aspiration-parathyroid hormone analysis. Various nonsurgical treatment modalities for hyperfunctioning parathyroid lesions have been developed with some efficacy. Especially for symptomatic nonfunctioning parathyroid cysts, simple aspiration is a first-line procedure for diagnosis and treatment, while ethanol ablation is a subsequent treatment modality for recurrent cases.

Preoperative imaging for focused parathyroidectomy: making a good strategy even better.

Surgical treatment for primary hyperparathyroidism (pHPT) has undergone a major paradigm shift during the last decades from bilateral cervicotomy with four-gland neck exploration to image-guided focused approaches. The primary objective of the present study was to compare the performances of parathyroid scintigraphy (PS), parathyroid ultrasonography (US), and the combination of both procedures for guiding a focused approach on the basis of modified interpretation criteria. Data from 199 patients operated for apparent sporadic pHPT and evaluated with US and PS using dual-isotope (123)I/(99m)Tc-sestamibi planar pinhole and single-photon emission computed tomography (SPECT) acqusitions were evaluated. A total of 127 patients underwent a focused approach and the remainder had bilateral cervicotomy. In 42 cases, a focused approach was not performed due to the absence of concordant results between US and PS for a single-gland abnormality. Four patients had persistent disease and three had recurrent disease. A localizing preoperative PS had a sensitivity of 93.3%, positive predictive value of 85.8%, negative predictive value of 73.0%, and accuracy of 83.4% for predicting uniglandular disease. Additional SPECT images accurately localize posterior adenomas that are often missed by US. Compared with PS, US had a lower sensitivity (P<0.01). Our imaging protocol also enabled diagnosis of multiglandular disease in 60.6%. PS using a highly sensitive dual-tracer subtraction method is the most accurate technique for directing a focused approach. PS could be sufficient for directing a focused approach in the presence of a negative US in two major circumstances: posterior locations due to acquired ectopia that could be missed by US, and previous history of thyroidectomy due to interpretation difficulties.

Ultrasonographic evaluation of parathyroid hyperplasia in multiple endocrine neoplasia type 1: Positive correlation between parathyroid volume and circulating parathyroid hormone concentration.

There are few reports on parathyroid ultrasonography of multiple endocrine neoplasia type 1 (MEN1). This study investigated the ultrasonographic features of parathyroid glands in 10 patients with MEN1 who underwent preoperative neck ultrasonography and parathyroidectomy between 2006 and 2010 at Toranomon Hospital. We retrospectively analyzed clinical features, laboratory and ultrasonographic data, and pathological diagnosis. A total of 38 parathyroid glands were surgically removed (three to five glands from each patient). All removed parathyroids were pathologically diagnosed as hyperplasia. Seven cases (70.0%) had adenomatous thyroid nodules. Twenty-five enlarged parathyroid glands (65.8%) were detected by preoperative ultrasonography with a detection rate of 81.8% (9/11) and 59.3% (16/27) for patients without and with adenomatous nodules, respectively. Total parathyroid gland weight and potentially predictable total parathyroid volume by preoperative ultrasonography were significantly correlated with preoperative serum intact parathyroid hormone (iPTH) concentration (R=0.97, P<0.001 and R=0.96, P<0.001, respectively). The equation used for prediction of the total volume by ultrasonography was 15×iPTH (pg/ml)-1,000 and that for total weight was 20×iPTH (pg/ml)-1,400. Although adenomatous nodules often coexisted with MEN1 and made identification of enlarged parathyroid glands by ultrasonography difficult, the positive correlation between the predictable parathyroid volume by ultrasonography and serum iPTH suggests that their measurement is useful in the preoperative detection and localization of enlarged parathyroid glands in patients with MEN1. Furthermore, the presence of parathyroid glands that should be resected can be predicted before surgery using the equation proposed here.

Preoperative localisation of parathyroid adenomas with mibi and ultrasonography: Is there an advantage of a combined approach?

s / International Journal of Surgery 11 (2013) 589e685 634 ABSTRACTS Clinical teaching was provided to junior AE Countess Chester Hospital, Chester, UK. Aim: To evaluate the outcome of sialendoscopy performed at Arrowe Park DGH, and to compare this to NICE findings. Method: A first cycle audit was performed. Retrospectively, the case notes of patients undergoing sialendoscopy between December 2004 and November 2008 were reviewed. Data was collected with regards to patient demographics, presentation, operative findings, length of stay, complications and outcome. A second cycle comparing the same parameters was subsequently undertaken for patients undergoing sialendoscopy between December 2008 to August 2012. Results: 51 patients in the 1st cycle and 61 in the second were reviewed. In both there is a female preponderance and an average age of 54 and 50 respectively. Swelling is the most prevalent presentation, and the most frequent gland affected is the left parotid. 61% of cases in the 1st cycle were daycase procedures, increasing to 90% in the 2nd. In comparison to NICE findings 80-88% of our patients had symptom relief (82-87% NICE). 2-3% suffered ductal wall perforation (9% NICE) and no patients had nerve damage (1 patient NICE). Our own complication rate also decreased between the two cycles. Conclusion: The outcome of sialendoscopy at our unit is improving over time and is comparable with NICE findings. 0417: PREOPERATIVE LOCALISATION OF PARATHYROID ADENOMAS WITH MIBI AND ULTRASONOGRAPHY: IS THERE AN ADVANTAGE OF A COMBINED APPROACH? Edward Ridyard , Derek Siau , Simon Hargreaves . University of Manchester, Manchester, UK; Royal Bolton Hospital, Farnworth, UK. Aim: To identify whether the combination of MIBI and ultrasound (USS) in localising a parathyroid adenoma preoperatively is more effective than either MIBI or USS used alone as the limitations of both imaging modalities are well documented. Method: Retrospective manual analysis of patients’ operative and medical notes (n1⁄476) reviewing the position of parathyroid adenoma localised via MIBI, USS and the subsequent confirmation of parathyroid adenoma on histological evaluation. Results: The combination of MIBI and USS provided a statistically significant improvement in preoperative localisation of parathyroid adenoma over MIBI or USS used alone (p1⁄40.033 and p1⁄40.043 respectively). There was no significant correlation between tumour volume and serum calcium or serum PTH (p1⁄40.234 and p1⁄40.742 respectively). There was a significant reduction in serum calcium and serum PTH postoperatively (p1⁄4 0.05). Conclusion: The value of CRP and coagulation tests in secondary PTH remains to be seen within our results. We suggest that routine CRP and coagulation studies should not be performed on PTH patients because it does not change management and isunlikely todiagnoseanunderling coagulopathy. If bleeding disorders are suspected clotting factors are a more appropriate investigation.

Causes of discordant or negative ultrasound of parathyroid glands in treatment naïve patients with primary hyperparathyroidism

ObjectivesTo describe causes of discordant or negative parathyroid ultrasound and to assess factors influencing them. Materials and methodsRetrospective review of patients who underwent parathyroidectomy between 2000 and 2012 was done. Imaging findings were compared with operative findings and pathology to identify discrepant (n=60; 32 negative, 28 incorrect) parathyroid ultrasounds. ResultsFifty (83.3%) patients had parathyroid adenoma, of which 10 (16.6%) were ectopic and three were double adenomas; 8 (13.3%) had multigland hyperplasia and two had parathyroid carcinoma. Discrepant reports were due to incorrect localisation in 8 (13.3%); difficulty in differentiating thyroid from parathyroid lesion in 12 (20%); large and small size in two and three patients, respectively; overcall in 5 (8.3%) and satisfaction of search in 7 (11.7%) patients. There was significant correlation between presence of multi-nodular goitre and incorrect reports (χ2=4.112, p=0.04). Experience of ultrasound operators performing initial and second look ultrasound was significantly different (p<0.0001). Second look ultrasound was concordant with surgical findings in 39(65%) patients; 21 (66%) patients with initially negative ultrasound and four out of five extra-mediastinal ectopic lesions. Ten patients with negative initial ultrasound had elongated parathyroid lesion. Scintigraphy was concordant in 44 (73.3%) patients and nine were ectopic. ConclusionSecond look ultrasound performed by experienced operator for negative or discordant initial ultrasound of parathyroid is a useful strategy which will improve the accuracy of parathyroid ultrasound. Being able to differentiate thyroid from parathyroid lesion is a factor which will influence performance of parathyroid ultrasound.

Parathyroid incidentalomas detected during thyroid ultrasonography and effect of chronic thyroiditis on false positive parathyroid lesions

We aimed to determine the prevalence of parathyroid incidentalomas in patients referred for thyroid ultrasonography (US) and investigate the role of chronic thyroiditis on false positive lesions. Patients suspected to have parathyroid lesions during thyroid US were recorded prospectively between August 2009 and January 2010. Patients referred for parathyroid US and patients with known high serum calcium or parathyroid hormone (PTH) levels were excluded. Suspected parathyroid lesions were defined as hypoechoic, homogeneous, solid lesions with regular margins located outside the thyroid lobe, most commonly inferior to the thyroid gland. Thyroid US was performed in 6,528 patients. There were 78 patients (1.19 %) (73 female and 5 male) with suspected parathyroid lesion. The diagnosis of a true parathyroid adenoma was confirmed in 6 (7.69 %) patients. In patients with true adenoma, mean serum calcium, phosphorus, and PTH levels were 10.57 ± 0.48 mg/dl, 3.03 ± 0.52 mg/dl, and 182.91 ± 46.62 pg/ml, respectively. Among 72 patients with false positive parathyroid lesion, antithyroid peroxidase antibody was positive in 50 (69.4 %), antithyroglobulin antibody was positive in 46 (63.9 %), and one of these antibodies were positive in 59 (81.9 %) patients. Also, 46 (63.9 %) of these patients had thyroid dysfunctions (43 hypothyroidism and 3 hyperthyroidism) and 59 (81.9 %) had chronic thyroiditis ultrasonographically. Parathyroid incidentaloma was detected in 0.09 % of patients referred for thyroid US. The presence of clinically or ultrasonographically chronic thyroiditis might cause inadvertent interpretation of a hypoechoic lesion as a parathyroid pathology during thyroid US.