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Gazivoda V, Prioli KM, Li AC, Pizzi L, Laird AM, Beninato T. Which Localizing Strategy is the Most Cost-Effective in Reoperative Primary Hyperparathyroidism? J Surg Res 2024; 296:547-555. [PMID: 38340488 DOI: 10.1016/j.jss.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 12/03/2023] [Accepted: 01/07/2024] [Indexed: 02/12/2024]
Abstract
INTRODUCTION 2%-10% of patients with primary hyperparathyroidism (PHPT) who undergo parathyroidectomy develop persistent/recurrent disease. The aim of this study was to determine which preoperative localization method is most cost-effective in reoperative PHPT. METHODS Clinical decision analytic models comparing cost-effectiveness of localizing studies in reoperative PHPT were constructed using TreeAge Pro. Cost and probability assumptions were varied via Probabilistic Sensitivity Analysis (PSA) to test the robustness of the base case models. RESULTS Base case analysis of model 1 revealed ultrasound (US)-guided fine-needle aspiration with PTH assay as most cost-effective after localizing US. This was confirmed on PSA of model 1. Model 2 showed four-dimensional computed tomography (4D-CT) as most cost-effective after negative US. If not localized by US, on PSA, 4D-CT was the next most cost-effective test. CONCLUSIONS US-guided FNA with PTH is the most cost-effective confirmatory test after US localization. 4D-CT should be considered as the next best test after negative US.
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Affiliation(s)
- Victor Gazivoda
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Katherine M Prioli
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Albert C Li
- Section of Vascular and Interventional Radiology, Department of Diagnostic Radiology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | - Laura Pizzi
- Center for Health Outcomes, Policy & Economics, Rutgers University, Piscataway, New Jersey
| | - Amanda M Laird
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey
| | - Toni Beninato
- Division of Surgical Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
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Uludag M, Unlu MT, Kostek M, Caliskan O, Aygun N, Isgor A. Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Pre-Operative Evaluation. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:1-17. [PMID: 37064844 PMCID: PMC10098391 DOI: 10.14744/semb.2023.39260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/08/2023] [Accepted: 03/09/2023] [Indexed: 04/18/2023]
Abstract
Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.
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Affiliation(s)
- Mehmet Uludag
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mehmet Taner Unlu
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
- Address for correspondence: Mehmet Taner Unlu, MD. Türkiye Sağlık Bilimleri Üniversitesi, Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi, Genel Cerrahi Kliniği, İstanbul, Türkiye Phone: +90 539 211 32 36 E-mail:
| | - Mehmet Kostek
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ozan Caliskan
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Nurcihan Aygun
- Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Adnan Isgor
- Deparment of General Surgery, Sisli Memorial Hospital, Istanbul, Türkiye
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Dimitroukas CP, Metaxas V, Efthymiou F, Zampakis P, Kalogeropoulou C, Panayiotakis G. Organs' absorbed dose and comparison of different methods for effective dose calculation in computed tomography of parathyroid glands. Biomed Phys Eng Express 2022; 8. [PMID: 35593909 DOI: 10.1088/2057-1976/ac7169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 05/19/2022] [Indexed: 11/12/2022]
Abstract
Objective:To estimate organs' absorbed dose from the two-phase CT of parathyroid glands, effective dose (ED) based on three different methods, and compare the dose values with those reported by other published protocols.Methods:Volumetric-computed-tomography-dose-index (CTDIvol), dose-length-product (DLP), and the corresponding scan length during each phase of a parathyroid protocol were recorded, for seventy-six patients. One k-factor, and two different k-factors for the neck and chest area were used to estimate the ED from DLP. A Monte Carlo software, VirtualDoseCT, was also used for the estimation of organs' absorbed dose and ED.Results:Two-phase parathyroid CT resulted in a mean ED of 3.93 mSv, 4.29 mSv and 4.21 mSv according to the one k-factor, two k-factors, and VirtualDoseCT methods, respectively. The two k-factors method resulted in a slight overestimation of 1.9% in total ED compared to VirtualDoseCT. No statistically significant difference was found in ED values between these methods (Wilcoxon test, p>0.05), except for female patients in the pre-contrast phase. The organs inside the SFOV received the following doses: thymus 23.3 mGy, lungs 11.5 mGy, oesophagus 9.2 mGy, thyroid 6.9 mGy, and breast 6.3 mGy. The ED and organs' dose (OD) values were significantly lower in the pre-contrast than in the arterial phase (Wilcoxon test, p<0.001). A statistically significant difference was observed between male and female patients for the pre-contrast phase (Mann-Whitney test, p<0.05), regarding the ED values obtained with the two k-factors method and VirtualDoseCT software.Conclusions:The two k-factors method could be applied for the ED estimation in clinical practice, if appropriate software is not available. An extensive range of ED values derived from the literature, mainly depending on the acquisition protocol parameters and the estimation method.
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Affiliation(s)
- Christos P Dimitroukas
- Department of Medical Physics, University of Patras, School of Medicine, Patra, 26504, GREECE
| | - Vasileios Metaxas
- University of Patras, Department of Medical Physics, Patra, Periféria Dhitikís Elládh, 26504, GREECE
| | - Fotios Efthymiou
- University of Patras, Department of Medical Physics, Patra, Periféria Dhitikís Elládh, 26504, GREECE
| | - Petros Zampakis
- Department of Radiology, University of Patras, School of Medicine, Patra, Periféria Dhitikís Elládh, 26504, GREECE
| | - Christina Kalogeropoulou
- Department of Radiology, University of Patras, School of Medicine, Patra, Periféria Dhitikís Elládh, 26504, GREECE
| | - George Panayiotakis
- Department of Medical Physics, University of Patras, School of Medicine, Patra, 26504, GREECE
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4DCT Scanning Technique for Primary Hyperparathyroidism: A Scoping Review. Radiol Res Pract 2021; 2021:6614406. [PMID: 34094599 PMCID: PMC8163538 DOI: 10.1155/2021/6614406] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 04/11/2021] [Accepted: 05/13/2021] [Indexed: 12/27/2022] Open
Abstract
Objective 4DCT for the detection of (an) enlarged parathyroid(s) is a commonly performed examination in the management of primary hyperparathyroidism. Protocols are often institution-specific; this review aims to summarize the different protocols and explore the reported sensitivity and specificity of different 4DCT protocols as well as the associated dose. Materials and Methods A literature study was independently conducted by two radiologists from April 2020 until May 2020 using the Medical Literature Analysis and Retrieval System Online (MEDLINE) database. Articles were screened and assessed for eligibility. From eligible studies, data were extracted to summarize different parameters of the scanning protocol and observed diagnostic attributes. Results A total of 51 articles were included and 56 scanning protocols were identified. Most protocols use three (n = 25) or four different phases (n = 23). Almost all authors include noncontrast enhanced imaging and an arterial phase. Arterial images are usually obtained 25–30 s after administration of contrast, and less agreement exists concerning the timing of the venous phase(s). A mean contrast bolus of 100 mL is administered at 3-4 mL/s. Bolus tracking is not often used (n = 3). A wide range of effective doses are reported, up to 28 mSv. A mean sensitivity of 81.5% and a mean specificity of 86% are reported. Conclusion Many different 4DCT scanning protocols for the detection of parathyroid adenomas exist in the literature. The number of phases does not appear to affect sensitivity or specificity. A triphasic approach, however, seems preferable, as three patterns of enhancement of parathyroid adenomas are described. Bolus tracking could help to reduce the variability of enhancement. Sensitivity and specificity also do not appear to be affected by other scan parameters like tube voltage or tube current. To keep the effective dose within limits, scanning at a lower fixed tube current seems preferable. Lowering tube voltage from 120 kV to 100 kV may yield similar image contrast but would also help lower the dose.
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Sandqvist P, Farnebo J, Nilsson IL, Grybäck P, Sundin A, Sanchez-Crespo A. The preoperative localisation of small parathyroid adenomas improves when adding Tc-99m-Sestamibi SPECT to multiphase contrast-enhanced CT. Insights Imaging 2021; 12:72. [PMID: 34091801 PMCID: PMC8179871 DOI: 10.1186/s13244-021-01016-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/18/2021] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To investigate the incremental value of Sestamibi SPECT combined with a non-enhanced and contrast-enhanced CT, using SPECT/CT, for the preoperative localisation of small parathyroid adenomas (PTA). METHODS Retrospectively, 147 patients surgically cured from primary hyperparathyroidism, as verified by biochemistry 6 months postoperatively, were included. All patients had preoperatively undergone a dual time 99mTechnetium-Sestamibi SPECT (S) with multiphase CT including native (N), arterial (A) and venous (V) phases. Independently, two radiologists blinded from both the surgical and the preoperative imaging reports, sequentially performed PTA localisation starting with either [A] or [V], thereafter [A + N] or [V + N] and finally with the complete [A + N + S] or [V + N + S]. PTA localisation was reported for each image-set. The readers results were combined and the diagnostic performance for each image set was determined. Sensitivity was also calculated for the different quartiles of PTA weight distribution. RESULTS The median adenoma weight was 315 mg. No statistically significant differences in diagnostic performance between arterial and venous based image sets were found. The net effect of adding [N] was to increase specificity. Sestamibi SPECT significantly increased the overall diagnostic accuracy for arterial- and venous-based image sets, p = 0.0008 and p = 0.001, respectively. [A + N + S] was found to have the highest diagnostic performance with 86.5% sensitivity and 94.9% overall accuracy. [A + N + S] was particularly advantageous for locating PTA in the lower weight quartiles. CONCLUSIONS Native CT-phase and dual time point Sestamibi SPECT increase specificity and sensitivity, respectively. These, in combination with a single contrast-enhanced CT-phase is the most optimal examination protocol for preoperative localisation of PTA using SPECT/CT.
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Affiliation(s)
- Patricia Sandqvist
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Jacob Farnebo
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Inga-Lena Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Endocrine Tumours and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Per Grybäck
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Sundin
- Department of Surgical Sciences, Section for Radiology and Molecular Imaging, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Alejandro Sanchez-Crespo
- Department of Oncology-Pathology, Karolinska Institute, SLL, 17177, Stockholm, Sweden.
- Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital, Stockholm, Sweden.
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Detection of parathyroid adenomas with multiphase 4DCT: towards a true four-dimensional technique. BMC Med Imaging 2021; 21:64. [PMID: 33827463 PMCID: PMC8028189 DOI: 10.1186/s12880-021-00597-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/29/2021] [Indexed: 12/15/2022] Open
Abstract
Background Four-dimensional computed tomography (4DCT) is a commonly performed examination in the management of primary hyperparathyroidism, combining three-dimensional imaging with enhancement over time as the fourth dimension. We propose a novel technique consisting of 16 different contrast phases instead of three or four different phases. The main aim of this study was to ascertain whether this protocol allows the detection of parathyroid adenomas within dose limits. Our secondary aim was to examine the enhancement of parathyroid lesions over time. Methods For this prospective study, we included 15 patients with primary hyperparathyroidism and a positive ultrasound prior to surgery. We performed 4DCT with 16 different phases: an unenhanced phase followed by 11 consecutive arterial phases and 4 venous phases. Continuous axial scanning centered on the thyroid was performed over a fixed 8 cm or 16 cm coverage volume after the start of contrast administration. Results In all patients, an enlarged parathyroid lesion was demonstrated, and the mean lesion size was 13.6 mm. The mean peak arterial enhancement for parathyroid lesions was 384 Hounsfield units (HU) compared to 333 HU for the normal thyroid. No significant difference could be found. The time to peak (TTP) was significantly earlier for parathyroid adenomas than for normal thyroid tissue: 30.8 s versus 32.3 s (p value 0.008). The mean slope of increase (MSI) of the enhancement curve was significantly steeper than that of normal thyroid tissue: 29.8% versus 22.2% (p value 0.012). The mean dose length product was 890.7 mGy cm with a calculated effective dose of 6.7 mSv. Conclusion Our 4DCT protocol may allow better visualization of the pattern of enhancement of parathyroid lesions, as enhancement over time curves can be drawn. In this way, wash-in and wash-out of contrast in suspected lesions can be readily demonstrated. Motion artifacts are less problematic as multiple phases are available. Exposure to our proposed 4DCT technique is comparable to that for classic helical 4DCT. Careful selection of parameters (lowering kV and SNR) can help to further reduce the dose.
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Becker JL, Patel V, Johnson KJ, Guerrero M, Klein RR, Ranvier GF, Owen RP, Pawha P, Nael K. 4D-Dynamic Contrast-Enhanced MRI for Preoperative Localization in Patients with Primary Hyperparathyroidism. AJNR Am J Neuroradiol 2020; 41:522-528. [PMID: 32165367 DOI: 10.3174/ajnr.a6482] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/01/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Our aim was to test the hypothesis that our recently introduced 4D-dynamic contrast-enhanced MR imaging with high spatial and temporal resolution has equivalent accuracy to 4D-CT for preoperative gland localization in primary hyperparathyroidism without requiring exposure to ionizing radiation. MATERIALS AND METHODS Inclusion criteria were the following: 1) confirmed biochemical diagnosis of primary hyperparathyroidism, 2) preoperative 4D-dynamic contrast-enhanced MR imaging, and 3) surgical cure with >50% decrease in serum parathyroid hormone intraoperatively. 4D-dynamic contrast-enhanced studies were reviewed independently by 2 neuroradiologists to identify the side, quadrant, and number of abnormal glands, and compared with surgical and pathologic results. RESULTS Fifty-four patients met the inclusion criteria: 37 had single-gland disease, and 17, multigland disease (9 with double-gland hyperplasia; 3 with 3-gland hyperplasia; and 5 with 4-gland hyperplasia). Interobserver agreement (κ) for the side (right versus left) was 0.92 for single-gland disease and 0.70 for multigland disease. Interobserver agreement for the quadrant (superior versus inferior) was 0.70 for single-gland disease and 0.69 for multigland disease. For single-gland disease, the gland was correctly located in 34/37 (92%) patients, with correct identification of the side in 37/37 (100%) and the quadrant in 34/37 (92%) patients. For multigland disease, the glands were correctly located in 35/47 (74%) patients, with correct identification of the side in 35/47 (74%) and the quadrant in 36/47 (77%). CONCLUSIONS The proposed high spatial and temporal resolution 4D-dynamic contrast-enhanced MR imaging provides excellent diagnostic performance for preoperative localization in primary hyperparathyroidism, with correct gland localization of 92% for single-gland disease and 74% in multigland disease, superior to 4D-CT studies.
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Affiliation(s)
- J L Becker
- From the Departments of Medical Imaging (J.L.B., V.P., K.J.J.)
| | - V Patel
- From the Departments of Medical Imaging (J.L.B., V.P., K.J.J.)
| | - K J Johnson
- From the Departments of Medical Imaging (J.L.B., V.P., K.J.J.)
| | | | - R R Klein
- Pathology (R.R.K.), University of Arizona, Tucson, Arizona
| | | | - R P Owen
- Departments of Surgery (G.F.R., R.P.O.)
| | - P Pawha
- Radiology (P.P., K.N.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - K Nael
- Radiology (P.P., K.N.), Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Radiological Sciences (K.N.), David Geffen School of Medicine at University of California, Los Angeles, Los Angeles, California
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Abstract
Primary hyperparathyroidism is a hormonal disorder whose prevalence is approximately 1–2% in the United States of America. The disease has become more recognizable to clinicians in an earlier phase and, at present, patients can be diagnosed with “classic”, “normocalcemic”, “normohormonal”, or “mild, asymptomatic” primary hyperparathyroidism. Surgery, with a focused parathyroidectomy when possible, or a four-gland exploration, is the only way to cure the disease. Cure is determined by use of intra-operative parathyroid hormone monitoring with long-term cure rates ranging from 90–95%. Newer adjuncts to surgery include CT or PET imaging and near-infrared immunofluorescence. This article highlights updates in parathyroid disease and advances in parathyroid surgery; it does not provide a comprehensive summary of the disease process or a review of surgical indications, which can be found in the AAES guidelines or NIH Symposium on primary hyperparathyroidism.
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Affiliation(s)
- Melanie Goldfarb
- Center for Endocrine Tumors and Disorders, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, John Wayne Cancer Institute at Providence Saint John's Health Center, Santa Monica, CA, 90404, USA
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Parikh AM, Grogan RH, Morón FE. Localization of Parathyroid Disease in Reoperative Patients with Primary Hyperparathyroidism. Int J Endocrinol 2020; 2020:9649564. [PMID: 32454822 PMCID: PMC7212332 DOI: 10.1155/2020/9649564] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023] Open
Abstract
The localization of persistent or recurrent disease in reoperative patients with primary hyperparathyroidism presents challenges for radiologists and surgeons alike. In this article, we summarize the relevant imaging modalities, compare their accuracy in identifying reoperative disease, and outline their advantages and disadvantages. Accurate localization by preoperative imaging is a predictor of operative success, whereas negative or discordant preoperative imaging is a risk factor for operative failure. Ultrasound is a common first-line modality because it is inexpensive, accessible, and radiation-free. However, it is highly operator-dependent and less accurate in the reoperative setting than in the primary setting. Sestamibi scintigraphy is superior to ultrasound in localizing reoperative disease but requires radiation, prolonged imaging times, and reader experience for accurate interpretation. Like ultrasound, sestamibi scintigraphy is less accurate in the reoperative setting because reoperative patients can exhibit distorted anatomy, altered perfusion of remaining glands, and interference of radiotracer uptake. Meanwhile, four-dimensional computed tomography (4DCT) is superior to ultrasound and sestamibi scintigraphy in localizing reoperative disease but requires the use of radiation and intravenous contrast. Both 4DCT and magnetic resonance imaging (MRI) do not significantly differ in accuracy between unexplored and reoperative patients. However, MRI is more costly, inaccessible, and time-consuming than 4DCT and is inappropriate as a first-line modality. Hybrid imaging with positron emission tomography and computed tomography (PET/CT) may be a promising second-line modality in the reoperative setting, particularly when first-line modalities are discordant or inconclusive. Lastly, selective venous sampling should be reserved for challenging cases in which noninvasive modalities are negative or discordant. In the challenging population of reoperative patients with PHPT, a multimodality approach that utilizes the expertise of high-volume centers can accurately localize persistent or recurrent disease and enable curative parathyroidectomy.
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Affiliation(s)
- Aaroh M. Parikh
- School of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Internal Medicine, Santa Clara Valley Medical Center, San Jose, CA 95128, USA
| | - Raymon H. Grogan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | - Fanny E. Morón
- Department of Radiology, Baylor College of Medicine, Houston, TX 77030, USA
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Sandqvist P, Nilsson IL, Grybäck P, Sanchez-Crespo A, Sundin A. Multiphase Iodine Contrast-Enhanced SPECT/CT Outperforms Nonenhanced SPECT/CT for Preoperative Localization of Small Parathyroid Adenomas. Clin Nucl Med 2019; 44:929-935. [PMID: 31689274 DOI: 10.1097/rlu.0000000000002778] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE The aim of this study was to assess the value of intravenously contrast-enhanced CT in conjunction with Tc-MIBI SPECT for preoperative localization of parathyroid adenoma. METHODS One hundred ninety-two patients with primary hyperparathyroidism were enrolled in the study between May 2015 and May 2017. The patients underwent a preoperative "one-stop shop" examination with Tc-MIBI SPECT/CT by using dual time-point (10 and 90 minutes) protocol and both nonenhanced CT and contrast-enhanced CT acquisition in the arterial and venous phase, 35 and 75 seconds, respectively, after contrast medium injection start. For 149 patients, the imaging results could be correlated to those at surgery and histopathology. RESULTS The median adenoma weight was 330 mg. The addition of contrast-enhanced CT increased the sensitivity from 81.1% to 89.9% (P = 0.003). The specificity of nonenhanced SPECT/CT was similar to contrast-enhanced CT (96.1% vs 97.9%; P = 0.077). For patients with uniglandular disease (n = 140, 94.0%), the sensitivity increased from 86.4% to 93.6% (P = 0.021) and the specificity from 96.2% to 97.9% (P = 0.118) by adding contrast-enhanced CT. In patients with multiglandular disease (n = 9, 6.0%), adding contrast-enhanced CT improved detection sensitivity from 42.1% to 63.2%. However, these patients were few and significance was not reached (P = 0.125). CONCLUSIONS In this cohort, with generally small parathyroid adenomas, the sensitivity in preoperative localization was greatly improved by adding contrast-enhanced CT to Tc-MIBI SPECT/CT.
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Affiliation(s)
- Patricia Sandqvist
- From the Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital
- Department of Molecular Medicine and Surgery, Karolinska Institute
| | - Inga-Lena Nilsson
- Department of Molecular Medicine and Surgery, Karolinska Institute
- Department of Endocrine Tumors and Sarcoma, Karolinska University Hospital
| | - Per Grybäck
- From the Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital
- Department of Molecular Medicine and Surgery, Karolinska Institute
| | - Alejandro Sanchez-Crespo
- From the Department of Medical Radiation Physics and Nuclear Medicine, Karolinska University Hospital
- Department of Oncology-Pathology, Karolinska Institute, Stockholm
| | - Anders Sundin
- Department of Radiology, Section for Molecular Imaging, Institution for Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Schwartz IE, Capra GG, Mullin DP, Johnson TE, Boswell GE. Parathyroid Computed Tomography Angiography: Early Experience with a Novel Imaging Technique in Primary Hyperparathyroidism. Otolaryngol Head Neck Surg 2019; 161:251-256. [DOI: 10.1177/0194599819842106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objectives To describe parathyroid computed tomography angiography (PCTA), determine its accuracy, and, as a secondary objective, calculate its mean radiation dosimetry. Study Design Retrospective chart review of patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015. Setting Single-center tertiary care academic military hospital. Subjects and Methods PCTA is a 2-phase computed tomography imaging technique that uses individualized timing of contrast infusion and novel patient positioning to accurately identify parathyroid adenomas. Consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism from 2007 to 2015 were reviewed; 55% of patients were women. The mean age was 50.9 years (range, 26-68 years). Sensitivity and specificity were calculated as well as mean radiation dosimetry and timing of contrast. Results A total of 108 procedures were performed during the study period. Twenty-one patients undergoing 22 PCTAs after prior sestamibi scans were nonlocalizing or equivocal. In this group, there were 15 true-positive, 3 false-positive, 4 true-negative, and 0 false-negative PCTAs. This represents a sensitivity of 100% (95% CI, 74.7%-100%) and a specificity of 57% (95% CI, 20%-88%). The mean calculated radiation dose was 5.15 mSv. In the most recent studies, a mean dose of 4.1 mSv was calculated. The ideal time of image acquisition contrast administration varied from 20 to 30 seconds after contrast infusion. Conclusions PCTA is a new technique in anatomic imaging for hyperparathyroidism. In a single-center, single-radiologist retrospective study, it demonstrates excellent accuracy for patients with parathyroid adenomas that are otherwise difficult to localize preoperatively. Preliminary experience suggests that its use may be indicated as a primary imaging modality in the future.
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Affiliation(s)
- Isaac E. Schwartz
- Department of Otolaryngology–Head and Neck Surgery, US Navy Hospital, Naples, Italy
| | - Gregory G. Capra
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia, USA
| | - David P. Mullin
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
| | - Terence E. Johnson
- Department of Otolaryngology–Head and Neck Surgery, Naval Medical Center San Diego, San Diego, California, USA
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