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Park HS, Hong N, Jeong JJ, Yun M, Rhee Y. Update on Preoperative Parathyroid Localization in Primary Hyperparathyroidism. Endocrinol Metab (Seoul) 2022; 37:744-755. [PMID: 36327985 PMCID: PMC9633222 DOI: 10.3803/enm.2022.1589] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 10/04/2022] [Indexed: 12/30/2022] Open
Abstract
Parathyroidectomy is the treatment of choice for primary hyperparathyroidism when the clinical criteria are met. Although bilateral neck exploration is traditionally the standard method for surgery, minimally invasive parathyroidectomy (MIP), or focused parathyroidectomy, has been widely accepted with comparable curative outcomes. For successful MIP, accurate preoperative localization of parathyroid lesions is essential. However, no consensus exists on the optimal approach for localization. Currently, ultrasonography and technetium-99m-sestamibi-single photon emission computed tomography/computed tomography are widely accepted in most cases. However, exact localization cannot always be achieved, especially in cases with multiglandular disease, ectopic glands, recurrent disease, and normocalcemic primary hyperparathyroidism. Therefore, new modalities for preoperative localization have been developed and evaluated. Positron emission tomography/computed tomography and parathyroid venous sampling have demonstrated improvements in sensitivity and accuracy. Both anatomical and functional information can be obtained by combining these methods. As each approach has its advantages and disadvantages, the localization study should be deliberately chosen based on each patient's clinical profile, costs, radiation exposure, and the availability of experienced experts. In this review, we summarize various methods for the localization of hyperfunctioning parathyroid tissues in primary hyperparathyroidism.
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Affiliation(s)
- Hye-Sun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Ju Jeong
- Department of Surgery, Thyroid Cancer Clinic, Seoul, Korea
| | - Mijin Yun
- Department of Nuclear Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yumie Rhee
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Corresponding author: Yumie Rhee. Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Korea Tel: +82-2-2228-1973, Fax: +82-2-393-6884, E-mail:
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Silberzweig AM, Xing M, Mundi N, Dowling E, Urken ML. An unusual case of retropharyngeal ectopic parathyroid adenoma. EAR, NOSE & THROAT JOURNAL 2022:1455613221101934. [PMID: 35538678 DOI: 10.1177/01455613221101934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Monica Xing
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, NY, USA
| | - Neil Mundi
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, NY, USA
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Eric Dowling
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, NY, USA
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Mark L Urken
- Thyroid, Head and Neck Cancer (THANC) Foundation, New York, NY, USA
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
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Kordahi AM, Newfield RS, Bickler SW, Mo JQ, Khanna PC, Bykowski J, Bouvet M. Undescended retropharyngeal parathyroid adenoma with adjacent thymic tissue in a 13-year-old boy with primary hyperparathyroidism. Oxf Med Case Reports 2019; 2019:519-523. [PMID: 31908827 PMCID: PMC6937453 DOI: 10.1093/omcr/omz129] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 10/03/2019] [Accepted: 11/07/2019] [Indexed: 11/17/2022] Open
Abstract
We describe a rare presentation of a symptomatic parathyroid adenoma located in an ectopic retropharyngeal position in a 13-year-old boy. Preoperative CT scan and MRI demonstrated the ectopic location of the parathyroid adenoma. The patient underwent successful parathyroidectomy with cure of his hyperparathyroidism. On pathologic exam, the specimen was made up of a parathyroid adenoma and adjacent thymic tissue, indicating that it was likely an undescended lower parathyroid gland arising from the third pharyngeal pouch. Ectopic retropharyngeal parathyroid adenomas are very rare and to our knowledge, none have been previously described in adolescents.
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Affiliation(s)
- Anthony M Kordahi
- Department of Surgery, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Ron S Newfield
- Department of Pediatrics, Division of Pediatric Endocrinology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Stephen W Bickler
- Department of Surgery, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA.,Department of Pediatrics, Division of Pediatric Endocrinology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Jun Q Mo
- Department of Pathology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Paritosh C Khanna
- Department of Pediatric Radiology, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
| | - Julie Bykowski
- Department of Radiology, University of California San Diego, San Diego, CA, USA
| | - Michael Bouvet
- Department of Surgery, University of California San Diego and Rady Children's Hospital, San Diego, CA, USA
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Kane AC, Walvekar RR, Hotaling JM. Transoral robotic resection of a retropharyngeal parathyroid adenoma: a case report. J Robot Surg 2018; 13:335-338. [PMID: 29987624 DOI: 10.1007/s11701-018-0843-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 07/04/2018] [Indexed: 01/02/2023]
Abstract
Transoral robotic surgery (TORS) has become an increasingly popular option for early malignancies of the oropharynx. It offers superior visualization and has been proven to have acceptable functional and oncologic outcomes. Additionally, indications in head neck have expanded to manage tumors of the thyroid, neck, parapharyngeal space and salivary glands. A 58-year-old female had an incidental finding on CT imaging of a retropharyngeal mass at the level of the hyoid bone. She was referred to a tertiary medical center for further workup and removal of this mass. Due to the midline position of the mass, favorable access and potentially decreased surgical morbidity, TORS excision of the mass was performed for diagnosis and treatment. Histopathology confirmed this to be a hypercellular parathyroid mass consistent with parathyroid adenoma. We report a relatively unusual location of parathyroid adenoma in an asymptomatic patient with normal parathyroid and calcium levels. TORS proves to be a feasible and safe method for complete surgical excision of retropharyngeal parathyroid adenoma without tumor spillage or violation.
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Affiliation(s)
- Anne C Kane
- Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA.
| | - Rohan R Walvekar
- Department of Otolaryngology Head and Neck Surgery, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Jeffrey M Hotaling
- Department of Otolaryngology - Head and Neck Surgery, Wayne State University, Detroit, MI, USA
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Gallagher JW, Kelley ML, Yip L, Carty SE, McCoy KL. Retropharyngeal Parathyroid Glands: Important Differences. World J Surg 2017; 42:437-443. [DOI: 10.1007/s00268-017-4236-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Kim J, Cubangbang M, Adkins L, Chia S, DeKlotz TR, Boyle L, Davidson B. Ectopic parathyroid adenoma in the pyriform sinus. Head Neck 2017; 39:E110-E113. [DOI: 10.1002/hed.24878] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/01/2017] [Accepted: 05/30/2017] [Indexed: 11/07/2022] Open
Affiliation(s)
- Jonathan Kim
- Department of Otolaryngology - Head and Neck Surgery; MedStar Georgetown University Hospital, Georgetown University Medical Center; Washington DC
| | - Maricel Cubangbang
- Department of Otolaryngology - Head and Neck Surgery; MedStar Georgetown University Hospital, Georgetown University Medical Center; Washington DC
| | - Lacey Adkins
- Department of Otolaryngology - Head and Neck Surgery; MedStar Georgetown University Hospital, Georgetown University Medical Center; Washington DC
| | - Stanley Chia
- Department of Otolaryngology; MedStar Washington Hospital Center; Washington DC
| | - Timothy R. DeKlotz
- Department of Otolaryngology - Head and Neck Surgery; MedStar Georgetown University Hospital, Georgetown University Medical Center; Washington DC
| | - Lisa Boyle
- Department of Surgery; MedStar Georgetown University Hospital; Washington DC
| | - Bruce Davidson
- Department of Otolaryngology - Head and Neck Surgery; MedStar Georgetown University Hospital, Georgetown University Medical Center; Washington DC
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Dual-Energy CT Characteristics of Parathyroid Adenomas on 25-and 55-Second 4D-CT Acquisitions: Preliminary Experience. J Comput Assist Tomogr 2017; 40:806-14. [PMID: 27224226 DOI: 10.1097/rct.0000000000000442] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The objective of this study was to compare the dual-energy computed tomography (CT) characteristics of parathyroid adenomas (PAs), thyroid tissue, and lymph nodes (LNs) and assess whether the spectral information can improve distinction of these tissues. METHODS Dual-energy CT scans from 20 patients with pathologically proven PAs were retrospectively evaluated, identifying 19 eligible PAs and region of interest analysis used for spectral characterization. RESULTS There was a significant difference in multiple spectral parameters between PAs, LNs, and the thyroid gland (P < 0.05-0.0001). The greatest difference in spectral characteristics of PAs compared with that of LNs was on the 25-second acquisition, whereas the 55-second acquisition was better for distinguishing PAs from the thyroid gland. CONCLUSIONS Four-dimensional CT acquired in dual-energy CT mode has the potential to further enhance diagnostic accuracy for PA identification on individual phases of the perfusion study.
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Effect of tumor volume on the enhancement pattern of parathyroid adenoma on parathyroid four-dimensional CT. Neuroradiology 2016; 58:495-501. [PMID: 26847704 DOI: 10.1007/s00234-016-1656-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/29/2016] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The purpose of this study is to assess the effect of tumor volume on the enhancement pattern of parathyroid adenoma (PTA) on four-dimensional computed tomography (4D-CT). METHODS We analyzed the enhancement patterns of PTA on four-phase 4D-CT in 44 patients. Dependency of the changes of Hounsfield unit values (ΔHU) on the tumor volumes and clinical characteristics was evaluated using linear regression analyses. In addition, an unpaired t test was used to compare ΔHU of PTAs between PTA volume ≥1 cm(3) and <1 cm(3), thyroid gland, and lymph node. RESULTS PTA volume based on CT was the strongest factor on the ΔHUPre to Arterial and ΔHUArterial to Venous and ΔHUArterial to Delayed (R (2) = 0.34, 0.25, and 0.32, respectively, P < 0.001 for both). PTA ≥1 cm(3) had statistically significant greater enhancement between the unenhanced phase and the arterial phase than PTA <1 cm(3) (mean values ± standard deviations (SDs) of ΔHUPre to Arterial, 102.7 ± 33.7 and 57.5 ± 28.8, respectively, P < 0.001). PTA ≥1 cm(3) showed an early washout pattern on the venous phase, whereas PTA <1 cm(3) showed a progressive enhancement pattern on the venous phase (mean values ± SDs of ΔHUArterial to Venous, -13.2 ± 31.6 and 14.4 ± 32.7, respectively; P = 0.009). CONCLUSION The enhancement pattern of PTA on 4D-CT is variable with respect to PTA volume based on CT. Therefore, the enhancement pattern of PTA on 4D-CT requires careful interpretation concerning the tumor volume, especially in cases of PTA <1 cm(3).
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Duke WS, Vernon HM, Terris DJ. Reoperative Parathyroidectomy. Otolaryngol Head Neck Surg 2015; 154:268-71. [DOI: 10.1177/0194599815619625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/06/2015] [Indexed: 11/17/2022]
Abstract
Objectives To identify the importance of the ectopic, overly descended superior parathyroid adenoma variant and its prevalence in primary and reoperative parathyroid surgery and the implications for successful initial parathyroidectomy. Study Design Case series with planned data collection. Setting Tertiary endocrine surgery practice in an academic medical center. Subjects and Methods An analysis was undertaken of 561 consecutive patients undergoing parathyroid surgery in a tertiary endocrine surgery practice from March 2004 to April 2013. There were 270 patients who had curative primary or reoperative surgery for single-gland parathyroid adenomas during this time. Clinical records, imaging studies, operative reports, and pathology findings were evaluated, and cases from a subset of patients who had an ectopic, overly descended superior parathyroid adenoma were further analyzed. The prevalence of this entity in primary and revision surgeries was calculated. Results Among the 270 patients with single-gland parathyroid adenomas, there were 251 primary operations and 19 reoperative procedures referred from outside institutions. An ectopic, overly descended superior parathyroid adenoma was present in 23 (9.2%) primary cases and 4 (21.1%) reoperative cases. Conclusion An overly descended superior parathyroid adenoma is frequently encountered during primary parathyroid surgery. It is more than twice as common in reoperative parathyroidectomy, reflecting the propensity to be missed at the first exploration. Recognition and proper treatment of this entity at the initial operation will reduce the need for revision surgery.
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Affiliation(s)
- William S. Duke
- Department of Otolaryngology–Head and Neck Surgery, Georgia Regents University, Augusta, Georgia, USA
| | - Hampton M. Vernon
- Department of Otolaryngology–Head and Neck Surgery, Georgia Regents University, Augusta, Georgia, USA
| | - David J. Terris
- Department of Otolaryngology–Head and Neck Surgery, Georgia Regents University, Augusta, Georgia, USA
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Roskies M, Liu X, Hier MP, Payne RJ, Mlynarek A, Forest V, Levental M, Forghani R. 3-phase dual-energy CT scan as a feasible salvage imaging modality for the identification of non-localizing parathyroid adenomas: a prospective study. J Otolaryngol Head Neck Surg 2015; 44:44. [PMID: 26521153 PMCID: PMC4628333 DOI: 10.1186/s40463-015-0098-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 10/19/2015] [Indexed: 12/12/2022] Open
Abstract
Objectives Accurate pre-operative imaging of parathyroid adenomas (PAs) is essential for successful minimally invasive surgery; however, rates of non-localizing PAs can be as high as 18 %. Multiphasic dual-energy CT (DECT) has the potential to increase accuracy of PA detection by enabling creation of paired material maps and spectral tissue characterization. This study prospectively evaluated the utility of 3-phase DECT for PA identification in patients with failed localizatio n via standard imaging. Methods Patients with primary hyperparathyroidism and non-localizing PAs underwent a 3 phase post-contrast DECT scan acquired at 25, 55, and 85 s. The scans were prospectively evaluated by two head and neck radiologists. Pre-operative localization was compared to intraoperative localization and final histopathology. A post-hoc DECT spectral density characterization was performed on pathologically-proven PAs. Results Out of 29 patients with primary hyperparathyroidism and non-localized PAs, DECT identified candidates in 26. Of the 23 patients who underwent parathyroidectomy, DECT provided precise anatomic localization in 20 patients (PPV = 87.0 %), one with multi-gland disease. The virtual unenhanced images were not found to be useful for diagnosis but successful diagnosis was made without an unenhanced phase regardless. Spectral analysis demonstrated a distinct spectral Hounsfield attenuation curve for PAs compared to lymph nodes on arterial phase images. Conclusion 3-phase DECT without an unenhanced phase is a feasible salvage imaging modality for previously non-localizing parathyroid adenomas. Optimal interpretation is achieved based on a combination of perfusion characteristics and other morphologic features. Advanced spectral DECT analysis has the potential for further increasing accuracy of PA identification in the future.
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Affiliation(s)
- Michael Roskies
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Xiaoyang Liu
- Department of Radiology, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Michael P Hier
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Richard J Payne
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Alex Mlynarek
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Veronique Forest
- Department of Otolaryngology-Head and Neck Surgery, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Mark Levental
- Department of Radiology, Jewish General Hospital & McGill University, Montreal, Quebec, Canada
| | - Reza Forghani
- Department of Radiology, Jewish General Hospital & McGill University, Montreal, Quebec, Canada. .,Segal Cancer Centre and Lady Davis Institute for Medical Research, Jewish General Hospital & McGillUniversity, Montreal, Quebec, Canada.
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Lifetime Attributable Risk of Cancer From Radiation Exposure During Parathyroid Imaging: Comparison of 4D CT and Parathyroid Scintigraphy. AJR Am J Roentgenol 2015; 204:W579-85. [PMID: 25905965 DOI: 10.2214/ajr.14.13278] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE The purpose of this study is to measure the organ doses and effective dose (ED) for parathyroid 4D CT and scintigraphy and to estimate the lifetime attributable risk of cancer incidence associated with imaging. MATERIALS AND METHODS Organ radiation doses for 4D CT and scintigraphy were measured on the basis of imaging with our institution's protocols. An anthropomorphic phantom with metal oxide semiconductor field effect transistor detectors was scanned to measure CT organ dose. Organ doses from the radionuclide were based on International Commission for Radiological Protection report 80. ED was calculated for 4D CT and scintigraphy and was used to estimate the lifetime attributable risk of cancer incidence for patients differing in age and sex with the approach established by the Biologic Effects of Ionizing Radiation VII report. A 55-year-old woman was selected as the standard patient according to the demographics of patients with primary hyperparathyroidism. RESULTS Organs receiving the highest radiation dose from 4D CT were the thyroid (150.6 mGy) and salivary glands (137.8 mGy). For scintigraphy, the highest organ doses were to the colon (41.5 mGy), gallbladder (39.8 mGy), and kidneys (32.3 mGy). The ED was 28 mSv for 4D CT, compared with 12 mSv for scintigraphy. In the exposed standard patient, the lifetime attributable risk for cancer incidence was 193 cancers/100,000 patients for 4D CT and 68 cancers/100,000 patients for scintigraphy. Given a baseline lifetime incidence of cancer of 46,300 cancers/100,000 patients, imaging results in an increase in lifetime incidence of cancer over baseline of 0.52% for 4D CT and 0.19% for scintigraphy. CONCLUSION The ED of 4D CT is more than double that of scintigraphy, but both studies cause negligible increases in lifetime risk of cancer. Clinicians should not allow concern for radiation-induced cancer to influence decisions regarding workup in older patients.
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Hoang JK, Sung WK, Bahl M, Phillips CD. How to perform parathyroid 4D CT: tips and traps for technique and interpretation. Radiology 2014; 270:15-24. [PMID: 24354373 DOI: 10.1148/radiol.13122661] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Parathyroid four-dimensional (4D) computed tomography (CT) is an imaging technique for preoperative localization of parathyroid adenomas that involves multidetector CT image acquisition during two or more contrast enhancement phases. Four-dimensional CT offers an alternative or additional tool in the evaluation of primary hyperparathyroidism. The purpose of this article is to describe the 4D CT technique and provide a practical guide to the radiologist for imaging interpretation. The article will discuss the rationale for imaging, approach to interpretation, imaging findings, and pitfalls.
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Affiliation(s)
- Jenny K Hoang
- From the Department of Radiology, Division of Neuroradiology, Duke University Medical Center, Box 3808, Erwin Rd, Durham NC, 27710 (J.K.H., W.K.S., M.B.); and Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY (C.D.P.)
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Schramm JC, Perry DA, Sewell RK. Retropharyngeal thymus and parathyroid gland: a case report. Int J Pediatr Otorhinolaryngol 2014; 78:163-5. [PMID: 24309004 DOI: 10.1016/j.ijporl.2013.10.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 10/22/2013] [Accepted: 10/29/2013] [Indexed: 10/26/2022]
Abstract
Cervical ectopic thymus occurs when thymic tissue arrests during its embryologic descent through the neck to the upper mediastinum. Most often it presents as an asymptomatic neck mass. Rarely does it present with airway compromise, particularly in neonates. A neonate presented with a retropharyngeal mass causing dynamic upper airway obstruction, mimicking a venolymphatic malformation. Ultimately this proved to be aberrant ectopic thymus with an associated parathyroid gland. While there have been isolated reports of thymus or parathyroid in the retropharyngeal space, none of the prior reports found both within the same patient.
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Affiliation(s)
- Jordan C Schramm
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Deborah A Perry
- Department of Pathology, Children's Hospital & Medical Center, Omaha, NE, USA
| | - Ryan K Sewell
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA; ENT Specialists, P.C., Omaha, NE, USA
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Hunter GJ, Ginat DT, Kelly HR, Halpern EF, Hamberg LM. Discriminating parathyroid adenoma from local mimics by using inherent tissue attenuation and vascular information obtained with four-dimensional CT: formulation of a multinomial logistic regression model. Radiology 2013; 270:168-75. [PMID: 24009349 DOI: 10.1148/radiol.13122851] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To identify a set of parameters, which are based on tissue enhancement and native iodine content obtained from a standardized triple-phase four-dimensional (4D) computed tomographic (CT) scan, that define a multinomial logistic regression model that discriminates between parathyroid adenoma (PTA) and thyroid nodules or lymph nodes. MATERIALS AND METHODS Informed consent was waived by the institutional review board for this retrospective HIPAA-compliant study. Electronic medical records were reviewed for 102 patients with hyperparathyroidism who underwent triple-phase 4D CT and parathyroid surgery resulting in pathologically proved removal of adenoma from July 2010 through December 2011. Hounsfield units were measured in PTA, thyroid, lymph nodes, and aorta and were used to determine seven parameters characterizing tissue contrast enhancement. These were used as covariates in 10 multinomial logistic regression models. Three models with one covariate, four models with two covariates, and three models with three covariates were investigated. Receiver operating characteristic (ROC) analysis was performed to determine how well each model discriminated between adenoma and nonadenomatous tissues. Statistical differences between the areas under the ROC curves (AUCs) for each model pair were calculated, as well as sensitivity, specificity, accuracy, negative predictive value, and positive predictive value. RESULTS A total of 120 lesions were found; 112 (93.3%) lesions were weighed, and mean and median weights were 589 and 335 mg, respectively. The three-covariate models were significantly identical (P > .65), with largest AUC of 0.9913 ± 0.0037 (standard error), accuracy of 96.9%, and sensitivity, specificity, negative predictive value, and positive predictive value of 94.3%, 98.3%, 97.1%, and 96.7%, respectively. The one- and two-covariate models were significantly less accurate (P < .043). CONCLUSION A three-covariate multinomial logistic model derived from a triple-phase 4D CT scan can accurately provide the probability that tissue is PTA and performs significantly better than models using one or two covariates.
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Affiliation(s)
- George J Hunter
- From the Departments of Neuroradiology (G.J.H., D.T.G., H.R.K.) and Radiology (E.F.H.), Massachusetts General Hospital, 55 Fruit St, Gray 273a, Boston, MA 02114; and Department of Radiology Physics, Brigham and Women's Hospital, Boston, Mass (L.M.H.)
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Preoperative Localization of Parathyroid Adenomas Using 4-Dimensional Computed Tomography: A Pictorial Essay. Can Assoc Radiol J 2013; 64:258-68. [DOI: 10.1016/j.carj.2012.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 02/10/2012] [Accepted: 03/07/2012] [Indexed: 11/18/2022] Open
Abstract
Accurate preoperative localization is the key to successful parathyroid surgery in the era of minimally invasive parathyroid surgery. This article presents and discusses the embryologic basis of parathyroid gland and ectopic location and different imaging modalities helpful in diagnosing and localizing parathyroid adenomas and/or hyperplasia. We also aim to review the current surgical concepts in treatment of parathyroid adenomas and/or hyperplasia, the utility of 4-dimensional computed tomography for accurate preoperative localization of hyperfunctioning parathyroid glands, imaging classification of adenomas and/or hyperplasia, and, finally, present some of the limitations of 4-dimensional computed tomography.
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Kelly HR, Hamberg LM, Hunter GJ. 4D-CT for preoperative localization of abnormal parathyroid glands in patients with hyperparathyroidism: accuracy and ability to stratify patients by unilateral versus bilateral disease in surgery-naive and re-exploration patients. AJNR Am J Neuroradiol 2013; 35:176-81. [PMID: 23868155 DOI: 10.3174/ajnr.a3615] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND PURPOSE 4D-CT is an emerging technique that uses high-resolution images, multiplanar reformats, and perfusion characteristics to identify abnormal parathyroid glands in patients with hyperparathyroidism. This study evaluates the accuracy of 4D-CT for localization and lateralization of abnormal parathyroid glands in preoperative planning for minimally invasive parathyroidectomy vs bilateral neck exploration at a tertiary referral center. MATERIALS AND METHODS Radiology, pathology, and operative reports were retrospectively reviewed for 208 patients with hyperparathyroidism who underwent 4D-CT and parathyroid surgery between May 2008 and January 2012. 4D-CT performance in localizing side and site was determined by use of surgical and pathologic findings as a reference. RESULTS Of 208 patients, 155 underwent initial surgery and 53 underwent re-exploration parathyroid surgery. No lesions were found in 8 patients (3.8%). A total of 284 lesions were found in 200 patients; 233 were correctly localized by 4D-CT (82.0%). Of the 200 patients with parathyroid lesions, 146 underwent unilateral and 54 bilateral neck exploration. 4D-CT correctly identified unilateral vs bilateral disease in 179 (89.5%) of 200. 4D-CT correctly localized parathyroid lesions in 126 of the unilateral cases (86.3%). In the re-exploration cohort, 4D-CT correctly identified unilateral vs bilateral disease in 46 (95.8%) of 48. There was no statistically significant difference in subgroups stratified by surgery type (primary or subsequent) and number of scan phases (3 or 4) (P > .56). CONCLUSIONS 4D-CT leverages modern high-resolution CT scanning and dynamic contrast enhancement to localize abnormal parathyroid glands in patients with hyperparathyroidism of any cause and can be used for planning minimally invasive parathyroidectomy vs bilateral neck exploration.
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Affiliation(s)
- H R Kelly
- Division of Diagnostic Neuroradiology, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts
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Gafton AR, Glastonbury CM, Eastwood JD, Hoang JK. Parathyroid lesions: characterization with dual-phase arterial and venous enhanced CT of the neck. AJNR Am J Neuroradiol 2012; 33:949-52. [PMID: 22241395 DOI: 10.3174/ajnr.a2885] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This clinical report describes the enhancement characteristics of hypersecreting parathyroid lesions on dual-phase neck CT. We retrospectively analyzed the enhancement characteristics of 5 pathologically confirmed PTH-secreting lesions on dual-phase CT examinations. Attenuation values were measured for PTH-secreting lesions, vascular structures (CCA and IJV), and soft tissue structures (thyroid gland, jugulodigastric lymph node, and submandibular gland). From the attenuation values, "relative enhancement washout percentage" and "tissue-vascular ratio" were calculated and compared. All lesions decreased in attenuation from arterial to venous phase, while the mean attenuation values of other soft tissue structures increased. A high relative enhancement washout percentage was correlated with parathyroid lesions (P < .006). The tissue-CCA ratio and tissue-IJV ratio for PTH-secreting lesions in the arterial phase were statistically significantly higher compared with soft tissue structures (P < .05). If these results are validated in future larger studies, noncontrast and delayed venous phases of 4D-CT could be eliminated to markedly reduce radiation exposure.
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Affiliation(s)
- A R Gafton
- Department of Radiology, Duke University Medical Center, Durham, NC 27710, USA
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Chazen JL, Gupta A, Dunning A, Phillips CD. Diagnostic accuracy of 4D-CT for parathyroid adenomas and hyperplasia. AJNR Am J Neuroradiol 2011; 33:429-33. [PMID: 22135127 DOI: 10.3174/ajnr.a2805] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND AND PURPOSE 4D-CT is a novel method of multiphase CT imaging. When used to localize parathyroid adenomas and hyperplasia, this technique may allow for more robust diagnostic accuracy than traditional sonography and nuclear scintigraphy techniques. The purpose of our study is to assess the accuracy of 4D-CT for localizing pathologically proved parathyroid adenomas and hyperplasia found during surgery. MATERIALS AND METHODS A total of 35 pathologically proved cases of parathyroid adenoma and hyperplasia were retrospectively reviewed between January 2009 and March 2011. Inclusion criteria were availability of final surgical pathology and performance of preoperative 4D-CT. No cases were excluded. Sensitivity, specificity, and accuracy of 4D-CT were ascertained including both the side and quadrant of the pathologically proved lesion. RESULTS Of the 35 pathologically proved cases collected over the study period, 32 (sensitivity = 91%) patients were found positive for parathyroid disease using 4D-CT, including 3 cases of multigland disease. For lateralization of single-gland disease, 4D-CT demonstrated an accuracy of 93%. 4D-CT revealed a suboptimal 44% sensitivity, but 100% specificity, for multigland disease. CONCLUSIONS 4D-CT demonstrated a high diagnostic accuracy for single and multigland disease in our cohort. Importantly, 4D-CT accurately lateralized single-gland adenomas in >90% of cases, allowing the surgeon to employ a directed operative approach. 4D-CT also showed a very high specificity for the detection of multigland disease.
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Affiliation(s)
- J L Chazen
- Section of Head and Neck Imaging in the Department of Radiology, Weill Cornell Medical College, New York, New York 10065, USA
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