Hyperparathyroidism other imaging findings: Difference between revisions

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==Overview==
==Overview==
Imaging modalities may be helpful in preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities.  Non-invasive imaging modalities for preoperative localization of hyper-functioning parathyroid glands include Tc-99m sestamibi scintigraphy (sestamibi or MIBI), single positron emission computed tomography (SPECT), positron emission tomography (PET).  Invasive modalities used for preoperative localization of hyper-functioning parathyroid glands include selective arteriography and angiography. Dual energy X-ray absorptiometry is helpful in detecting low bone mineral density caused by hyperparathyroidism.
Imaging modalities may be helpful in preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]]. This includes both non-invasive and [[Invasive (medical)|invasive]] modalities.  Non-invasive imaging modalities for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]] include [[Tc-99m sestamibi scintigraphy]] ([[sestamibi]] or [[Sestamibi|MIBI]]), [[single photon emission computed tomography]] ([[Single photon emission computed tomography|SPECT]]), [[positron emission tomography]] ([[Positron emission tomography|PET]]).  Invasive modalities used for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]] include selective [[Angiogram|arteriography]] and [[Angiogram|angiography]]. [[Dual energy X-ray absorptiometry]] is helpful in detecting low [[bone mineral density]] (BMD) caused by hyperparathyroidism.


==Other Imaging Findings==
==Other Imaging Findings==
Other imaging modalities are used for preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities. Another modality used in hyperparathyroidism is dual energy X-ray absorptiomerty (DXA). DXA  is helpful in detecting low bone mineral density caused by hyperparathyroidism.
Other imaging modalities are used for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]]. This includes both non-invasive and [[Invasive (medical)|invasive]] modalities. Another modality used in hyperparathyroidism is [[dual energy X-ray absorptiometry]] ([[DXA]]). [[Dual energy X-ray absorptiometry|DXA]] is helpful in detecting low [[bone mineral density]] (BMD) caused by hyperparathyroidism.


===Non-invasive modalities===
===Non-invasive modalities===
====TC-99m Sestamibi Scintigraphy====
====TC-99m Sestamibi Scintigraphy====
*Technetium-99m-methoxyisobutylisonitrile (99mTc-sestamibi or MIBI) scintigraphy is the most popular investigation for preoperative localization of hyper-functioning parathyroid glands.<ref name="pmid16150247">{{cite journal| author=Palestro CJ, Tomas MB, Tronco GG| title=Radionuclide imaging of the parathyroid glands. | journal=Semin Nucl Med | year= 2005 | volume= 35 | issue= 4 | pages= 266-76 | pmid=16150247 | doi=10.1053/j.semnuclmed.2005.06.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16150247  }} </ref>
*[[Technetium-99m]]-methoxyisobutylisonitrile ([[Tc-99m sestamibi scintigraphy|99mTc-sestamibi]] or MIBI) scintigraphy is the most popular investigation for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]].<ref name="pmid16150247">{{cite journal| author=Palestro CJ, Tomas MB, Tronco GG| title=Radionuclide imaging of the parathyroid glands. | journal=Semin Nucl Med | year= 2005 | volume= 35 | issue= 4 | pages= 266-76 | pmid=16150247 | doi=10.1053/j.semnuclmed.2005.06.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16150247  }} </ref>
*Most of the sestamibi is retained in mitochondria of thyroid and abnormal parathyroid tissue and is a function of mitochondrial activity.<ref name="pmid11742331">{{cite journal| author=Hetrakul N, Civelek AC, Stagg CA, Udelsman R| title=In vitro accumulation of technetium-99m-sestamibi in human parathyroid mitochondria. | journal=Surgery | year= 2001 | volume= 130 | issue= 6 | pages= 1011-8 | pmid=11742331 | doi=10.1067/msy.2001.118371 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742331  }} </ref>
*Most of the sestamibi is retained in [[Mitochondrion|mitochondria]] of [[thyroid]] and abnormal [[Parathyroid gland|parathyroid]] tissue and is a function of [[mitochondrial]] activity.<ref name="pmid11742331">{{cite journal| author=Hetrakul N, Civelek AC, Stagg CA, Udelsman R| title=In vitro accumulation of technetium-99m-sestamibi in human parathyroid mitochondria. | journal=Surgery | year= 2001 | volume= 130 | issue= 6 | pages= 1011-8 | pmid=11742331 | doi=10.1067/msy.2001.118371 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742331  }} </ref>
*The basis of this "single-isotope, double-phase technique" is that sestamibi washes out of the thyroid more rapidly than from abnormal parathyroid tissue.<ref name="pmid1328564">{{cite journal| author=Taillefer R, Boucher Y, Potvin C, Lambert R| title=Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study) | journal=J Nucl Med | year= 1992 | volume= 33 | issue= 10 | pages= 1801-7 | pmid=1328564 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1328564  }} </ref>
*Single-isotope, double-phase technique is used. The basis of "single-isotope, double-phase technique" is that [[sestamibi]] washes out of the [[thyroid]] more rapidly than from abnormal [[Parathyroid gland|parathyroid]] tissue.<ref name="pmid1328564">{{cite journal| author=Taillefer R, Boucher Y, Potvin C, Lambert R| title=Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study) | journal=J Nucl Med | year= 1992 | volume= 33 | issue= 10 | pages= 1801-7 | pmid=1328564 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1328564  }} </ref>
*Multiple planar images are obtained, typically one shortly after injection of 99mTc-sestamibi and another after two hours to identify the foci of retained sestamibi showing hyper-functioning parathyroid tissue.
*Multiple planar images are obtained, typically one shortly after injection of 99mTc-sestamibi and another after two hours to identify the areas of retained [[sestamibi]] showing hyper-functioning [[Parathyroid gland|parathyroid]] tissue.
*As all parathyroid lesions does not retain sestamibi nor all thyroid tissue washes out quickly, subtraction imaging may be beneficial.<ref name="pmid8288719">{{cite journal| author=Thulé P, Thakore K, Vansant J, McGarity W, Weber C, Phillips LS| title=Preoperative localization of parathyroid tissue with technetium-99m sestamibi 123I subtraction scanning. | journal=J Clin Endocrinol Metab | year= 1994 | volume= 78 | issue= 1 | pages= 77-82 | pmid=8288719 | doi=10.1210/jcem.78.1.8288719 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8288719  }} </ref>
*As all [[Parathyroid gland|parathyroid]] lesions does not retain [[sestamibi]] nor all [[thyroid]] tissue washes out quickly, subtraction imaging may be beneficial.<ref name="pmid8288719">{{cite journal| author=Thulé P, Thakore K, Vansant J, McGarity W, Weber C, Phillips LS| title=Preoperative localization of parathyroid tissue with technetium-99m sestamibi 123I subtraction scanning. | journal=J Clin Endocrinol Metab | year= 1994 | volume= 78 | issue= 1 | pages= 77-82 | pmid=8288719 | doi=10.1210/jcem.78.1.8288719 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8288719  }} </ref>
*Subtraction technique uses dual contrast Tc-99m sestamibi along with iodine-123 or 99m-technicium pertechnetate which is taken by thyroid tissue only. Iodine-123/99m-technicium pertechnetate images of thyroid are later digitally subtracted from Tc-99m sestamibi images leading to visualization of parathyroid tissue only.<ref name="pmid25722888">{{cite journal| author=Ryhänen EM, Schildt J, Heiskanen I, Väisänen M, Ahonen A, Löyttyniemi E et al.| title=(99m)Technetium Sestamibi-(123)Iodine Scintigraphy Is More Accurate Than (99m)Technetium Sestamibi Alone before Surgery for Primary Hyperparathyroidism. | journal=Int J Mol Imaging | year= 2015 | volume= 2015 | issue=  | pages= 391625 | pmid=25722888 | doi=10.1155/2015/391625 | pmc=4333274 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25722888  }} </ref>
*Subtraction technique uses dual contrast [[Tc-99m sestamibi scintigraphy|Tc-99m sestamibi]] along with iodine-123 or 99m-technicium pertechnetate, which are taken by thyroid tissue only. Iodine-123/99m-technicium pertechnetate images of thyroid are later digitally subtracted from Tc-99m sestamibi images leading to visualization of [[Parathyroid gland|parathyroid]] tissue only.<ref name="pmid25722888">{{cite journal| author=Ryhänen EM, Schildt J, Heiskanen I, Väisänen M, Ahonen A, Löyttyniemi E et al.| title=(99m)Technetium Sestamibi-(123)Iodine Scintigraphy Is More Accurate Than (99m)Technetium Sestamibi Alone before Surgery for Primary Hyperparathyroidism. | journal=Int J Mol Imaging | year= 2015 | volume= 2015 | issue=  | pages= 391625 | pmid=25722888 | doi=10.1155/2015/391625 | pmc=4333274 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25722888  }} </ref>
*Presence of solid thyroid nodule is the most common cause of false positive results. Other causes of false positive results may include thyroid carcinoma, lymphoma, and lymphadenopathy.
*Presence of solid [[thyroid nodule]] is the most common cause of [[false positive]] results. Other causes of [[false positive]] results may include [[thyroid carcinoma]], [[lymphoma]], and [[lymphadenopathy]].
*The sensitivity of sestamibi scintigraphy can be increased by using it concomitantly with neck ultrasound and/or SPECT. <ref name="pmid18794320">{{cite journal| author=Eslamy HK, Ziessman HA| title=Parathyroid scintigraphy in patients with primary hyperparathyroidism: 99mTc sestamibi SPECT and SPECT/CT. | journal=Radiographics | year= 2008 | volume= 28 | issue= 5 | pages= 1461-76 | pmid=18794320 | doi=10.1148/rg.285075055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18794320  }} </ref><ref name="pmid12153604">{{cite journal| author=Haber RS, Kim CK, Inabnet WB| title=Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99m)technetium sestamibi scintigraphy. | journal=Clin Endocrinol (Oxf) | year= 2002 | volume= 57 | issue= 2 | pages= 241-9 | pmid=12153604 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12153604  }} </ref>
*The sensitivity of [[sestamibi]] scintigraphy can be increased by using it concomitantly with neck [[ultrasound]] and/or [[Single photon emission computed tomography|SPECT]]. <ref name="pmid18794320">{{cite journal| author=Eslamy HK, Ziessman HA| title=Parathyroid scintigraphy in patients with primary hyperparathyroidism: 99mTc sestamibi SPECT and SPECT/CT. | journal=Radiographics | year= 2008 | volume= 28 | issue= 5 | pages= 1461-76 | pmid=18794320 | doi=10.1148/rg.285075055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18794320  }} </ref><ref name="pmid12153604">{{cite journal| author=Haber RS, Kim CK, Inabnet WB| title=Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99m)technetium sestamibi scintigraphy. | journal=Clin Endocrinol (Oxf) | year= 2002 | volume= 57 | issue= 2 | pages= 241-9 | pmid=12153604 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12153604  }} </ref>
*The sensitivity of sestamibi scintigraphy is 80% - 90%.<ref name="pmid8678959">{{cite journal |vauthors=Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, Richard B |title=Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism |journal=World J Surg |volume=20 |issue=7 |pages=835–9; discussion 839–40 |year=1996 |pmid=8678959 |doi= |url=}}</ref><ref name="pmid17685957">{{cite journal |vauthors=Prasannan S, Davies G, Bochner M, Kollias J, Malycha P |title=Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi |journal=ANZ J Surg |volume=77 |issue=9 |pages=774–7 |year=2007 |pmid=17685957 |doi=10.1111/j.1445-2197.2007.04227.x |url=}}</ref><ref name="pmid20625763">{{cite journal |vauthors=Gómez-Ramírez J, Sancho-Insenser JJ, Pereira JA, Jimeno J, Munné A, Sitges-Serra A |title=Impact of thyroid nodular disease on 99mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism |journal=Langenbecks Arch Surg |volume=395 |issue=7 |pages=929–33 |year=2010 |pmid=20625763 |doi=10.1007/s00423-010-0680-8 |url=}}</ref>
*The sensitivity of [[sestamibi]] scintigraphy is 80% - 90%.<ref name="pmid8678959">{{cite journal |vauthors=Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, Richard B |title=Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism |journal=World J Surg |volume=20 |issue=7 |pages=835–9; discussion 839–40 |year=1996 |pmid=8678959 |doi= |url=}}</ref><ref name="pmid17685957">{{cite journal |vauthors=Prasannan S, Davies G, Bochner M, Kollias J, Malycha P |title=Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi |journal=ANZ J Surg |volume=77 |issue=9 |pages=774–7 |year=2007 |pmid=17685957 |doi=10.1111/j.1445-2197.2007.04227.x |url=}}</ref><ref name="pmid20625763">{{cite journal |vauthors=Gómez-Ramírez J, Sancho-Insenser JJ, Pereira JA, Jimeno J, Munné A, Sitges-Serra A |title=Impact of thyroid nodular disease on 99mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism |journal=Langenbecks Arch Surg |volume=395 |issue=7 |pages=929–33 |year=2010 |pmid=20625763 |doi=10.1007/s00423-010-0680-8 |url=}}</ref>
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====Single positron emission computed tomography (SPECT)====
====Single photon emission computed tomography (SPECT)====
*Single positron emission computed tomography may be used along with Tc-99m sestamibi scintigraphy for preoperative evaluation of hyper-functioning parathyroid gland.<ref name="pmid8917173">{{cite journal| author=Billotey C, Sarfati E, Aurengo A, Duet M, Mündler O, Toubert ME et al.| title=Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy. | journal=J Nucl Med | year= 1996 | volume= 37 | issue= 11 | pages= 1773-8 | pmid=8917173 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8917173  }} </ref><ref name="pmid11854692">{{cite journal| author=Civelek AC, Ozalp E, Donovan P, Udelsman R| title=Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. | journal=Surgery | year= 2002 | volume= 131 | issue= 2 | pages= 149-57 | pmid=11854692 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11854692  }} </ref>
*[[Single photon emission computed tomography]] may be used along with [[Tc-99m sestamibi scintigraphy]] for preoperative evaluation of hyper-functioning [[Parathyroid gland|parathyroid]] gland.<ref name="pmid8917173">{{cite journal| author=Billotey C, Sarfati E, Aurengo A, Duet M, Mündler O, Toubert ME et al.| title=Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy. | journal=J Nucl Med | year= 1996 | volume= 37 | issue= 11 | pages= 1773-8 | pmid=8917173 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8917173  }} </ref><ref name="pmid11854692">{{cite journal| author=Civelek AC, Ozalp E, Donovan P, Udelsman R| title=Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. | journal=Surgery | year= 2002 | volume= 131 | issue= 2 | pages= 149-57 | pmid=11854692 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11854692  }} </ref>
*Sestamibi-SPECT is also called pinhone-SPECT (P-SPECT). P-SPECT uses cone beam collimator in contrast to parallel-hole collimator used in SPECT. cone bean collimator possess more suitable geometric properties leading to high spatial resolution.<ref name="pmid8306288">{{cite journal| author=Strand SE, Ivanovic M, Erlandsson K, Franceschi D, Button T, Sjögren K et al.| title=Small animal imaging with pinhole single-photon emission computed tomography. | journal=Cancer | year= 1994 | volume= 73 | issue= 3 Suppl | pages= 981-4 | pmid=8306288 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8306288  }} </ref><ref name="pmid15551591">{{cite journal| author=Jaszczak RJ, Li J, Wang H, Zalutsky MR, Coleman RE| title=Pinhole collimation for ultra-high-resolution, small-field-of-view SPECT. | journal=Phys Med Biol | year= 1994 | volume= 39 | issue= 3 | pages= 425-37 | pmid=15551591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15551591  }} </ref>
*Sestamibi-SPECT is also called pinhone-SPECT (P-SPECT). P-SPECT uses cone beam collimator in contrast to parallel-hole collimator used in [[Single photon emission computed tomography|SPECT]]. cone bean collimator possess more suitable geometric properties leading to high spatial resolution.<ref name="pmid8306288">{{cite journal| author=Strand SE, Ivanovic M, Erlandsson K, Franceschi D, Button T, Sjögren K et al.| title=Small animal imaging with pinhole single-photon emission computed tomography. | journal=Cancer | year= 1994 | volume= 73 | issue= 3 Suppl | pages= 981-4 | pmid=8306288 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8306288  }} </ref><ref name="pmid15551591">{{cite journal| author=Jaszczak RJ, Li J, Wang H, Zalutsky MR, Coleman RE| title=Pinhole collimation for ultra-high-resolution, small-field-of-view SPECT. | journal=Phys Med Biol | year= 1994 | volume= 39 | issue= 3 | pages= 425-37 | pmid=15551591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15551591  }} </ref>
*Using SPECT with sestamibi scintigraphy improves detection and localization of hyper-functioning parathyroid gland.<ref name="pmid15078713">{{cite journal| author=Schachter PP, Issa N, Shimonov M, Czerniak A, Lorberboym M| title=Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy. | journal=Arch Surg | year= 2004 | volume= 139 | issue= 4 | pages= 433-7 | pmid=15078713 | doi=10.1001/archsurg.139.4.433 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15078713  }} </ref><ref name="pmid8816526">{{cite journal| author=Perez-Monte JE, Brown ML, Shah AN, Ranger NT, Watson CG, Carty SE et al.| title=Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT. | journal=Radiology | year= 1996 | volume= 201 | issue= 1 | pages= 85-91 | pmid=8816526 | doi=10.1148/radiology.201.1.8816526 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8816526  }} </ref>
*Using [[Single photon emission computed tomography|SPECT]] with [[sestamibi]] scintigraphy improves detection and localization of hyper-functioning [[parathyroid gland]].<ref name="pmid15078713">{{cite journal| author=Schachter PP, Issa N, Shimonov M, Czerniak A, Lorberboym M| title=Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy. | journal=Arch Surg | year= 2004 | volume= 139 | issue= 4 | pages= 433-7 | pmid=15078713 | doi=10.1001/archsurg.139.4.433 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15078713  }} </ref><ref name="pmid8816526">{{cite journal| author=Perez-Monte JE, Brown ML, Shah AN, Ranger NT, Watson CG, Carty SE et al.| title=Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT. | journal=Radiology | year= 1996 | volume= 201 | issue= 1 | pages= 85-91 | pmid=8816526 | doi=10.1148/radiology.201.1.8816526 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8816526  }} </ref>
*SPECT provides more precise result of sestamibi scitigraphy allowing surgeon to choose best route for surgical intervention.
*P-SPECT provides more precise result of [[sestamibi]] scitigraphy allowing surgeon to choose best route for surgical intervention.
*P-SPECT may detect glands not visible on planer images leading to increased sensitivity. It is very useful in case of uncertain result from conventional sestamibi scitigraphy.<ref name="pmid14734671">{{cite journal| author=Spanu A, Falchi A, Manca A, Marongiu P, Cossu A, Pisu N et al.| title=The usefulness of neck pinhole SPECT as a complementary tool to planar scintigraphy in primary and secondary hyperparathyroidism. | journal=J Nucl Med | year= 2004 | volume= 45 | issue= 1 | pages= 40-8 | pmid=14734671 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14734671  }} </ref><ref name="pmid17960377">{{cite journal |vauthors=Carlier T, Oudoux A, Mirallié E, Seret A, Daumy I, Leux C, Bodet-Milin C, Kraeber-Bodéré F, Ansquer C |title=99mTc-MIBI pinhole SPECT in primary hyperparathyroidism: comparison with conventional SPECT, planar scintigraphy and ultrasonography |journal=Eur. J. Nucl. Med. Mol. Imaging |volume=35 |issue=3 |pages=637–43 |year=2008 |pmid=17960377 |pmc=2964350 |doi=10.1007/s00259-007-0625-9 |url=}}</ref>
*P-SPECT may detect glands not visible on planer images leading to increased [[sensitivity]]. It is very useful in case of uncertain result from conventional [[sestamibi]] scitigraphy.<ref name="pmid14734671">{{cite journal| author=Spanu A, Falchi A, Manca A, Marongiu P, Cossu A, Pisu N et al.| title=The usefulness of neck pinhole SPECT as a complementary tool to planar scintigraphy in primary and secondary hyperparathyroidism. | journal=J Nucl Med | year= 2004 | volume= 45 | issue= 1 | pages= 40-8 | pmid=14734671 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14734671  }} </ref><ref name="pmid17960377">{{cite journal |vauthors=Carlier T, Oudoux A, Mirallié E, Seret A, Daumy I, Leux C, Bodet-Milin C, Kraeber-Bodéré F, Ansquer C |title=99mTc-MIBI pinhole SPECT in primary hyperparathyroidism: comparison with conventional SPECT, planar scintigraphy and ultrasonography |journal=Eur. J. Nucl. Med. Mol. Imaging |volume=35 |issue=3 |pages=637–43 |year=2008 |pmid=17960377 |pmc=2964350 |doi=10.1007/s00259-007-0625-9 |url=}}</ref>
*P-SPECT also enables accurate interpretation sestamibi uptake in upper mediastinum leading to a higher specificity.
*P-SPECT also enables accurate interpretation [[sestamibi]] uptake in upper [[mediastinum]] leading to a higher [[specificity]].
*In difficult cases, P-SPECT may also be adjuncted with subtraction Tc-99m sestamibi and I-123 scintigraphy or positron emission tomography.<ref name="pmid10336191">{{cite journal| author=Nguyen BD| title=Parathyroid imaging with Tc-99m sestamibi planar and SPECT scintigraphy. | journal=Radiographics | year= 1999 | volume= 19 | issue= 3 | pages= 601-14; discussion 615-6 | pmid=10336191 | doi=10.1148/radiographics.19.3.g99ma10601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10336191  }} </ref>
*In difficult cases, P-SPECT may also be adjuncted with subtraction [[Sestamibi scan|Tc-99m sestamibi]] and I-123 scintigraphy or [[positron emission tomography]].<ref name="pmid10336191">{{cite journal| author=Nguyen BD| title=Parathyroid imaging with Tc-99m sestamibi planar and SPECT scintigraphy. | journal=Radiographics | year= 1999 | volume= 19 | issue= 3 | pages= 601-14; discussion 615-6 | pmid=10336191 | doi=10.1148/radiographics.19.3.g99ma10601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10336191  }} </ref>
*P-SPECT is approximately  84% sensitive, 91% specific with positive predictive value of around 91% and negative predictive value of around 84%.<ref name="pmid19578871">{{cite journal |vauthors=Lindqvist V, Jacobsson H, Chandanos E, Bäckdahl M, Kjellman M, Wallin G |title=Preoperative 99Tc(m)-sestamibi scintigraphy with SPECT localizes most pathologic parathyroid glands |journal=Langenbecks Arch Surg |volume=394 |issue=5 |pages=811–5 |year=2009 |pmid=19578871 |doi=10.1007/s00423-009-0536-2 |url=}}</ref>
*P-SPECT is approximately  84% [[Sensitivity|sensitive]], 91% [[Specificity|specific]] with [[positive predictive value]] of around 91% and [[negative predictive value]] of around 84%.<ref name="pmid19578871">{{cite journal |vauthors=Lindqvist V, Jacobsson H, Chandanos E, Bäckdahl M, Kjellman M, Wallin G |title=Preoperative 99Tc(m)-sestamibi scintigraphy with SPECT localizes most pathologic parathyroid glands |journal=Langenbecks Arch Surg |volume=394 |issue=5 |pages=811–5 |year=2009 |pmid=19578871 |doi=10.1007/s00423-009-0536-2 |url=}}</ref>
*Fusion images of CT-MIBI-SPECT is superior to CT or MIBI-SPECT alone in preoperative localization of hyper-functioning parathyroid gland.<ref name="pmid19705144">{{cite journal| author=Wimmer G, Profanter C, Kovacs P, Sieb M, Gabriel M, Putzer D et al.| title=CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism. | journal=Langenbecks Arch Surg | year= 2010 | volume= 395 | issue= 1 | pages= 73-80 | pmid=19705144 | doi=10.1007/s00423-009-0545-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19705144  }} </ref>
*Fusion images of CT-MIBI-SPECT is superior to [[Computed tomography|CT scan]] or MIBI-SPECT alone in preoperative localization of hyper-functioning [[parathyroid gland]].<ref name="pmid19705144">{{cite journal| author=Wimmer G, Profanter C, Kovacs P, Sieb M, Gabriel M, Putzer D et al.| title=CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism. | journal=Langenbecks Arch Surg | year= 2010 | volume= 395 | issue= 1 | pages= 73-80 | pmid=19705144 | doi=10.1007/s00423-009-0545-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19705144  }} </ref>


====Positron Emission Tomography (PET)====
====Positron Emission Tomography (PET)====

Revision as of 13:36, 7 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

Imaging modalities may be helpful in preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities. Non-invasive imaging modalities for preoperative localization of hyper-functioning parathyroid glands include Tc-99m sestamibi scintigraphy (sestamibi or MIBI), single photon emission computed tomography (SPECT), positron emission tomography (PET). Invasive modalities used for preoperative localization of hyper-functioning parathyroid glands include selective arteriography and angiography. Dual energy X-ray absorptiometry is helpful in detecting low bone mineral density (BMD) caused by hyperparathyroidism.

Other Imaging Findings

Other imaging modalities are used for preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities. Another modality used in hyperparathyroidism is dual energy X-ray absorptiometry (DXA). DXA is helpful in detecting low bone mineral density (BMD) caused by hyperparathyroidism.

Non-invasive modalities

TC-99m Sestamibi Scintigraphy

Dual tracer Tc-99m sestamibi scintigraphy - A nuclear medicine parathyroid scan demonstrates a parathyroid adenoma adjacent to the left inferior pole of the thyroid gland. The above study was performed with Technetium-Sestamibi (1st column) and Iodine-123 (2nd column) simultaneous imaging and the subtraction technique (3rd column). -- Source:Myohan at en.wikipedia, via Wikimedia Commons
Tc-99m sestamibi scan - Parathyroid adenomas typically retain activity on late scans after wash-out in the thyroid has occurred. - Source:Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16675

Single photon emission computed tomography (SPECT)

Positron Emission Tomography (PET)

  • 11C-methionine PET along with CT scan (MET-PET/CT) may be used for preoperative localization of hyper-functioning gland.[22][23]
  • MET-PET/CT may be used as an complimentary imaging modality for localizing hyper-functioning parathyroid glands in patients with negative Tc-99m sestamibi scintigraphy/SPECT results.[24]

Invasive modalities

Selective arteriography

  • Selective transarterial hypocalcemic stimulation is combined with nonselective venous sampling to perform selective arteriography.[25]
  • Sodium citrate is injected to induce hypocalcemia. Simultaneous arteriography is performed.
  • Samples are taken for superior vena cava at basaeline and timed intervals (20 sec, 40 sec, and 60 sec).
  • An increase in the parathyroid hormone level to 1.4 times above the baseline or a clear blush observed on arteriography is considered as positive localization.
  • Arterial stimulation venous sampling is performed simultaneously with arteriogram due to similarly high PPV.

Angiography

  • Superselective arterial digital subtraction angiography (DSA) and superselective conventional angiography (CA) may be used for preoperative localization of hyper-functioning parathyroid glands in which noninvasive imaging modalities are negative or inconclusive.[26]
  • Sensitivity of superselective digital subtraction angiography appears to be similar to conventional angiography.
  • Superselective arterial digital subtraction angiography may be more sensitive than conventional angiography for preoperative localization of mediastinal hyper-functioning parathyroid glands.

Dual Energy X-ray Absorptiometry

  • Low bone mineral density (BMD) is caused by primary hyperparathyroidism. Distal forearm is affected most commonly.
  • DXA of distal forearm should be done in all patients of primary hyperparathyroidism. Worst T-score of distal forearm is observed in patients with primary hyperparathyroidism.[27]

References

  1. ↑ Palestro CJ, Tomas MB, Tronco GG (2005). "Radionuclide imaging of the parathyroid glands". Semin Nucl Med. 35 (4): 266–76. doi:10.1053/j.semnuclmed.2005.06.001. PMID 16150247.
  2. ↑ Hetrakul N, Civelek AC, Stagg CA, Udelsman R (2001). "In vitro accumulation of technetium-99m-sestamibi in human parathyroid mitochondria". Surgery. 130 (6): 1011–8. doi:10.1067/msy.2001.118371. PMID 11742331.
  3. ↑ Taillefer R, Boucher Y, Potvin C, Lambert R (1992). "Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study)". J Nucl Med. 33 (10): 1801–7. PMID 1328564.
  4. ↑ Thulé P, Thakore K, Vansant J, McGarity W, Weber C, Phillips LS (1994). "Preoperative localization of parathyroid tissue with technetium-99m sestamibi 123I subtraction scanning". J Clin Endocrinol Metab. 78 (1): 77–82. doi:10.1210/jcem.78.1.8288719. PMID 8288719.
  5. ↑ Ryhänen EM, Schildt J, Heiskanen I, Väisänen M, Ahonen A, Löyttyniemi E; et al. (2015). "(99m)Technetium Sestamibi-(123)Iodine Scintigraphy Is More Accurate Than (99m)Technetium Sestamibi Alone before Surgery for Primary Hyperparathyroidism". Int J Mol Imaging. 2015: 391625. doi:10.1155/2015/391625. PMC 4333274. PMID 25722888.
  6. ↑ Eslamy HK, Ziessman HA (2008). "Parathyroid scintigraphy in patients with primary hyperparathyroidism: 99mTc sestamibi SPECT and SPECT/CT". Radiographics. 28 (5): 1461–76. doi:10.1148/rg.285075055. PMID 18794320.
  7. ↑ Haber RS, Kim CK, Inabnet WB (2002). "Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99m)technetium sestamibi scintigraphy". Clin Endocrinol (Oxf). 57 (2): 241–9. PMID 12153604.
  8. ↑ Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, Richard B (1996). "Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism". World J Surg. 20 (7): 835–9, discussion 839–40. PMID 8678959.
  9. ↑ Prasannan S, Davies G, Bochner M, Kollias J, Malycha P (2007). "Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi". ANZ J Surg. 77 (9): 774–7. doi:10.1111/j.1445-2197.2007.04227.x. PMID 17685957.
  10. ↑ Gómez-Ramírez J, Sancho-Insenser JJ, Pereira JA, Jimeno J, Munné A, Sitges-Serra A (2010). "Impact of thyroid nodular disease on 99mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism". Langenbecks Arch Surg. 395 (7): 929–33. doi:10.1007/s00423-010-0680-8. PMID 20625763.
  11. ↑ Billotey C, Sarfati E, Aurengo A, Duet M, Mündler O, Toubert ME; et al. (1996). "Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy". J Nucl Med. 37 (11): 1773–8. PMID 8917173.
  12. ↑ Civelek AC, Ozalp E, Donovan P, Udelsman R (2002). "Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism". Surgery. 131 (2): 149–57. PMID 11854692.
  13. ↑ Strand SE, Ivanovic M, Erlandsson K, Franceschi D, Button T, Sjögren K; et al. (1994). "Small animal imaging with pinhole single-photon emission computed tomography". Cancer. 73 (3 Suppl): 981–4. PMID 8306288.
  14. ↑ Jaszczak RJ, Li J, Wang H, Zalutsky MR, Coleman RE (1994). "Pinhole collimation for ultra-high-resolution, small-field-of-view SPECT". Phys Med Biol. 39 (3): 425–37. PMID 15551591.
  15. ↑ Schachter PP, Issa N, Shimonov M, Czerniak A, Lorberboym M (2004). "Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy". Arch Surg. 139 (4): 433–7. doi:10.1001/archsurg.139.4.433. PMID 15078713.
  16. ↑ Perez-Monte JE, Brown ML, Shah AN, Ranger NT, Watson CG, Carty SE; et al. (1996). "Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT". Radiology. 201 (1): 85–91. doi:10.1148/radiology.201.1.8816526. PMID 8816526.
  17. ↑ Spanu A, Falchi A, Manca A, Marongiu P, Cossu A, Pisu N; et al. (2004). "The usefulness of neck pinhole SPECT as a complementary tool to planar scintigraphy in primary and secondary hyperparathyroidism". J Nucl Med. 45 (1): 40–8. PMID 14734671.
  18. ↑ Carlier T, Oudoux A, Mirallié E, Seret A, Daumy I, Leux C, Bodet-Milin C, Kraeber-Bodéré F, Ansquer C (2008). "99mTc-MIBI pinhole SPECT in primary hyperparathyroidism: comparison with conventional SPECT, planar scintigraphy and ultrasonography". Eur. J. Nucl. Med. Mol. Imaging. 35 (3): 637–43. doi:10.1007/s00259-007-0625-9. PMC 2964350. PMID 17960377.
  19. ↑ Nguyen BD (1999). "Parathyroid imaging with Tc-99m sestamibi planar and SPECT scintigraphy". Radiographics. 19 (3): 601–14, discussion 615-6. doi:10.1148/radiographics.19.3.g99ma10601. PMID 10336191.
  20. ↑ Lindqvist V, Jacobsson H, Chandanos E, Bäckdahl M, Kjellman M, Wallin G (2009). "Preoperative 99Tc(m)-sestamibi scintigraphy with SPECT localizes most pathologic parathyroid glands". Langenbecks Arch Surg. 394 (5): 811–5. doi:10.1007/s00423-009-0536-2. PMID 19578871.
  21. ↑ Wimmer G, Profanter C, Kovacs P, Sieb M, Gabriel M, Putzer D; et al. (2010). "CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism". Langenbecks Arch Surg. 395 (1): 73–80. doi:10.1007/s00423-009-0545-1. PMID 19705144.
  22. ↑ Tang BN, Moreno-Reyes R, Blocklet D, Corvilain B, Cappello M, Delpierre I; et al. (2008). "Accurate pre-operative localization of pathological parathyroid glands using 11C-methionine PET/CT". Contrast Media Mol Imaging. 3 (4): 157–63. doi:10.1002/cmmi.243. PMID 18781582.
  23. ↑ Weber T, Maier-Funk C, Ohlhauser D, Hillenbrand A, Cammerer G, Barth TF; et al. (2013). "Accurate preoperative localization of parathyroid adenomas with C-11 methionine PET/CT". Ann Surg. 257 (6): 1124–8. doi:10.1097/SLA.0b013e318289b345. PMID 23478517.
  24. ↑ Traub-Weidinger T, Mayerhoefer ME, Koperek O, Mitterhauser M, Duan H, Karanikas G; et al. (2014). "11C-methionine PET/CT imaging of 99mTc-MIBI-SPECT/CT-negative patients with primary hyperparathyroidism and previous neck surgery". J Clin Endocrinol Metab. 99 (11): 4199–205. doi:10.1210/jc.2014-1267. PMID 25029418.
  25. ↑ Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF; et al. (2009). "Reoperation for parathyroid adenoma: a contemporary experience". Surgery. 146 (6): 1144–55. doi:10.1016/j.surg.2009.09.015. PMC 3467310. PMID 19958942.
  26. ↑ Miller DL, Chang R, Doppman JL, Norton JA (1989). "Localization of parathyroid adenomas: superselective arterial DSA versus superselective conventional angiography". Radiology. 170 (3 Pt 2): 1003–6. doi:10.1148/radiology.170.3.2644666. PMID 2644666.
  27. ↑ Wood K, Dhital S, Chen H, Sippel RS (2012). "What is the utility of distal forearm DXA in primary hyperparathyroidism?". Oncologist. 17 (3): 322–5. doi:10.1634/theoncologist.2011-0285. PMC 3316917. PMID 22258698.

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