4D-CT demonstrated high accuracy for the determination of both lesion side and quadrant location for single-gland dis- ease. Our series suggests that 4D-CT agrees with the pathology findings in most of the cases and is a reliable choice for para- thyroid adenoma detection. Importantly, 4D-CT accurately lateralized single-gland adenomas in 93% of cases, allowing the surgeon to perform a unilateral neck dissection with asso- ciated decreased morbidity and length of hospital stay. The ability to accurately lateralize the side of disease is a commonly used end point in parathyroid imaging because it enables a directed surgical approach. By comparison, sonography has a cited sensitivity for lateralization ranging from 57% to 86%. 5,11
Background : 4D-CT has been used to localize the parathyroidadenomas and hyperplasia since 2006 as a second line study after TC-99 m MIBI and ultra- sonography. However, multiple studies have shown that 4D-CT is a robust imaging method with high diagnosticaccuracy, becoming increasingly popu- lar among surgeons and radiologists. Purpose : To assess the diagnostic per- formance of 4D-CT scans to identify the pathologic gland(s), using pathology and intraoperative findings as gold standards. Methods : We analyzed patients with primary and secondary hyperparathyroidism who had intraoperative reports, pathology, parathyroid hormone levels, and preoperative 4D-CT. Histology, surgical findings, and decreased parathyroid hormone levels were used as gold standards. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and 95% confidence inter- val were calculated. Fleiss’ kappa was used to assess the inter-observer agree- ment. Results : Sixty-seven patients were included. Sixty-two patients had a single adenoma, and five patients had a multiple gland disease (adenomas or hyperplasia). A total of 72 glands were proven to have parathyroidadenomas or hyperplasia. The sensitivity, specificity, PPV, NPV and accuracy are 85%, 97%, 96%, 87% and 91% for lateralization and 76%, 96%, 85%, 92% and 90% How to cite this paper: Tantiwongkosi, B.,
Two-phase parathyroidCT offers an additional potential method for the preoperative localization of parathyroid ade- nomas with sensitivities for lateralization and quadrant-spe- cific localization of 78.8% and 55.4%, respectively. Despite lower accuracy rates than those of 4D-CT techniques in the literature, the lower accuracy rates must be balanced with the potential reduction in radiation dose. In addition, the clinical environment in which this study was performed, which sub- jects radiologists to the same limitations routinely encoun- tered during study interpretation, may more fairly represent the accuracy of this technique when implemented in everyday clinical practice. Further large cohort prospective studies are needed to definitively determine the optimal number of phases required and the appropriate population for each technique.
gression model that incorporates infor- mation from a triple-phase 4DCT scan of the neck to provide improved discrimina- tory ability compared with a dual-phase 4DCT scan when used to distinguish parathyroidadenomas and local mimics. Their data indicate that a model using an unenhanced, arterial phase had an accu- racy of 94.7% compared with 96.9% in a model built from 3 phases. While statisti- cally significant and interesting, the clini- cal utility of a 1.9% gain in accuracy would have to be evaluated in a prospec- tive study. Such a model also has the lim- itation of requiring a stand-alone calcula- tor, an endeavor that is not trivial in routine clinical practice. Furthermore, not all parathyroidadenomas enhance in- tensely in the arterial phase. These include lipoadenomas and cystic adenomas, both rare lesions. 17,18 It may
Instead, radiologists often use the relationship between the parathyroid adenoma and the thyroid gland to de- cide on its location [16, 17] (Fig. 4). This can be mislead- ing however, as the exact cranio-caudal location with respect to the thyroid gland can vary. Intra-operatively, surgeons more commonly use the relationship to the plane of the recurrent laryngeal nerve in order to localize parathyroidadenomas. Hauty et al., found using technetium-thallium scintiscanning for localizing parathy- roid adenomas, a sensitivity in the detection of parathy- roid adenomas of 82%, a diagnosticaccuracy of 78% and a positive predictive value of 94% . These accuracies are using the thyroid gland as standard of reference. It is im- portant to note that the reason why we see these differ- ences in accuracy is because there is a difference in the standard of reference. The method we have described uses a more embryologically and anatomically sound technique than standard radiological reporting and is thus shown to be more clinically relevant for the surgical approach.
This study has several limitations, including a relatively small sample size drawn from a single institution, possibly introducing a sample bias. In addition, inclusion of patients with known PTAs can further introduce selection bias. Another limitation is the retrospective nature of the study, possibly introducing unknown bias. The diagnosticaccuracy of this MR imaging technique for the localization of PTA should be evaluated prospectively in a larger cohort. The last limitation is the insufficient availability and technical demands due to the 3T MR imaging scanners and mul- FIG 4. A 47-year-old woman with primary hyperparathyroidism (parathyroid hormone ⫽ 164 pg/mL, Ca 2⫹ ⫽ 10.8 mg/dL). Axial arterial phase contrast-enhanced image from MR perfusion data demonstrates a PTA (arrow) in the left tracheoesophageal groove. Contrast-time curve analysis from ROIs placed over the PTA, thyroid gland, and a cervical lymph node shows signiﬁcantly faster TTP and higher wash-in and signiﬁcant washout values in the PTA compared with the thyroid gland and cervical lymph node. PTA: TTP, 30 seconds; wash-in, 5.6; washout, 0.64 Thyroid: TTP, 38 seconds; wash-in, 3.8 seconds; washout, 0.43 seconds. Lymph node: TTP, 62 seconds; wash-in, 2.9; washout, 0.23.
NCCTN and CECTN were acquired on a 64-row multidetector CT scanner (Somatom Sensation 64; Siemens, Erlangen, Ger- many) in the craniocaudal direction with a collimation of 0.6 mm, gantry rotation of 500 ms, and a pitch of 0.9. Automated dose- control software was used with 120-kV(peak) and reference mil- liampere-second (maximum, 200). For the CECTN, 100 mL of nonionic, iodinated low-osmolar contrast medium (Niopam, io- pamidol, 340 mg I/mL; Bracco Imaging, Milan, Italy) was injected through a 20-ga or larger cannula, typically sited in the antecubital fossa, at a rate of 2 mL/s with acquisition performed after a delay of 60 seconds. Images for the NCCTN and CECTN were recon- structed with a 512 ⫻ 512 matrix and a smooth kernel, with 3-mm axial-section-thickness images set as standard and 3-mm coronal and sagittal reformats. Images were reviewed with syngo Portal Radiologist (Siemens).
This retrospective study was approved by our institutional review board, waiving consent in accordance with the Health Insurance Portability and Accountability Act. We began performing 4D-CT examinations at our institution in May 2008. Patients were in- cluded in the study if they carried a clinical and biochemical di- agnosis of hyperparathyroidism, had 4D-CT for preoperative lo- calization between May 2008 and July 2011, and subsequently underwent surgical exploration between May 2008 and January 2012. Inclusion criteria also included the availability of the oper- ative report and final pathology report. Patient demographic data including age and sex were obtained from the electronic medical record (EMR).
In our case, the PTx allowed us to both treat the ectopic calcification and diagnose it as parathyroid car- cinoma, and the serum calcium and PTH dropped when parathyroid carcinoma was removed. The iPTH value of SHPT patients who should be treated with PTx is rec- ommended as 500,000 μg/L by the Japanese guideline . Most symptomatic patients who receive chronic dialysis and who undergo PTx have a serum iPTH level of more than 800,000 μg/L . Asymptomatic patients are, however, commonly referred for parathyroidectomy when they have a sustained PTH of more than 1000,000 μg/L [7, 30]. Indeed, cinacalcet came on the market in Japan in 2008, and the number of PTx in Japan decreased strikingly as a result [15, 18, 31]. Earlier PTx should be considered before a vicious exacerbation of ectopic calcification. Further study is required to de- termine the new indications of PTx in patients receiving chronic dialysis therapy and cinacalcet treatment.
Spontaneous parathyroid haemorrhage is a rare but po- tentially life-threatening complication. The diagnosis should be considered in any patient presenting with a spontaneous cervical haemorrhage of unknown aeti- ology, particularly if there is evidence of hypercalcemia, history of hyperparathyroidism or ecchymosis of the neck or chest wall. Initial evaluation should include a calcium and PTH level although these may have fallen if significant glandular haemorrhage has led to infarction of the gland. While some propose conservative manage- ment, surgery is the preferred option, particularly in the presence of acute airway compromise.
From table 7, it is observed that the accuracy measure Area under the curve (AUC) is 0.8314 with the cutoff 4 with SPECT/CT. i.e. an individual’s lesions score exceeding 4 can easily be identified as the one with parathyroid disease with 83% accuracy. Whereas the AUC is found to be 0.6404 and 0.6534 for NO SPECT and SPECT diagnostic tests respectively with the cutoff value 5 (test score greater than or equal to 5 are positive cases of disease). Therefore, the two diagnostic tests NO SPECT and SPECT are almost identical in identifying the number of glands of Parathyroid disease. From this it can be concluded that the diagnostic test SPECT/CT is superior in identifying the positive cases of disease than the other two diagnostic tests. Further, the ROC Curves (Figure 2) are also drawn in supporting the interpretation of results among the three diagnostic tests.
Various studies have shown that there has been increase in use of CT by the physicians and surgeon, as the first line imaging modality. There is a decline in the USG imaging. However USG may play its role in some diagnosis, mainly in female patients like fibroid, ovarian cyst and pelvic inflammatory disease.
• We conduct an initial review of 20 minutes and 2–3 hours delayed planer images of the neck and chest obtained in the anterior and bilateral anterior oblique positions. Any foci of increased tracer uptake regardless of their intensity are noted for further evaluation on the SPECT/CT images. Faint foci of uptake may occasionally be seen on oblique images of the neck rather than on the anterior planar image. Focal increased uptake seen on early images may or may not show retention on delayed planer images in parathyroidadenomas but will direct the readers’ attention to the side of possible adenoma. We also look for possible ectopic parathyroidadenomas between the thyroid gland and floor of the mouth or submandibular glands as well as between the heart and the thyroid gland.
demonstrable in 6 of 16 informative patients (38%) with primary parathyroidhyperplasia. Histopathologic categories of nodular versus generalized hyperplasia were not useful predictors of clonal status. These observations indicate that monoclonal parathyroid neoplasms are common in patients with uremic refractory hyperparathyroidism and also develop in a substantial group of patients with sporadic primary parathyroidhyperplasia, thereby changing our concept of the pathogenesis of these diseases. Neoplastic
tory of lithium use. After surgical removal, tissues were dissected and quickly frozen in liquid nitrogen before being stored at -80°C. Peripheral blood leukocyte sam- ples were obtained from the same patients, to serve as non-parathyroid germline controls. Also included in this study were five normal parathyroid glands and one nor- mal thyroid gland from five patients with primary hyper- parathyroidism due to a single adenoma. One normal parathyroid gland and a normal thyroid gland were obtained on autopsy. The remaining normal parathyroid glands were obtained from patients who had the glands removed incidental to an operation for thyroid disease. Mitochondrial Genome Sequencing
Focal nodular hyperplasia (FNH) has a demographic variation with a male and children of either gender preponderance in countries where oral contraceptives use has been less prevalent (i.e., China). There is not the impact on size variation from oral contraceptives use and from pregnancy and is not indispensable, though recommended, to stop oral contraceptive use .
Results of MDCT imaging were compatible with histo- pathological findings in 84.6%. When there was a differ- ent MDCT mostly under-estimated the stage of the tumor. Accuracy of MDCT was higher in advanced stages compared to earlier stages (I and II). This maybe explained by high capability of MDCT to illustrate peri- toneal seeding and involvement of abdominal visceral organs. Similar results have been reported by Tsili et al.
Parathyroid adenoma to background contrast ratios were calculated and compared, using standardized uptake values (SUVs). Data was reconstructed with varying scan durations (1, 2.5, 5, and 10 min) at 20 – 30-min p.i. (established optimal uptake time), mimicking less administered radioactivity. To establish the minimal required radioactivity, the SUVs in the shorter scan durations (1, 2.5, and 5 min) were compared to the 10-min scan duration to determine whether increased variability and/or statistical differences were observed. Four observers analyzed the 11 C-choline PET/CT in four randomized rounds for all patients.