Twin pregnancy with triple parathyroid adenoma: A case report and review of literature

Primary hyperparathyroidism (PHPT) is rare during pregnancy. A case of twin pregnancy with three simultaneous parathyroid adenomas at the same time has not been reported. Multiple parathyroid lesions are difficult to diagnose, as pregnant women who insist upon continuing a pregnancy are not able to undergo 99mTc-sestamibi scintigraphy, so cases of PHPT are easily unobserved and often can have serious consequences for the patient and the fetus. Therefore, we reported a case of a 28-year-old woman mid-pregnancy with twins, who had hypercalcemia and was eventually diagnosed with twin pregnancy with PHPT due to a triple parathyroid adenoma, had good pregnancy outcomes after undergoing surgery in mid-pregnancy. Twin pregnancy with PHPT due to a triple parathyroid adenoma, as presented in this case, is very rare and surgery in mid-pregnancy is demonstrated here as safe. Intraoperative parathormone monitoring was and remains key to a successful operation.     

Thyroid and parathyroid imaging

This article reviews the current roles of imaging in the diagnosis of thyroid and parathyroid disorders, with an emphasis on ultrasound evaluation. Imaging of the thyroid and parathyroid can be performed with nuclear medicine, ultrasound, CT, and MRI. Indications for thyroid and parathyroid imaging studies have recently changed. The availability of experienced endocrine surgeons, as well as the development of accurate laboratory tests, fine-needle aspiration (FNA) biopsy, and high-resolution ultrasound, have dramatically influenced the evaluation of thyroid and parathyroid disease. In patients with thyroid nodular disease, a clinical examination by an experienced clinician with appropriate lab values and palpation-guided FNA is the current diagnostic protocol of choice. Ultrasound evaluation of high-risk patients and ultrasound-guided FNA both augment this protocol when necessary. In patients with diffuse thyroid glandular disease, radionuclide imaging and color Doppler sonography both can be used for evaluation. When preoperative imaging is clinically necessary, sonography or scintigraphy can be used for parathyroid adenoma localization in patients with primary hyperparathyroidism. The recent development of technetium-99m sestamibi as a parathyroid imaging agent has improved the sensitivity of scintigraphy for parathyroid adenoma localization. Ultrasound and radionuclide imaging have also become valuable imaging techniques for parathyroid localization in patients with recurrent or persistent hyperparathyroidism.     

Localization of Parathyroid Adenomas by Sonography and Technetium Tc 99m Sestamibi Single‐Photon Emission Computed Tomography Before Minimally Invasive Parathyroidectomy

Objective. The purpose of this study was to determine the utility of radiologist‐performed sonography as the principal modality for parathyroid localization before minimally invasive parathyroidectomy. Methods. Both sonography and technetium Tc 99m sestamibi single‐photon emission computed tomography (SPECT) are commonly performed during imaging evaluation of patients with primary hyperparathyroidism (HPTH). Sonographic examinations ordered during the study period were performed by 1 author (M.E.T.), and results were immediately reported. Findings of a subsequent Tc 99m sestamibi study were recorded blinded to the sonographic results. The sensitivity and specificity of sonography and Tc 99m sestamibi SPECT were assessed with the use of surgery and pathology reports as a reference standard. The 2007 global Medicare reimbursement rates were used to assess the costs of preoperative localization. Results. Parathyroidectomy was performed in 144 of 172 patients evaluated by both modalities. The sensitivity, specificity, and positive predictive value of sonography for identifying abnormal parathyroid glands were 74%, 96%, and 90%, respectively. Sonography correctly localized a single adenoma or suggested multiglandular disease in 112 of 144 patients (78%). The sensitivity, specificity, and positive predictive value of SPECT were 58%, 96%, and 89%. Technetium 99m sestamibi SPECT correctly predicted an adenoma or multiglandular disease in 88 of 144 patients (61%). Five patients with negative sonographic findings were shown to have uniglandular disease on Tc 99m sestamibi SPECT. Selective use of Tc 99m sestamibi SPECT (ie, when sonographic findings were negative or equivocal) would have decreased the cost of imaging by 53%. Conclusions. Radiologist‐performed sonography may potentially be used as a principal imaging modality for patients with HPTH. Selective use of Tc 99m sestamibi in cases with negative or equivocal sonographic findings can decrease the cost of imaging before parathyroid resection considerably.     

Preoperative localization of parathyroid adenoma with sonography and 99mTc-sestamibi scintigraphy in primary hyperparathyroidism

PURPOSE: To evaluate the sensitivity, specificity, and usefulness of dual-phase 99mTc-Sestamibi scintigraphy (SS) and sonography (US) of the neck, alone and in combination, as noninvasive adenoma localizing procedures in patients with primary hyperparathyroidism prior to parathyroidectomy. METHODS: We retrospectively analyzed the charts of 79 patients with parathyroid (PT) adenomas and confirmed diagnosis of hyperparathyroidism who were evaluated with SS and US prior to successful parathyroidectomy. RESULTS: Ninety-three adenomas were removed during bilateral neck exploration. SS alone showed a sensitivity of 76% and a specificity of 79% compared with 89% and 75%, respectively, for US performed after SS on the same day. Combination of the 2 procedures yielded a sensitivity of 89% and a specificity of 90%, with 22% discordant results. The differences in sensitivity and specificity between the 2 techniques alone or in combination were not statistically significant. CONCLUSIONS: No benefit was gained from using both SS and US for the preoperative localization of PT adenomas in patients with primary hyperparathyroidism. Each technique can be negatively affected by thyroid enlargement and nodularity. US, when performed by a skilled operator, is a reliable tool for PT adenoma localization. If the US findings are inconclusive, SS should be used.     

Use of technetium Tc 99m sestamibi scintigraphy for recurrent tertiary hyperparathyroidism from a parathyroid forearm graft

Technetium Tc 99m sestamibi scintigraphy is a sensitive technique for localizing recurrent parathyroid disease in the neck or mediastinum. We report the case of a 60-year-old woman with recurrent tertiary hyperparathyroidism after total parathyroidectomy. Technetium Tc 99m sestamibi images of the neck and mediastinum were negative; however, images of the right arm revealed a hyperfunctioning parathyroid autotransplant. Partial resection of the autograft resulted in prompt resolution of the hyperparathyroidism.     

Minimally invasive procedure for resection of a parathyroid adenoma: the role of preoperative high-resolution ultrasonography

PURPOSE: Solitary adenoma of the parathyroid is the major cause of primary hyperparathyroidism. Many centers advocate a minimally invasive surgical approach, wherein the surgeon explores only a localized area of the neck according to the preoperative imaging evaluation, and the adenoma is resected without histological sampling from the other parathyroid glands. The aim of this study was to evaluate the ability of high-resolution ultrasonography (US) to localize adenomas preoperatively and thereby aid in patient selection for minimal procedures. METHODS: We reviewed the medical records of 77 consecutive patients who underwent resection of a parathyroid adenoma following ultrasonographic imaging between 2001 and 2002, and we assessed the accuracy of the preoperative localization of the adenomas as well as the efficacy of the minimally invasive procedure. RESULTS: US correctly localized the adenoma to a specific quadrant of the neck in 87% of the cases and to a specific side of the neck in 94%. Overall, US sensitivity was 89%, with a positive predictive value of 98%. Its sensitivity was not reduced by the presence of nodular disease of the thyroid gland. Success rate for the minimal procedure was 98% (50/51 patients). CONCLUSIONS: US performed by a skilled operator is a reliable tool for adenoma localization prior to minimally invasive parathyroidectomy. If the US findings are inconclusive, a Tc-sestamibi scan should be used. If there is a high clinical suspicion of adenoma in the presence of negative imaging studies, bilateral neck exploration should be performed.     

原发性甲状旁腺功能亢进症的影像学诊断

目的:探讨超声、CT、99mTc-MIBI和MRI对原发性甲状旁腺功能亢进症(PHPT)的诊断价值。方法:对手术病理证实的142例PHPT患者的影像学资料进行回顾性分析。其中行CT检查113例,B超检查126例,99mTc-MIBI检查81例,MRI检查8例。结果:142例PHPT患者中,手术确诊为单发甲状旁腺腺瘤123例,占86.6%;异位甲状旁腺病变7例;多发性内分泌腺瘤病(MEN)伴甲状旁腺功能亢进症6例;甲状旁腺腺癌8例。CT检查98例诊断为甲状旁腺腺瘤或占位(98/113),B超检查100例诊断为甲旁腺腺瘤(100/126),99mTc-MIBI检查76例诊断为甲状腺腺瘤或病变。结论:PHPT的定性诊断主要靠临床及生化检查,定位诊断靠B超、CT及99mTc-MIBI等影像学检查。如B超、CT和99mTc-MIBI检查相结合,可有助于提高本病诊断的准确度。我们应提高对异位甲状旁腺病变、MEN伴HPT和甲状旁腺腺癌影像表现的认识,避免误诊、漏诊。     

Correlation between serum calcium levels and dual-phase (99m)Tc-sestamibi parathyroid scintigraphy in primary hyperparathyroidism

Aim: The goal of the study is to correlate serum calcium levels with the results of dual‐phase ^99mTc‐sestamibi parathyroid scintigraphy to find the best cut‐off level of the serum calcium that correlates with a positive presurgery. Methods: In 111 patients, serum calcium and plasma parathormone (PTH) levels were compared with the results of the ^99mTc‐MIBI scintigraphy and with this data determined the level of calcium above which the ^99mTc‐MIBI scintigraphy was likely to be positive and below which the study was likely to be negative. Results: In total, 11 men (18%) and 50 women (82%) had a positive ^99mTc‐MIBI study. Overall 67% of those patients with a positive ^99mTc‐MIBI study had a PTH >200 ng l^?1 compared to only 9% of those with a negative ^99mTc‐MIBI scintigraphy; however, for those with a positive study on an early ^99mTc‐MIBI scintigraphy, this rose to 85%. Overall a serum calcium of >2·70 mmol l^?1 was found in 82% of patients with a positive ^99mTc‐MIBI study but only 14% of those with a negative ^99mTc‐MIBI study, this is rose to 97% of patients with a parathyroid adenoma identified on early images. It is also shown that patients whose serum total calcium <2·51 mmol l^?1 rarely have positive ^99mTc‐MIBI scintigraphy. Conclusion: ^99mTc‐MIBI parathyroid scintigraphy is most likely to yield identification and localization of a parathyroid adenoma when both PTH and calcium are elevated; however, although there is no lower limit of PTH which can predict a negative study, we cannot recommend ^99mTc‐MIBI parathyroid scintigraphy if the serum calcium is <2·51 mmol l^?1.     

Mediastinal Ectopic Parathyroid Adenoma in a Patient Followed for Colon Cancer and Chronic Renal Failure: A Challenging Case

Colorectal cancer is a significant cause of morbidity and mortality worldwide. The advances in early diagnosis and treatment have increasingly expanded the patient population surviving from colorectal cancer. Herein, we present a case of a patient with mediastinal ectopic parathyroid adenoma who has been followed up for postoperative colon cancer. The patient is a 59-year-old man with postoperative colon cancer and chronic renal failure in whom control positron emission tomography/computed tomography revealed multiple bone metastases. However, on methylene-diphosphonate bone scintigraphy, multiple involvement with increased uptake was associated with renal osteodystrophy/hyperparathyroidism; technetium-99m 2-methoxyisobutylisonitrile parathyroid scintigraphy was performed, which revealed mediastinal ectopic parathyroid adenoma. To the best of our knowledge, this is the first case report in the literature reporting the co-occurrence of colon cancer, chronic renal failure, and ectopic parathyroid adenoma.     

Giant cystic parathyroid adenoma: two case reports and a literature review

An uncommon cause of primary hyperparathyroidism is a cystic parathyroid adenoma. This paper describes two patients with hypercalcemia and right knee disease. Their serum calcium concentration was high, phosphorus concentration was low, and parathyroid hormone (PTH) concentration was high. Ultrasound and computed tomography scans of the neck indicated a cystic mass near the thyroid. Parathyroid scintigraphy showed no focal uptake in one patient and low tracer concentration in the cystic mass in the other patient. Following resection of the cystic masses, both were pathologically confirmed to be a cystic parathyroid adenoma with predominantly cystic degeneration. The calcium and PTH concentrations gradually decreased to the reference range. Both patients were stable at their last follow-up. The diagnosis of a functional cystic parathyroid adenoma is highly challenging because of the different clinical manifestations and negative result on parathyroid tracer scintigraphy. For patients with high serum calcium and PTH concentrations and a cystic mass in the neck, resection of the mass and subsequent postoperative pathological diagnosis is necessary even if the clinical diagnosis of a parathyroid adenoma cannot be confirmed preoperatively. Decreases in the PTH and serum calcium concentrations indicate successful resection of a functional parathyroid adenoma.     

Does (99m)Tc-Sestamibi in high-grade malignant brain tumors reflect blood-brain barrier damage only?

(99m)Tc-Sestamibi (MIBI) has been successfully applied in recurrent glioblastoma. The aim of this study was to evaluate the incremental diagnostic information of MIBI as a tumor-avid radiopharmaceutical compared with (99m)Tc-pertechnetate ((99m)Tc) as sole indicator of the integrity of the blood-brain barrier. Twenty-five patients with confirmed recurrent brain tumors were included. MIBI SPET was performed 10 min after injection of 555 MBq MIBI intravenously with a triple-headed gamma camera equipped with LE-UHR-PAR collimators over 360 degrees (3 degrees /step) and stored in a 128(2) matrix. Identical acquisition parameters were used for (99m)Tc SPET, which was acquired 3 h after injection of 740 MBq (99m)Tc. Normalized tumor uptake (NU) was calculated from attenuation-corrected transaxial slices. In addition, tumor/plexus, tumor/nasopharynx, and tumor/parotid gland ratios were assessed in both studies. No statistically significant differences were detected for the mean NU of tumor tissue with MIBI (0.26 +/- 0.10) and (99m)Tc (0.39 +/- 0. 33) and for the tumor/nasopharynx and tumor/parotid gland ratios; only the tumor/plexus ratio was significantly higher for (99m)Tc than for MIBI (p < 0.05). In conclusion, our data indicate that MIBI scintigraphy in brain tumors at 10 min postinjection reveals no additional visual information over that provided by the conventional (99m)Tc-pertechnetate brain scan, and in addition, tracer retention reflects primarily blood-brain barrier damage.     

Preoperative localization of parathyroid adenomas using thallium-technetium subtraction scintigraphy

Primary hyperparathyroidism can be diagnosed by laboratory values, yet localization of the adenomas preoperatively has always presented difficulties. Dual isotope scintigraphy with technetium Tc 99m sodium pertechnetate and thallium Tl-201 chloride has recently been used for the localization of parathyroid adenomas. In this paper, we review our experience with scintigraphy in 53 patients suspected of having hyperparathyroidism. Based on favorable results, we recommend this technique for preoperative detection of parathyroid adenomas.     

99mTc-MIBI SPECT/CT诊断原发性甲状旁腺功能亢进症

目的 探讨SPECT/CT同机融合技术在99mTc-MIBI核素显像诊断原发性甲状旁腺功能亢进症(PHPT)中的价值.方法 于患者静脉注射99mTc-MIBI 370～740 MBq后行颈胸部的即刻和40 min延迟的双时相静态平面采集;注药后20 min行同部位的SPECT/CT采集,评价常规SPECT显像断层采集提供信息是否明显优于平面采集,SPECT/CT显像提供信息是否明显优于平面采集和常规SPECT显像断层采集,并对血清生物化学指标进行相关性统计学分析.结果 与术后病理诊断比较,平面采集加SPECT与平面采集加SPECT/CT诊断甲状旁腺病变符合率为86.96%,多结节腺体符合率为100%,总符合率为91.30%.SPECT/CT显像使1例阴性诊断改为阳性,并为3例患者提供更确切的腺体定位.SPECT/CT在2例异位甲状旁腺腺瘤定位诊断中显示出较为显著的优势.各血生化指标与显像结果 无相关性.结论 SPECT/CT同机融合技术在异位PHPT定位诊断上有较高的应用价值.     

Ultrasound of the thyroid and parathyroid glands

Ultrasound plays a prominent role in the management of thyroid disease and parathyroid adenomas. It can detect clinically impalpable thyroid nodules and characterize them as cystic, solid, or complex. Determining that a nodule is definitively benign or malignant is difficult, and so when indicated an ultrasound-guided fine-needle aspiration can be performed. In the follow-up of patients with thyroid cancer, ultrasound can be used alone or in conjunction with computed tomography (CT)/magnetic resonance imaging (MRI) to detect recurrent disease. Recurrences can be confirmed using ultrasound to guide fine-needle aspirations. To locate parathyroid adenomas, ultrasound is often used in conjunction with sestamibi scanning. If both studies agree on the location of the adenoma, the surgeon can perform focused surgery for its removal. In patients in whom the studies do not agree or in whom they do not detect the adenoma, further evaluation with CT or more preferably MRI is indicated.     

Magnetic resonance tomography as a localization method in hyperparathyroidism

Magnetic Resonance Imaging (MRT) was performed in 36 consecutive patients with hyperparathyroidism. MR tomograms of 31 patients were evaluated and compared with the results of operation and histology (n = 29). In the remaining 5 patients MR examination was not completed, due to claustrophobia or motion artefacts. MR examinations were performed in 2 superconductive magnets (0.5 and 1.5 Tesla). A surface coil with following spinecho sequences was used: SE: TR/TE: 550-700/15-30; 2000/22-100. All patients were subjected to additional sonography. Out of 28 parathyroid adenomas 25 were identified on MR tomograms (sensitivity: 73%, specificity: 90%). However, only 2 out of 6 hyperplastic parathyroid glands were localized on MR tomograms. Lesions missed on MR tomograms measured 15 mm and less in diameter. It is characteristic that parathyroid adenomas showed isointense MR signal to the thyroid (SE 550/30 and hyperintense MR signal to fat (SE 2000/100). Different signal intensities of the adenomas were observed in 25% of the cases. MR imaging is a valuable diagnostic method for preoperative localisation of parathyroid adenomas. We think that MR imaging should be performed when sonography and subtraction scintigraphy are not able to identify a suspected adenoma in the same location.     

Recurrent hyperparathyroidism secondary to parathyromatosis: clinical and imaging findings.

OBJECTIVE: Parathyromatosis, a condition in which hyperfunctioning parathyroid tissue is distributed throughout the neck, is a rare but challenging cause of recurrent hyperparathyroidism after parathyroidectomy. The purpose of this series is to describe the imaging appearance of parathyromatosis and the potential utility of sonographic localization before resection. METHODS: Imaging is routinely performed in an attempt to identify autonomous residual parathyroid glands in patients with recurrent hyperparathyroidism after parathyroidectomy. The sonographic and technetium Tc 99m sestamibi studies and the clinical records of 2 patients with recurrent hyperparathyroidism secondary to parathyromatosis were reviewed. RESULTS: Color Doppler sonography easily identified scattered deep and superficial hypoechoic, hypervascular cervical nodules that did not conform to typical anatomic locations of parathyroid glands; the nodules corresponded to areas of delayed tracer uptake at Tc 99m sestamibi single-photon emission computed tomography. Intraoperative mapping of nodules aided the successful resection of widespread parathyromatosis in 1 patient. CONCLUSIONS: Although the sonographic appearance of parathyromatosis may mimic disseminated cervical malignancy, a confident diagnosis of this rare entity may be made in the appropriate clinical setting. Sonography may also aid in directing the resection of disseminated parathyroid tissue in selected patients.     

Section 1. Parathyroid: Sestamibi scintigraphy for the application of minimally invasive surgery of hyperfunctioning parathyroid lesions

Complete surgical resection of hyperfunctioning parathyroid tissue is essential for the curative treatment of hyperparathyroidism. It is very important to identify the accurate location of the affected parathyroid glands by imaging tests to successfully achieve this surgical treatment. Tc-99m labeled sestamibi is a radiopharmaceutical with high affinity for endocrinologically active parathyroid tissue, and scintigraphic evaluation using this radioactive agent is very useful in confirming the location of the affected parathyroid glands. The recent remarkable development of hand-held gamma-ray detectors makes it easy to perform radio-guided surgery, which is a combination of a preoperative intravenous injection of sestamibi and intraoperative navigation by the gamma-rays radiating from the pathological sites. This strategy can be easily applied to the resection of the ectopically located gland and is also useful to confirm the absence of endocrinologically active tissue after the operation. Additional chest SPECT imaging might be effective in the risk assessment of cardiac incidence in the perioperative period, as sestamibi was originally developed for the evaluation of myocardial perfusion. In conclusion, Tc-99m sestamibi will be more popularly applied to the treatment of hyperparathyroidism as minimally invasive surgery increases in favor.     

Value of parathyroid hormone assay for preoperative sonographically guided parathyroid aspirates for minimally invasive parathyroidectomy

PURPOSE: The key to successful parathyroid surgery is accurate preoperative tumor localization. This study investigates the use of ultrasound (US)-guided parathyroid fine needle aspiration (FNA) as a confirmatory diagnostic method in patients with hyperparathyroidism undergoing minimally invasive parathyroidectomy. METHODS: Patients were selected for minimally invasive parathyroidectomy based on the finding of a single parathyroid adenoma identified with US and/or sestamibi scans and confirmation of the suspected parathyroid lesion via FNA and parathyroid hormone (PTH) assay. The value of aspirate obtained from the thyroid gland intraoperatively served as the negative control. RESULTS: A total of 56 tissue FNAs were performed in 27 patients. US detected masses suggestive of parathyroid lesion in all 27 patients, and 31 US-guided FNAs were performed. No complications related to the procedure were noted. Intraoperatively, FNA was performed in the thyroids of 25 patients undergoing minimally invasive parathyroidectomy. Aspirates from lesions subsequently confirmed as having developed from the parathyroid gland had a mean PTH level of 4,677 +/- 123 pg/ml (range, 3,600-5,000 pg/ml), which was significantly higher than thyroid aspirates, which yielded a mean PTH level of 48 +/- 7 pg/ml (range, 5-57 pg/ml). The sensitivity of US and sestamibi scans in the detection of abnormal parathyroid glands was 88% and 77%, respectively. The sensitivity of US-guided FNA in confirming the parathyroid origin of a lesion was 100%. CONCLUSION: US-guided FNA for PTH assay can be performed safely for the confirmation of lesions identified with preoperative US for the selection of patients eligible for minimally invasive parathyroidectomy.     

Metastatic microcalcification in the lungs and stomach due to hyperparathyroidism: A case report

We present a case of a 34-year-old man who was admitted to our hospital with a six-month history of nausea and vomiting that had worsened over the past two weeks. Diagnosis of primary hyperparathyroidism (PHPT) due to a single parathyroid adenoma was confirmed by laboratory results and imaging but following pharmacological therapy the patient developed a dry cough. Single-photon emission tomography/computed tomography (SPECT/CT) with technetium-99m-diphosphonate (^99mTc-MDP) was used to assist in the diagnosis and results showed diffuse metastatic microcalcification in the lungs and stomach. The patient underwent right parathyroidectomy and ^99mTc-MDP SPECT/CT scan six months later showed a significantly reduced radioactive distribution in the lungs and none in the stomach. Diffuse metastatic microcalcification in the lungs and stomach due to PHTP is rare and can easily be misdiagnosed.     

甲状腺腺瘤血管结构的三维重建及血管容积指数特点分析

目的　探讨甲状腺腺瘤的血流三维空间结构及其血管容积指数 (VI)特点。方法　对 2 1个甲状腺腺瘤进行三维超声检查 ,重建甲状腺腺瘤血管的三维超声图像 ,并计算腺瘤肿块及其中央部的血管容积指数。结果　腺瘤内外血管空间结构形态直观 ,血管来源明确 ,腺瘤血管呈球形网状结构。甲状腺腺瘤的彩色血管容积指数 VI1 =2 8.34± 5 .12 ,腺瘤内部的血管容积指数 VI2 =12 .5 3± 6 .2 2 ,两者的差异具有显著性。结论　三维超声能较好地显示甲状腺腺瘤的血管空间结构 ,腺瘤周边与腺瘤内部的血管容积指数之间的差异具有显著性。因此对其诊断有着重要的应用价值。