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. 2014 Jan 31;17(1):1-12.
doi: 10.1007/s40477-014-0067-8. eCollection 2014 Mar.

Role of ultrasonography in the management of patients with primary hyperparathyroidism: retrospective comparison with technetium-99m sestamibi scintigraphy

Giovanni Mariano Vitetta  1 , Pierluigi Neri  2 , Andrea Chiecchio  3 , Alessandro Carriero  2 , Stefano Cirillo  1 , Annalisa Balbo Mussetto  1 , Alessandra Codegone  4
Affiliations

Role of ultrasonography in the management of patients with primary hyperparathyroidism: retrospective comparison with technetium-99m sestamibi scintigraphy

Giovanni Mariano Vitetta et al. J Ultrasound. .

Abstract
in English, German

Objective: Primary hyperparathyroidism (PHPT) is a common endocrine disorder that can be cured only by parathyroidectomy. Cervical ultrasonography and scintigraphy are the imaging studies most widely used for preoperative localization of the affected glands. The aim of this retrospective comparative study was to define the respective roles of ultrasonography and parathyroid scintigraphy in these cases.

Materials and methods: We analyzed 108 patients who had undergone parathyroidectomies for PHPT following cervical ultrasonographic and scintigraphic examinations. The ultrasound examinations were carried out by an expert physician sonographer in 61 cases and by various physician sonographers with different levels of experience in 47 cases. Sonographic and scintigraphic findings were compared with surgical findings and the diagnostic performance of the two imaging methods was evaluated by means of statistical analysis.

Results: The operator dependency of ultrasonography was confirmed by marked variations in sensitivity related to the experience of the sonographer. When sonography was performed by an expert, the sensitivity of combined use of the two methods was not significantly higher than that of sonography alone.

Conclusions: In expert hands, the diagnostic yield of ultrasound is appreciably superior. It can therefore be used as the main and possibly sole method for preoperative localization of pathological parathyroid tissues. Combined use of ultrasound and scintigraphy is not cost-effective in these cases. Scintigraphy is indicated only when the ultrasound examination produces negative results.

Obiettivo: L’iperparatiroidismo primitivo (PHPT) è una frequente patologia endocrina che ha come unico trattamento risolutivo quello chirurgico (paratiroidectomia). L’ecografia del collo e la scintigrafia sono gli esami strumentali più comunemente utilizzati nella localizzazione preoperatoria delle paratiroidi patologiche. Scopo di questo studio retrospettivo è definire il ruolo dell’ecografia, confrontandolo con quello della scintigrafia paratiroidea.

Materiali e metodi: 108 pazienti sottoposti a intervento di paratiroidectomia per PHPT che hanno eseguito pre-operatoriamente sia l’ecografia del collo che la scintigrafia. L’ecografia è stata eseguita in 61 pazienti da un medico ecografista esperto e in 47 pazienti da più medici ecografisti con esperienza eterogenea. Gli esiti dell’ecografia e della scintigrafia sono stati confrontati con le risultanze dell’atto operatorio e i dati relativi alle loro prestazioni diagnostiche sono stati elaborati mediante analisi statistica.

Risultati: L’ecografia si è confermata metodica operatore-dipendente, dipendendo la sua sensibilità in modo marcato dall’esperienza dell’operatore. Nel caso dell’operatore esperto, l’incremento di sensibilità ottenuto con il contemporaneo uso della scintigrafia si è dimostrato poco rilevante.

Conclusioni: Se eseguita da un operatore esperto, l’ecografia ha una resa diagnostica sensibilmente superiore e può assumere il ruolo di principale ed eventualmente unica metodica di localizzazione preoperatoria delle paratiroidi patologiche. L’uso parallelo dell’ecografia e della scintigrafia risulta in tal caso non giustificato e non cost-effective. Si ritiene invece corretto esclusivamente il loro uso seriale (esecuzione della scintigrafia solamente in caso di negatività dell’ecografia).

Keywords: Localization; Parathyroid adenoma; Primary hyperparathyroidism; Ultrasonography.

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Figures

Fig. 1
Fig. 1
The thyroid region (the gland is morphologically normal)
Fig. 2
Fig. 2
Adenoma of the upper right parathyroid gland. The middle retrothyroidal lesion is indicated by the red arrow; maximum diameter 2.2–2.3 cm. Longitudinal scan (panel A); axial scan (panel B)
Fig. 3
Fig. 3
Adenoma of the upper left parathyroid gland (middle-superior retrothyroidal, maximum diameter approx. 1.1 cm). Longitudinal (panel A) and axial (panel B) scans. The overlying thyroid parenchyma appears inhomogeneously hypoechoic as a result of chronic autoimmune thyroiditis
Fig. 4
Fig. 4
Longitudinal (panel A) and axial (panel B) scans of an adenoma of the left inferior parathyroid gland (inferior retrothyroidal, maximum diameter 3.2–3.3 cm)
Fig. 5
Fig. 5
Adenoma of the left inferior parathyroid gland (inferior retrothyroidal, content: partially fluid, maximum diameter approx. 3 cm): longitudinal (panel A) and axial (panel B) scans
Fig. 6
Fig. 6
Paratracheal adenoma (maximum diameter approx. 1.8 cm) of the right inferior parathyroid gland located near the inferior pole of the thyroid lobe. Axial scan (panel A), longitudinal scan (panel B), longitudinal scan with color Doppler imaging (panel C, monopolar vascular pattern referred to as the arc or rim sign)
Fig. 7
Fig. 7
Intrathyroidal adenoma of the right inferior parathyroid gland (maximum diameter approx. 1.5 cm circa) that developed within a multinodular goiter. Axial scan (panel A), longitudinal scan (panel B), longitudinal scan with color Doppler imaging (panels C and D). The vascular pattern is predominantly monopolar. Pulsed Doppler sampling of the afferent artery (panel D) revealed typical low-resistance flow (RI 0.52)
Fig. 8
Fig. 8
Scintigraphic images documenting uptake by a left inferior parathyroid adenoma. The images were obtained using the dual-phase, single-tracer technique (panel A) and the dual-tracer subtraction technique (panel B)
Fig. 9
Fig. 9
Algorithm for preoperative localization and surgical treatment
See this image and copyright information in PMC

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