Hyperfunctioning Parathyroid Tissue: Spectrum of Appearances on Noninvasive Imaging
Michael B. Gotway1,2,
Jessica W. T. Leung3,
Gretchen A. Gooding4,
Harold I. Litt2,
Gautham P. Reddy2,
Eugene T. Morita2,
W. Richard Webb2,
Orlo H. Clark5 and
Charles B. Higgins2
1 Department of Radiology, San Francisco General Hospital, Rm. 1x 55A, Box
1325, 1001 Potrero Ave., San Francisco, CA 94110.
2 Department of Radiology, University of California, Rm. M-391, 505 Parnassus
Ave., San Francisco, CA 94143.
3 Department of Radiology, Brigham and Women's Hospital, Harvard Medical School,
75 Francis St., Boston, MA 02115.
4 Department of Radiology, Veterans Affairs Medical Center, 4150 Clement St.,
San Francisco, CA 94121.
5 Department of Surgery, University of California, Mt. Zion Hospital, Box 1674
C347, Surgery Faculty Practice, 2330 Post St., Rm. 420, San Francisco, CA
94115.
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Fig. 1A. —50-year-old man with hyperparathyroidism. Longitudinal
sonogram obtained with 15-MHz linear transducer shows no evidence of abnormal
parathyroid tissue. T = thyroid gland.
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Fig. 1B. —50-year-old man with hyperparathyroidism. Longitudinal
sonogram obtained with 6-MHz linear transducer shows deeper tissue penetration
than revealed in A. Note hypoechoic focus (cursors) with poor
sound transmission, consistent with parathyroid adenoma. Although sonographic
evaluation of patients with hyperparathyroidism generally requires use of
high-frequency (7- to 15-MHz) linear transducers to achieve maximal spatial
resolution, care is required to visualize posterior aspects of thyroid gland,
thereby ensuring that most common position for abnormal parathyroid tissue is
evaluated.
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Fig. 1C. —50-year-old man with hyperparathyroidism. Color Doppler
sonogram shows vascularity in lesion (arrow).
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Fig. 2. —54-year-old man with hyperparathyroidism. Longitudinal
sonogram (7-MHz linear transducer) shows mass (large arrows) with
mixed hypoechoic and hyperechoic foci (small arrows), representing
parathyroid adenoma. Hyperechoic foci may occasionally be encountered in
larger adenomas.
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Fig. 3A. —45-year-old man with hyperparathyroidism. Gray-scale sonogram
(8-MHz linear transducer) reveals hypoechoic lesion (cursors) in neck
with no sound transmission, consistent with parathyroid adenoma.
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Fig. 3B. —45-year-old man with hyperparathyroidism. Color Doppler
sonogram reveals vascularity in lesion (arrow).
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Fig. 4. —62-year-old man with parathyroid carcinoma. Transverse color
Doppler sonogram (8-MHz linear transducer) of neck reveals hypoechoic nodule
(arrows) with poor sound transmission and extensive vascularity.
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Fig. 5. —45-year-old man with recurrent hyperparathyroidism.
Contrast-enhanced axial CT scan (collimation, 5 mm; window width, 440 H;
level, 40 H) reveals large, intensely enhancing nodule just posterior to
inferior aspect of right thyroid gland (arrow), consistent with
parathyroid adenoma.
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Fig. 6A. —201Tl-99mTc pertechnetate subtraction
scintigrams in 61-year-old man with hyperparathyroidism after cervical
exploration. Planar scintigram after IV injection of 2 µCi (74 MBq)
201Tl shows tracer uptake in thyroid gland and small nodular focus
of tracer uptake along inferior border of right lobe of thyroid gland
(arrow), representing parathyroid adenoma.
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Fig. 6B. —201Tl-99mTc pertechnetate subtraction
scintigrams in 61-year-old man with hyperparathyroidism after cervical
exploration. Planar scintigram after IV injection of 10 µCi (370 MBq)
99mTc pertechnetate shows normal distribution of tracer in thyroid
gland. Note that focus of tracer uptake in A is not present on
99mTc pertechnetate portion of examination.
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Fig. 6C. —201Tl-99mTc pertechnetate subtraction
scintigrams in 61-year-old man with hyperparathyroidism after cervical
exploration. Early (20-min) planar scintigram after IV injection of 26 µCi
(962 MBq) of 99mTc sestamibi shows focus of activity localized to
inferior aspect of right lobe of thyroid gland, representing parathyroid
adenoma (arrow).
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Fig. 6D. —201Tl-99mTc pertechnetate subtraction
scintigrams in 61-year-old man with hyperparathyroidism after cervical
exploration. Delayed (2-hr) planar scintigram shows relatively improved
conspicuity of parathyroid adenoma (arrow) compared with C.
Note improved resolution of 99mTc sestamibi scintigram compared
with A. Improved resolution, because of more favorable energy of
99mTc photons, is one advantage 99mTc sestamibi has
compared with 201Tl imaging.
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Fig. 7A. —99mTc sestamibi-123I subtraction
scintigraphy in 58-year-old man with recurrent hyperparathyroidism after
cervical exploration. Planar scintigram obtained 20 min after IV injection of
25 µCi (925 MBq) 99mTc sestamibi reveals focus of tracer uptake
just cranial to superior aspect of left lobe of thyroid gland
(arrow), consistent with parathyroid adenoma.
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Fig. 7B. —99mTc sestamibi-123I subtraction
scintigraphy in 58-year-old man with recurrent hyperparathyroidism after
cervical exploration. Planar scintigram after subtraction of 123I
portion of study. 123I localizes in thyroid gland and not within
hyperfunctioning parathyroid tissue; therefore, 123I subtraction
removes tracer activity in thyroid gland, increasing conspicuity of abnormal
parathyroid tissue (arrow) cranial to superior aspect of left lobe of
thyroid gland. Photopenic area in center of image represents subtracted
thyroid tissue activity. Similar subtraction techniques may be performed using
pertechnetate in place of 123I. (Courtesy of Newberg A,
Philadelphia, PA)
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Fig. 8. —99mTc sestamibi-123I subtraction
scintigram in 45-year-old woman with hyperparathyroidism. Planar image
obtained after subtraction of 123I portion of study reveals focus
of increased tracer uptake (large arrow) along inferior aspect of
left lower portion of photopenic area, representing subtracted thyroid gland
activity, consistent with parathyroid adenoma. Tracer uptake at superior
aspect of image (small arrows) represents salivary tissue. (Courtesy
of Newberg A, Philadelphia, PA)
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Fig. 9A. —45-year-old man with recurrent hyperparathyroidism after
cervical exploration. Axial T1-weighted MR image (TR/TE, 500/8) obtained
through lower neck reveals nodule (arrow) just caudal to right lobe
of thyroid gland that is slightly hypointense relative to skeletal muscle.
Location and appearance are typical of parathyroid adenoma.
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Fig. 9B. —45-year-old man with recurrent hyperparathyroidism after
cervical exploration. Axial fast spin-echo T2-weighted MR image (4000/105) at
same level as A shows lesion (arrow) is hyperintense relative
to skeletal muscle, also characteristic of hyperfunctioning parathyroid
tissue.
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Fig. 9C. —45-year-old man with recurrent hyperparathyroidism after
cervical exploration. Enhanced axial T1-weighted fat-saturated MR image
(500/8) reveals that lesion (arrow) enhances brightly. Intense
enhancement is typical of hyperfunctioning parathyroid tissue. (Reprinted with
permission from [2])
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Fig. 10A. —55-year-old woman with renal disease and hyperparathyroidism.
Axial T1-weighted MR image (TR/TE, 500/8) shows nodule (arrow) with
signal intensity slightly greater than adjacent skeletal muscle in left
sternocleidomastoid muscle. Increased signal intensity on T1-weighted MR image
is somewhat unusual for hyperfunctioning parathyroid tissue.
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Fig. 10B. —55-year-old woman with renal disease and hyperparathyroidism.
Axial fast spin-echo T2-weighted MR image (4000/105) shows nodule
(arrow) has markedly increased T2 signal intensity compared with
adjacent skeletal muscle.
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Fig. 10C. —55-year-old woman with renal disease and hyperparathyroidism.
Enhanced axial T1-weighted fat-saturated MR image (500/8) reveals intense
enhancement of nodule (arrow). (Reprinted with permission from
[6])
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Fig. 11A. —85-year-old woman with recurrent hyperparathyroidism. Axial
T1-weighted MR image (TR/TE, 500/8) obtained through upper mediastinum shows
right paratracheal mass (arrow) with mildly increased T1 signal.
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Fig. 11B. —85-year-old woman with recurrent hyperparathyroidism. Axial
T2-weighted MR image (4000/90) shows hyperintense T2 signal in nodule
(arrow). Combination of hyperintense T1 and T2 signals suggests that
lesion is cystic. Cystic parathyroid adenoma was proven at surgery. (Reprinted
with permission from [8])
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Fig. 12A. —61-year-old woman with persistent hyperparathyroidism after
cervical exploration. e = esophagus. Axial T1-weighted MR image (TR/TE, 550/8)
obtained through lower neck reveals isointense nodule (arrow)
immediately posterior to esophagus.
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Fig. 12B. —61-year-old woman with persistent hyperparathyroidism after
cervical exploration. e = esophagus. Axial fast spin-echo T2-weighted MR image
(4000/90) reveals nodule (arrow) is hyperintense. Note thin rim of
low-signal-intensity tissue surrounding lesion, characteristic of parathyroid
adenomas.
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Fig. 12C. —61-year-old woman with persistent hyperparathyroidism after
cervical exploration. e = esophagus. Enhanced axial T1-weighted fat-saturated
MR image (550/8) shows nodule (arrow) enhances intensely. Signal
intensity patterns are characteristic of parathyroid adenoma. Paraesophageal
position is recognized, but uncommon ectopic location. (Reprinted with
permission from [2])
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Fig. 13A. —36-year-old man with recurrent hyperparathyroidism after
cervical exploration. Axial T1-weighted MR image (TR/TE, 500/8) obtained
through upper neck reveals iso- to low-intensity nodule (arrow) in
left retropharyngeal space.
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Fig. 13B. —36-year-old man with recurrent hyperparathyroidism after
cervical exploration. Axial fast spin-echo T2-weighted MR image (4000/90)
shows increased T2 signal intensity (arrow) in lesion.
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Fig. 13C. —36-year-old man with recurrent hyperparathyroidism after
cervical exploration. Enhanced axial T1-weighted fat-saturated MR image
(500/8) shows intense enhancement of nodule (arrow), characteristic
of parathyroid adenoma. (Reprinted with permission from
[6])
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Fig. 14. —50-year-old man with hyperparathyroidism. Coronal T1-weighted
MR image (TR/TE, 500/8) shows slightly hyperintense nodule in aortopulmonary
window (arrow), surgically proven to represent parathyroid
adenoma.
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Copyright © 2002 by the American Roentgen Ray Society.
