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Parathyroid Imaging: Technique and Role in the Preoperative Evaluation of Primary Hyperparathyroidism

¹ Department of Radiology, University of Pittsburgh Medical Center and School of Medicine, 200 Lothrop St., 3950 CHP/MT, Pittsburgh, PA 15213.
² Department of Surgery, University of Pittsburgh Medical Center and School of Medicine, Pittsburgh, PA 15213.

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1 —Diagram shows posterior view of typical locations of paired superior (white arrows) and inferior (arrowheads) parathyroid glands and their relationship to thyroid gland and surrounding structures. Note close relationship parathyroid glands have with recurrent laryngeal nerves (black arrows), illustrating why nerve injury is a significant concern of endocrine surgeons, particularly with four-gland explorations.

View larger version (82K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2 —Sonogram of 25-year-old woman with possible thyroid enlargement (thyroid was normal). Note subtle isoechoic parathyroid gland inferior to lower pole of thyroid (arrows). Normal parathyroid glands are uncommonly seen on sonography because of their small size.

View larger version (56K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —44-year-old woman with hyperparathyroidism due to right inferior parathyroid adenoma. Resected gland weighed 629 mg, nearly 15 times weight of a normal gland (40–50 mg). Sonogram shows typical hypoechoic adenoma (arrows) deep in relation to lower pole of thyroid.

View larger version (62K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —44-year-old woman with hyperparathyroidism due to right inferior parathyroid adenoma. Resected gland weighed 629 mg, nearly 15 times weight of a normal gland (40–50 mg). Color Doppler sonogram shows peripheral feeding vessel (arrow) characteristic of parathyroid adenomas. Also note typical arc or rim vascularity.

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —55-year-old woman with primary hyperparathyroidism due to large left superior adenoma. Sonogram shows hypoechoic nodule suspected of being parathyroid medial to common carotid artery (arrow).

View larger version (78K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —55-year-old woman with primary hyperparathyroidism due to large left superior adenoma. Graded compression sonogram increases conspicuity of adenoma (arrows).

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —15-year-old girl with hyperparathyroidism due to parathyroid hyperplasia. Sonograms show four slightly enlarged parathyroid glands (arrows): right superior (A), right inferior (B), left superior (C), and left inferior (D). Patient subsequently underwent four-gland exploration and subtotal parathyroidectomy, leaving portion of right superior gland. Largest of resected hyperplastic glands weighed only 322 mg. Relatively small size of typical hyperplastic glands decreases sensitivity of sonography.

View larger version (70K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —15-year-old girl with hyperparathyroidism due to parathyroid hyperplasia. Sonograms show four slightly enlarged parathyroid glands (arrows): right superior (A), right inferior (B), left superior (C), and left inferior (D). Patient subsequently underwent four-gland exploration and subtotal parathyroidectomy, leaving portion of right superior gland. Largest of resected hyperplastic glands weighed only 322 mg. Relatively small size of typical hyperplastic glands decreases sensitivity of sonography.

View larger version (66K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5C —15-year-old girl with hyperparathyroidism due to parathyroid hyperplasia. Sonograms show four slightly enlarged parathyroid glands (arrows): right superior (A), right inferior (B), left superior (C), and left inferior (D). Patient subsequently underwent four-gland exploration and subtotal parathyroidectomy, leaving portion of right superior gland. Largest of resected hyperplastic glands weighed only 322 mg. Relatively small size of typical hyperplastic glands decreases sensitivity of sonography.

View larger version (73K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5D —15-year-old girl with hyperparathyroidism due to parathyroid hyperplasia. Sonograms show four slightly enlarged parathyroid glands (arrows): right superior (A), right inferior (B), left superior (C), and left inferior (D). Patient subsequently underwent four-gland exploration and subtotal parathyroidectomy, leaving portion of right superior gland. Largest of resected hyperplastic glands weighed only 322 mg. Relatively small size of typical hyperplastic glands decreases sensitivity of sonography.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —25-year-old woman with Hashimoto's thyroiditis. Sonograms show how prominent central compartment lymph nodes (arrows) may mimic adenomatous parathyroid glands.

View larger version (96K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —25-year-old woman with Hashimoto's thyroiditis. Sonograms show how prominent central compartment lymph nodes (arrows) may mimic adenomatous parathyroid glands.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —25-year-old woman with Hashimoto's thyroiditis. Color Doppler sonogram may aid in differentiating between lymph nodes and adenomas: Lymph nodes are supplied by a central hilar vessel (arrow), whereas vessels that supply adenomas typically enter either pole.

View larger version (67K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7 —67-year-old woman with hyperparathyroidism and left tracheoesophageal groove adenoma that could easily be mistaken for posterior thyroid nodule. Peripheral, polar vascularity seen on color Doppler sonogram helps to identify this as adenoma. Subsequent parathyroidectomy preformed at time of total thyroidectomy revealed this to be a supernumerary hyperplastic parathyroid gland.

View larger version (52K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —52-year-old woman with hyperparathyroidism and right superior parathyroid adenoma. Early-phase 99mTc-sestamibi SPECT image shows physiologic uptake in salivary glands and thyroid gland, with focus of more intense uptake overlying superior pole of right thyroid lobe (arrow).

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —52-year-old woman with hyperparathyroidism and right superior parathyroid adenoma. Two-hour delayed SPECT image shows radiotracer retention in adenoma (arrow) but clearing of tracer from overlying thyroid.

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —40-year-old woman who presented with recurrent hypercalcemia and hyperparathyroidism after resection of both left-sided glands. Contrast-enhanced CT scan shows brisk enhancement of 8-mm soft-tissue nodule (arrow) in mediastinum that correlated anatomically with focus of radiotracer retention in mediastinum on prior sestamibi SPECT. This was found to be a hyperplastic right inferior parathyroid gland.

View larger version (138K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —39-year-old woman with left superior adenoma showing typical MRI signal characteristics. T2-weighted MR image shows increased T2 signal in adenoma (arrow) relative to thyroid gland and surrounding soft tissues.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —39-year-old woman with left superior adenoma showing typical MRI signal characteristics. Axial T1-weighted MR image shows typical intermediate T1 signal (arrow) seen in adenomas.

View larger version (139K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —39-year-old woman with left superior adenoma showing typical MRI signal characteristics. Gadolinium-enhanced T1-weighted image with fat suppression shows intense enhancement typical of adenomas (arrow). These imaging characteristics can be indistinguishable from those of lymph nodes and thus must be interpreted in clinical context and in concert with other imaging techniques.

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