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| __NOTOC____NOTOC__
| | __NOTOC__ |
| {{Hyperparathyroidism}}
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| {{CMG}}; {{AE}} {{Anmol}} | | {{CMG}}; {{AE}} {{Anmol}} |
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| == Classification == | | ==Tables== |
| {| class="wikitable" | | {| class="wikitable" |
| ! colspan="4" |Classification of hyperparathyridism | | |+ |
| | !Diagnosis |
| | !Lab findings |
| | ! |
| | ! |
| |- | | |- |
| |Features
| | ! |
| |'''Primary hyperparathyroidism'''
| | ! |
| |'''Secondary hyperparathyroidism'''
| | ! |
| |'''Tertiary hyperparathyroidism'''
| | ! |
| |- | | |- |
| |Pathology | | | |
| |Hyperfunction of parathyroid cells due to hyperplasia, adenoma or carcinoma. | | | |
| |Physiological stimulation of parathyroid in response to hypocalcaemia. | | | |
| |Following long term physiological stimulation leading to hyperplasia. | | | |
| |- | | |- |
| |Cause | | | |
| | | | | |
| | | | | |
| | | | | |
| |- | | |- |
| |Associations
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| |May be associated with multiple endocrine neoplasia.
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| |Usually due to chronic renal failure or other causes of Vitamin D deficiency.
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| |Seen in chronic renal failure.
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| |-
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| |Serum calcium
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| |High
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| |Low/Normal
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| |High
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| |-
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| |Serum phosphate
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| |Low/Normal
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| |High
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| |High
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| |-
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| |Management
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| |Usually surgery if symptomatic. Cincacalcet can be considered in those not fit for surgery.
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| |Treatment of underlying cause.
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| |Usually cinacalcet or surgery in those that don't respond.
| |
| |}
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| =Causes=
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| ===Genetic causes===
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| *HRPT2 gene mutations:<ref name="pmid14585940">{{cite journal| author=Shattuck TM, Välimäki S, Obara T, Gaz RD, Clark OH, Shoback D et al.| title=Somatic and germ-line mutations of the HRPT2 gene in sporadic parathyroid carcinoma. | journal=N Engl J Med | year= 2003 | volume= 349 | issue= 18 | pages= 1722-9 | pmid=14585940 | doi=10.1056/NEJMoa031237 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14585940 }} </ref>
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| **HRPT2 gene code for parafibromin protein.
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| **HRPT2 gene mutations are found in a type of familial hyperparathyroidism, hyperparathyroidism-jaw tumor (HPT-JT) syndrome.
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| **HRTP2 gene mutations increases risk of parathyroid carcinoma.
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| *Cyclin D1 gene (CCND1)/PRAD1 gene:<ref name="pmid19373510">{{cite journal| author=Westin G, Björklund P, Akerström G| title=Molecular genetics of parathyroid disease. | journal=World J Surg | year= 2009 | volume= 33 | issue= 11 | pages= 2224-33 | pmid=19373510 | doi=10.1007/s00268-009-0022-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19373510 }} </ref><ref name="pmid8626826">{{cite journal| author=Hsi ED, Zukerberg LR, Yang WI, Arnold A| title=Cyclin D1/PRAD1 expression in parathyroid adenomas: an immunohistochemical study. | journal=J Clin Endocrinol Metab | year= 1996 | volume= 81 | issue= 5 | pages= 1736-9 | pmid=8626826 | doi=10.1210/jcem.81.5.8626826 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8626826 }} </ref>
| |
| **PRAD1 (parathyroid adenoma 1) is a protooncogene located on chromosome 11q13.
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| **Cyclin D1 gene translocation and oncogene action observerd in 8% of adenomas
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| **Cyclin D1 gene overexpression is pbserved in 20% to 40% of parathyroid adenomas
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| *MEN1 gene:<ref name="pmid19373510">{{cite journal| author=Westin G, Björklund P, Akerström G| title=Molecular genetics of parathyroid disease. | journal=World J Surg | year= 2009 | volume= 33 | issue= 11 | pages= 2224-33 | pmid=19373510 | doi=10.1007/s00268-009-0022-6 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19373510 }} </ref><ref name="pmid9215689">{{cite journal| author=Agarwal SK, Kester MB, Debelenko LV, Heppner C, Emmert-Buck MR, Skarulis MC et al.| title=Germline mutations of the MEN1 gene in familial multiple endocrine neoplasia type 1 and related states. | journal=Hum Mol Genet | year= 1997 | volume= 6 | issue= 7 | pages= 1169-75 | pmid=9215689 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9215689 }} </ref>
| |
| **MEN1 is a tumor supressor gene on chronosome 11q13.
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| **Somatic loss of single MEN1 allele is observed in 25% to 40% of sporadic parathyroid adenomas.
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| =Pathogenesis=
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| ==Associated conditions==
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| =ECG=
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| There are no CT scan findings associated with hyperparathyroidism. However, a CT scan may be helpful in the diagnosis of cardiac complications of hyperparathyroidism.
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| Findings on ECG are due to hypercalcemia and includes:<ref name="pmid8201301">{{cite journal |vauthors=Lind L, Ljunghall S |title=Serum calcium and the ECG in patients with primary hyperparathyroidism |journal=J Electrocardiol |volume=27 |issue=2 |pages=99–103 |year=1994 |pmid=8201301 |doi= |url=}}</ref>
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| *ST segment - ST segment is short in patients with hyperparathyroidism when compared to normocalcemic patients. This represents a decrease in systolic interval.
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| *QRS complex - QRS complex has an increased amplitudein patients with hyperparathyroidism when compared to normocalcemic patients. This represents an increase in ventricular muscle mass.
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| *T wave - T wave is prolonged in patients with hyperparathyroidism when compared to normocalcemic patients.
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| =X-ray=
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| =CT scan=
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| =MRI=
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| =Ultrasound=
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| =TC-99m Sestamibi Scintigraphy=
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| *Technetium-99m-methoxyisobutylisonitrile (99mTc-sestamibi or MIBI) scintigraphy is the most popular investigation for preoperative localization of hyper-functioning parathyroid glands.<ref name="pmid16150247">{{cite journal| author=Palestro CJ, Tomas MB, Tronco GG| title=Radionuclide imaging of the parathyroid glands. | journal=Semin Nucl Med | year= 2005 | volume= 35 | issue= 4 | pages= 266-76 | pmid=16150247 | doi=10.1053/j.semnuclmed.2005.06.001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16150247 }} </ref>
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| *Most of the sestamibi is retained in mitochondria of thyroid and abnormal parathyroid tissue and is a function of mitochondrial activity.<ref name="pmid11742331">{{cite journal| author=Hetrakul N, Civelek AC, Stagg CA, Udelsman R| title=In vitro accumulation of technetium-99m-sestamibi in human parathyroid mitochondria. | journal=Surgery | year= 2001 | volume= 130 | issue= 6 | pages= 1011-8 | pmid=11742331 | doi=10.1067/msy.2001.118371 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11742331 }} </ref>
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| *The basis of this "single-isotope, double-phase technique" is that sestamibi washes out of the thyroid more rapidly than from abnormal parathyroid tissue.<ref name="pmid1328564">{{cite journal| author=Taillefer R, Boucher Y, Potvin C, Lambert R| title=Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study) | journal=J Nucl Med | year= 1992 | volume= 33 | issue= 10 | pages= 1801-7 | pmid=1328564 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1328564 }} </ref>
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| *Multiple planar images are obtained, typically one shortly after injection of 99mTc-sestamibi and another after two hours to identify the foci of retained sestamibi showing hyper-functioning parathyroid tissue.
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| *As all parathyroid lesions does not retain sestamibi nor all thyroid tissue washes out quickly, subtraction imaging may be beneficial.<ref name="pmid8288719">{{cite journal| author=Thulé P, Thakore K, Vansant J, McGarity W, Weber C, Phillips LS| title=Preoperative localization of parathyroid tissue with technetium-99m sestamibi 123I subtraction scanning. | journal=J Clin Endocrinol Metab | year= 1994 | volume= 78 | issue= 1 | pages= 77-82 | pmid=8288719 | doi=10.1210/jcem.78.1.8288719 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8288719 }} </ref>
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| *Subtraction technique uses dual contrast Tc-99m sestamibi along with iodine-123 or 99m-technicium pertechnetate which is taken by thyroid tissue only. Iodine-123/99m-technicium pertechnetate images of thyroid are later digitally subtracted from Tc-99m sestamibi images leading to visualization of parathyroid tissue only.<ref name="pmid25722888">{{cite journal| author=Ryhänen EM, Schildt J, Heiskanen I, Väisänen M, Ahonen A, Löyttyniemi E et al.| title=(99m)Technetium Sestamibi-(123)Iodine Scintigraphy Is More Accurate Than (99m)Technetium Sestamibi Alone before Surgery for Primary Hyperparathyroidism. | journal=Int J Mol Imaging | year= 2015 | volume= 2015 | issue= | pages= 391625 | pmid=25722888 | doi=10.1155/2015/391625 | pmc=4333274 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25722888 }} </ref>
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| *Presence of solid thyroid nodule is the most common cause of false positive results. Other causes of false positive results may include thyroid carcinoma, lymphoma, and lymphadenopathy.
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| *The sensitivity of sestamibi scintigraphy can be increased by using it concomitantly with neck ultrasound and/or SPECT. <ref name="pmid18794320">{{cite journal| author=Eslamy HK, Ziessman HA| title=Parathyroid scintigraphy in patients with primary hyperparathyroidism: 99mTc sestamibi SPECT and SPECT/CT. | journal=Radiographics | year= 2008 | volume= 28 | issue= 5 | pages= 1461-76 | pmid=18794320 | doi=10.1148/rg.285075055 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18794320 }} </ref><ref name="pmid12153604">{{cite journal| author=Haber RS, Kim CK, Inabnet WB| title=Ultrasonography for preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism: comparison with (99m)technetium sestamibi scintigraphy. | journal=Clin Endocrinol (Oxf) | year= 2002 | volume= 57 | issue= 2 | pages= 241-9 | pmid=12153604 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12153604 }} </ref>
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| *The sensitivity of sestamibi scintigraphy is 80% - 90%.<ref name="pmid8678959">{{cite journal |vauthors=Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, Richard B |title=Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism |journal=World J Surg |volume=20 |issue=7 |pages=835–9; discussion 839–40 |year=1996 |pmid=8678959 |doi= |url=}}</ref><ref name="pmid17685957">{{cite journal |vauthors=Prasannan S, Davies G, Bochner M, Kollias J, Malycha P |title=Minimally invasive parathyroidectomy using surgeon-performed ultrasound and sestamibi |journal=ANZ J Surg |volume=77 |issue=9 |pages=774–7 |year=2007 |pmid=17685957 |doi=10.1111/j.1445-2197.2007.04227.x |url=}}</ref><ref name="pmid20625763">{{cite journal |vauthors=Gómez-Ramírez J, Sancho-Insenser JJ, Pereira JA, Jimeno J, Munné A, Sitges-Serra A |title=Impact of thyroid nodular disease on 99mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism |journal=Langenbecks Arch Surg |volume=395 |issue=7 |pages=929–33 |year=2010 |pmid=20625763 |doi=10.1007/s00423-010-0680-8 |url=}}</ref>
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| {|
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| [[image:Parathyroid subtraction.jpg|center|thumb|450px|Dual tracer Tc-99m sestamibi scintigraphy - A nuclear medicine parathyroid scan demonstrates a parathyroid adenoma adjacent to the left inferior pole of the thyroid gland. The above study was performed with Technetium-Sestamibi (1st column) and Iodine-123 (2nd column) simultaneous imaging and the subtraction technique (3rd column). -- [https://commons.wikimedia.org/wiki/File%3AParathyroid_subtraction.jpg Source:Myohan at en.wikipedia, via Wikimedia Commons]]]
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| [[image:Sestamibi scan gif.gif|center|thumb|600px|Tc-99m sestamibi scan - Parathyroid adenomas typically retain activity on late scans after wash-out in the thyroid has occurred. - [https://radiopaedia.org/cases/16675 Source:Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16675]]]
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| =SPECT=
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| *Single positron emission computed tomography may be used along with Tc-99m sestamibi scintigraphy for preoperative evaluation of hyper-functioning parathyroid gland.<ref name="pmid8917173">{{cite journal| author=Billotey C, Sarfati E, Aurengo A, Duet M, Mündler O, Toubert ME et al.| title=Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy. | journal=J Nucl Med | year= 1996 | volume= 37 | issue= 11 | pages= 1773-8 | pmid=8917173 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8917173 }} </ref><ref name="pmid11854692">{{cite journal| author=Civelek AC, Ozalp E, Donovan P, Udelsman R| title=Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. | journal=Surgery | year= 2002 | volume= 131 | issue= 2 | pages= 149-57 | pmid=11854692 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11854692 }} </ref>
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| *Sestamibi-SPECT is also called pinhone-SPECT (P-SPECT). P-SPECT uses cone beam collimator in contrast to parallel-hole collimator used in SPECT. cone bean collimator possess more suitable geometric properties leading to high spatial resolution.<ref name="pmid8306288">{{cite journal| author=Strand SE, Ivanovic M, Erlandsson K, Franceschi D, Button T, Sjögren K et al.| title=Small animal imaging with pinhole single-photon emission computed tomography. | journal=Cancer | year= 1994 | volume= 73 | issue= 3 Suppl | pages= 981-4 | pmid=8306288 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8306288 }} </ref><ref name="pmid15551591">{{cite journal| author=Jaszczak RJ, Li J, Wang H, Zalutsky MR, Coleman RE| title=Pinhole collimation for ultra-high-resolution, small-field-of-view SPECT. | journal=Phys Med Biol | year= 1994 | volume= 39 | issue= 3 | pages= 425-37 | pmid=15551591 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15551591 }} </ref>
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| *Using SPECT with sestamibi scintigraphy improves detection and localization of hyper-functioning parathyroid gland.<ref name="pmid15078713">{{cite journal| author=Schachter PP, Issa N, Shimonov M, Czerniak A, Lorberboym M| title=Early, postinjection MIBI-SPECT as the only preoperative localizing study for minimally invasive parathyroidectomy. | journal=Arch Surg | year= 2004 | volume= 139 | issue= 4 | pages= 433-7 | pmid=15078713 | doi=10.1001/archsurg.139.4.433 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15078713 }} </ref><ref name="pmid8816526">{{cite journal| author=Perez-Monte JE, Brown ML, Shah AN, Ranger NT, Watson CG, Carty SE et al.| title=Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT. | journal=Radiology | year= 1996 | volume= 201 | issue= 1 | pages= 85-91 | pmid=8816526 | doi=10.1148/radiology.201.1.8816526 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8816526 }} </ref>
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| *SPECT provides more precise result of sestamibi scitigraphy allowing surgeon to choose best route for surgical intervention.
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| *P-SPECT may detect glands not visible on planer images leading to increased sensitivity. It is very useful in case of uncertain result from conventional sestamibi scitigraphy.<ref name="pmid14734671">{{cite journal| author=Spanu A, Falchi A, Manca A, Marongiu P, Cossu A, Pisu N et al.| title=The usefulness of neck pinhole SPECT as a complementary tool to planar scintigraphy in primary and secondary hyperparathyroidism. | journal=J Nucl Med | year= 2004 | volume= 45 | issue= 1 | pages= 40-8 | pmid=14734671 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14734671 }} </ref><ref name="pmid17960377">{{cite journal |vauthors=Carlier T, Oudoux A, Mirallié E, Seret A, Daumy I, Leux C, Bodet-Milin C, Kraeber-Bodéré F, Ansquer C |title=99mTc-MIBI pinhole SPECT in primary hyperparathyroidism: comparison with conventional SPECT, planar scintigraphy and ultrasonography |journal=Eur. J. Nucl. Med. Mol. Imaging |volume=35 |issue=3 |pages=637–43 |year=2008 |pmid=17960377 |pmc=2964350 |doi=10.1007/s00259-007-0625-9 |url=}}</ref>
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| *P-SPECT also enables accurate interpretation sestamibi uptake in upper mediastinum leading to a higher specificity.
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| *In difficult cases, P-SPECT may also be adjuncted with subtraction Tc-99m sestamibi and I-123 scintigraphy or positron emission tomography.<ref name="pmid10336191">{{cite journal| author=Nguyen BD| title=Parathyroid imaging with Tc-99m sestamibi planar and SPECT scintigraphy. | journal=Radiographics | year= 1999 | volume= 19 | issue= 3 | pages= 601-14; discussion 615-6 | pmid=10336191 | doi=10.1148/radiographics.19.3.g99ma10601 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10336191 }} </ref>
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| *P-SPECT is approximately 84% sensitive, 91% specific with positive predictive value of around 91% and negative predictive value of around 84%.<ref name="pmid19578871">{{cite journal |vauthors=Lindqvist V, Jacobsson H, Chandanos E, Bäckdahl M, Kjellman M, Wallin G |title=Preoperative 99Tc(m)-sestamibi scintigraphy with SPECT localizes most pathologic parathyroid glands |journal=Langenbecks Arch Surg |volume=394 |issue=5 |pages=811–5 |year=2009 |pmid=19578871 |doi=10.1007/s00423-009-0536-2 |url=}}</ref>
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| *Fusion images of CT-MIBI-SPECT is superior to CT or MIBI-SPECT alone in preoperative localization of hyper-functioning parathyroid gland.<ref name="pmid19705144">{{cite journal| author=Wimmer G, Profanter C, Kovacs P, Sieb M, Gabriel M, Putzer D et al.| title=CT-MIBI-SPECT image fusion predicts multiglandular disease in hyperparathyroidism. | journal=Langenbecks Arch Surg | year= 2010 | volume= 395 | issue= 1 | pages= 73-80 | pmid=19705144 | doi=10.1007/s00423-009-0545-1 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19705144 }} </ref>
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| =PET=
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| *11C-methionine PET along with CT scan (MET-PET/CT) may be used for preoperative localization of hyper-functioning gland.<ref name="pmid18781582">{{cite journal| author=Tang BN, Moreno-Reyes R, Blocklet D, Corvilain B, Cappello M, Delpierre I et al.| title=Accurate pre-operative localization of pathological parathyroid glands using 11C-methionine PET/CT. | journal=Contrast Media Mol Imaging | year= 2008 | volume= 3 | issue= 4 | pages= 157-63 | pmid=18781582 | doi=10.1002/cmmi.243 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18781582 }} </ref><ref name="pmid23478517">{{cite journal| author=Weber T, Maier-Funk C, Ohlhauser D, Hillenbrand A, Cammerer G, Barth TF et al.| title=Accurate preoperative localization of parathyroid adenomas with C-11 methionine PET/CT. | journal=Ann Surg | year= 2013 | volume= 257 | issue= 6 | pages= 1124-8 | pmid=23478517 | doi=10.1097/SLA.0b013e318289b345 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23478517 }} </ref>
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| *MET-PET/CT may be used as an complimentary imaging modality for localizing hyper-functioning parathyroid glands in patients with negative Tc-99m sestamibi scintigraphy/SPECT results.<ref name="pmid25029418">{{cite journal| author=Traub-Weidinger T, Mayerhoefer ME, Koperek O, Mitterhauser M, Duan H, Karanikas G et al.| title=11C-methionine PET/CT imaging of 99mTc-MIBI-SPECT/CT-negative patients with primary hyperparathyroidism and previous neck surgery. | journal=J Clin Endocrinol Metab | year= 2014 | volume= 99 | issue= 11 | pages= 4199-205 | pmid=25029418 | doi=10.1210/jc.2014-1267 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25029418 }} </ref>
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| =DXA=
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| *Low bone mineral density (BMD) is caused by primary hyperparathyroidism. Distal forearm is affected most commonly.
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| *DXA of distal forearm should be done in all patients of primary hyperparathyroidism. Worst T-score of distal forearm is observed in patients with primary hyperparathyroidism.<ref name="pmid22258698">{{cite journal| author=Wood K, Dhital S, Chen H, Sippel RS| title=What is the utility of distal forearm DXA in primary hyperparathyroidism? | journal=Oncologist | year= 2012 | volume= 17 | issue= 3 | pages= 322-5 | pmid=22258698 | doi=10.1634/theoncologist.2011-0285 | pmc=3316917 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22258698 }} </ref>
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| =Other diagnostic studies=
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| ==Intraoperative parathyroid hormone (IOPTH)==
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| *Measurement of intraoperative parathyroid hormone (IOPTH) by using a modified sensitive assay (immunoradiometric assay) is beneficial for long term surgical outcomes.Post-surgical success is defined as postoperative normocalcemia.
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| *Patients with hyperparathyroidism due to lesion in a single gland shows a rapid decline of intact parathyroid hormone. The levels of intact parathyroid hormone reached to indetectable levels within hours of resection.<ref name="pmid3194839">{{cite journal| author=Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA| title=Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. | journal=Surgery | year= 1988 | volume= 104 | issue= 6 | pages= 1121-7 | pmid=3194839 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3194839 }} </ref>
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| *After resection of parathyroid adenoma, intact parathyroid hormone levels decrease by 85% is observed in first 15 minutes. This fall in parathyroid hormone levels is due to short half-life of parathyroid hormone.<ref name="pmid8145618">{{cite journal| author=Bergenfelz A, Isaksson A, Ahrén B| title=Intraoperative monitoring of intact PTH during surgery for primary hyperparathyroidism. | journal=Langenbecks Arch Chir | year= 1994 | volume= 379 | issue= 1 | pages= 50-3 | pmid=8145618 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8145618 }} </ref>
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| *The fall in parathyroid hormone level is significantly more after resection of parathyroid adenoma than after resection of parathyroid hyperplasia.
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| *A fall in level of parathyroid hormone 15 minutes after resection of hyper-functioning parathyroid glands may help differentiating sigle gland disease from multi gland disease.<ref>{{cite journal |last1=Irvin III |first1=George L. |last2=Dembrow |first2=Victor D. |last3=Prudhomme |first3=David L. |date= December 1993 |title=Clinical usefulness of an intraoperative “quick parathyroid hormone” assay |url=http://www.surgjournal.com/article/0039-6060(93)90317-7/abstract |journal=Surgery |volume=114 |issue=6 |pages=1019 - 1023 |doi= |access-date= }}</ref><ref name="pmid9718013">{{cite journal| author=Bergenfelz A, Isaksson A, Lindblom P, Westerdahl J, Tibblin S| title=Measurement of parathyroid hormone in patients with primary hyperparathyroidism undergoing first and reoperative surgery. | journal=Br J Surg | year= 1998 | volume= 85 | issue= 8 | pages= 1129-32 | pmid=9718013 | doi=10.1046/j.1365-2168.1998.00824.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9718013 }} </ref>
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| *IOPTH monitoring has a predictive accuracy of 97%. <ref name="pmid8957480">{{cite journal| author=Boggs JE, Irvin GL, Molinari AS, Deriso GT| title=Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy. | journal=Surgery | year= 1996 | volume= 120 | issue= 6 | pages= 954-8 | pmid=8957480 | doi=10.1016/S0039-6060(96)80040-7 | pmc= | url=http://ac.els-cdn.com/S0039606096800407/1-s2.0-S0039606096800407-main.pdf?_tid=99caa004-930c-11e7-92b8-00000aab0f01&acdnat=1504706978_12ba7c16e03bb28c66dc1c17a05074c4}} </ref>
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| ===Technique for intraoperative parathyroid hormone (IOPTH) monitoring===
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| *When the enlarged parathyroid gland is first visualized intraoperatively, the baseline sample should be obtained.<ref name="pmid11822958">{{cite journal| author=Westerdahl J, Lindblom P, Bergenfelz A| title=Measurement of intraoperative parathyroid hormone predicts long-term operative success. | journal=Arch Surg | year= 2002 | volume= 137 | issue= 2 | pages= 186-90 | pmid=11822958 | doi=10.1001/archsurg.137.2.186 | pmc= | url=http://jamanetwork.com/journals/jamasurgery/fullarticle/212128 }} </ref>
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| *The baseline samples should never be obtained before induction of anesthesia. It is due to the fact that an increase in parathyroid hormone level may be observed after general anesthesia.
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| *After excision of enlarged gland, 2nd and 3rd samples are collected at 5 and 10 minutes respectively.
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| *Several criteria are used for predicting post-operative normocalcemia including:
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| **A decline in parathyroid hormone levels of ≥60% from baseline value at 15 minutes.
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| **A decline in parathyroid hormone levels of ≥50% from baseline value at 10 minutes.
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| ==Super Selective Venous Sampling==
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| ==Selective arteriography==
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| *Selective transarterial hypocalcemic stimulation is combined with nonselective venous sampling to perform selective arteriography.<ref name="pmid19958942">{{cite journal| author=Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF et al.| title=Reoperation for parathyroid adenoma: a contemporary experience. | journal=Surgery | year= 2009 | volume= 146 | issue= 6 | pages= 1144-55 | pmid=19958942 | doi=10.1016/j.surg.2009.09.015 | pmc=3467310 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19958942 }} </ref>
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| *Sodium citrate is injected to induce hypocalcemia. Simultaneous arteriography is performed.
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| *Samples are taken for superior vena cava at basaeline and timed intervals (20 sec, 40 sec, and 60 sec).
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| *An increase in the parathyroid hormone level to 1.4 times above the baseline or a clear blush observed on arteriography is considered as positive localization.
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| * Arterial stimulation venous sampling is performed simultaneously with arteriogram due to similarly high PPV.
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| ==Angiography==
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| *Superselective arterial digital subtraction angiography (DSA) and superselective conventional angiography (CA) may be used for preoperative localization of hyper-functioning parathyroid glands in which noninvasive imaging modalities are negative or inconclusive.<ref name="pmid2644666">{{cite journal| author=Miller DL, Chang R, Doppman JL, Norton JA| title=Localization of parathyroid adenomas: superselective arterial DSA versus superselective conventional angiography. | journal=Radiology | year= 1989 | volume= 170 | issue= 3 Pt 2 | pages= 1003-6 | pmid=2644666 | doi=10.1148/radiology.170.3.2644666 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2644666 }} </ref>
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| *Sensitivity of superselective digital subtraction angiography appears to be similar to conventional angiography.
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| *Superselective arterial digital subtraction angiography may be more sensitive than conventional angiography for preoperative localization of mediastinal hyper-functioning parathyroid glands.
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| ==References== | | ==References== |
| | {{reflist|2}} |