Hyperparathyroidism other imaging findings

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Overview

Imaging modalities may be helpful in preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities. Non-invasive imaging modalities for preoperative localization of hyper-functioning parathyroid glands include Tc-99m sestamibi scintigraphy (sestamibi or MIBI), single photon emission computed tomography (SPECT), positron emission tomography (PET). Invasive modalities used for preoperative localization of hyper-functioning parathyroid glands include selective arteriography and angiography. Dual energy X-ray absorptiometry is helpful in detecting low bone mineral density (BMD) caused by hyperparathyroidism.

Other Imaging Findings

Other imaging modalities are used for preoperative localization of hyper-functioning parathyroid glands. This includes both non-invasive and invasive modalities. Another modality used in hyperparathyroidism is dual energy X-ray absorptiometry (DXA). DXA is helpful in detecting low bone mineral density (BMD) caused by hyperparathyroidism.

Non-invasive modalities

TC-99m Sestamibi Scintigraphy

Factors influencing sensitivity of Tc-99m sestamibi scintigraphy
Factors Sensitivity
Biochemical factors High serum calcium level[11] Increased
High serum parathyroid hormone level[11][12] Increased
Hypovitaminosis D [13]

(only in primary hyperparathyroidism)

Increased
Calcium channel blocker use[14]

(only in primary hyperparathyroidism)

Decreased
Gross and architectural factors Size (Large)[15][16] Increased
Multi-glandular disease[17] Decreased
Cytological factors Increased amount of cellular content[15][16]

(Chief cells and oxyphil cells)

Increased
Immunohistochemical factors Increased P-glycoprotien expression[18] Decreased
Note: P-glycoprotein (Pgp) is a plasma membrane protein encoded by mammalian multidrug resistance gene (MDRI). Many drugs that are lipophilic and cationic at physiological pH interact with P-gp. Sestamibi is a lipophilic cationic on physioligical pH. P-gp acts as ATP-dependent efflux pump and prevents accumulation of sestamibi in parathyroid tissue. So, the uptake of sestamibi into parathyroid adenoma cells depends on the activity of the P-gp[19].
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). -- Source:Myohan at en.wikipedia, via Wikimedia Commons
Tc-99m sestamibi scan - Parathyroid adenomas typically retain activity on late scans after wash-out in the thyroid has occurred. - Source:Case courtesy of Dr Roberto Schubert, Radiopaedia.org, rID: 16675

Single photon emission computed tomography (SPECT)

Positron Emission Tomography (PET)

Invasive modalities

Selective arteriography

Angiography

Dual Energy X-ray Absorptiometry (DXA)

  • Low bone mineral density (BMD) is caused by primary hyperparathyroidism. Distal forearm is affected most commonly.
  • DXA of distal forearm should be done in all patients of primary hyperparathyroidism. Very low T-score of distal forearm is observed in patients with primary hyperparathyroidism.[36]

References

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