Preoperative localization of hyperfunctioning parathyroid glands with 4D-CT

Abstract

Primary hyperparathyroidism (pHPT) is almost exclusively the result of a solitary parathyroid adenoma. In most cases, the affected gland can be surgically removed, but precise preoperative imaging is essential for adenoma localization prior to surgical intervention. In this study, we evaluated the diagnostic value of four-dimensional computed tomography (4D-CT) as a preoperative imaging tool in relation to the localization of pathologic parathyroid glands in patients with pHPT and negative sestamibi scans. This study included 43 consecutive patients with pHPT referred for parathyroidectomy at the Department of Head and Neck Surgery of Copenhagen University Hospital Rigshospitalet in 2011 and 2012. All patients had a 4D-CT performed prior to parathyroidectomy. CT localization of the suspected adenoma was correlated to the actual surgical findings and subsequent histological diagnosis was also available as references for the accuracy of this imaging tool. Hyperfunctioning parathyroid glands were found in 40 patients. 4D-CT identified 32 solitary hyperfunctioning parathyroid glands located on the correct side of the neck (PPV 76 %) and 21 located within the correct quadrant (PPV 49 %). Unilateral resection was performed in 72 % of patients due to the localization findings of preoperative imaging. 4D-CT can, therefore, be considered an effective method for the preoperative localization of parathyroid adenomas and is an important tool in surgical intervention for patients referred to parathyroidectomy.

Better performance of four‐dimension computed tomography as a localization procedure in normocalcemic primary hyperparathyroidism

“…It is known that a second cervical operation is comparatively more difficult, increasing the risk of recurrent laryngeal nerve damage from 1% to 15%. 21 The available evidence suggest that 4D CT is a superior method of preoperative localization in relation to the traditionally used methods (ultrasonography and scintigraphy) with most studies being performed in hypercalcemic PHPT, 16,17,[22][23][24][25][26][27][28] and this is in agreement with our findings. It is noteworthy that few studies directly compared the three preoperative localization techniques (USG, scintigraphy and 4D CT).…”

Surgical options in treating patients with primary hyperparathyroidism

“…Different PET tracers can be used ( 18 F-fluorodeoxyglucose, 18 F-fluorocholine (FCH) etc.). 19,21 Many studies are comparing FCH PET/CT with conventional imaging modalities. Behera and Damle reported the incremental role of PET/CT over sestamibi scan in 2016 because of better spacial resolution, possible detection of smaller adenomas and reduced scanning time.…”

“…5,6 Accurate preoperative localization (with neck ultrasound, sestamibi scan and/or FCH PET-CT) is critical to the success of this type of surgery. [17][18][19][20] Directed parathyroidectomy is a procedure recommended for patients with solitary adenoma. 7 Worldwide, this type of surgery accounts for 70% of all minimally invasive procedures.…”

“…35 As with all minimally invasive procedures, good preoperative imaging plays an important role. [17][18][19][20] Good interaction between the entire surgical team and nuclear medicine experts is a prerequisite for this type of surgical intervention. The patient is given an intravenous dose of 99m Tc-sestamibi approximately 2 to 4 hours before the surgery.…”

“…53 As for every other minimal invasive surgical approach, preoperative imaging studies that assist in the localization of lesions have been key elements in patients' selection for targeted robotic-assisted parathyroid surgeries. [17][18][19][20]54 Before robotic-assisted parathyroidectomy is preformed, parathyroid adenoma should be properly localized. 54 Tolley et al preformed first robotic-assisted surgery (RAS) for parathyroidectomy in which they made an incision in infraclavicular region on the side of the lesion.…”