Diagnostic Imaging Pathways - Suspected Primary Hyperparathyroidism

Primary Hyperparathyroidism

• Primary hyperparathyroidism is an endocrine disorder resulting from the autonomous functioning of one or more parathyroid glands. 1
• The causes of primary hyperparathyroidism include a single parathyroid adenoma (80-85%), parathyroid hyperplasia (10-15%), multiple adenomas (2-3%), and very rarely, parathyroid adenocarcinoma (<1%). 1
• The role of imaging for preoperative localisation of the parathyroid glands remains controversial. 1
• Traditionally, bilateral neck exploration with direct visualisation and evaluation of all four parathyroid glands has been the primary surgical method for treating primary hyperparathyroidism, with success rates >95% in experienced hands. Therefore, pre-operative localisation studies were not usually necessary. 2
• Increasingly, surgeons prefer pre-operative imaging, especially when considering minimally invasive surgery. 1,2
• Imaging is usually required when there is recurrent disease as the success rates for repeat bilateral neck exploration after an initial failed surgery may be as low as 60%. In such cases of recurrent or persistent hyperparathyroidism, localisation studies have improved the ability to identify the site of the remaining abnormal parathyroid tissue. 3,4
• The main advantages of pre-operative imaging are:
  1. The potential to reduce the time in surgery. 5,6
  2. The ability to limit surgical exploration to the affected side. 7,8
  3. The detection of ectopic abnormal parathyroid glands. 9
• Technetium Tc-99m sestamibi imaging and sonography have been the most widely used imaging techniques for the localisation of parathyroid adenomas. 1
• Invasive procedures such as selective venous sampling and selective angiography are expensive and technically difficult and therefore rarely used. 10
• Image-guided biopsy is performed in cases where percutaneous ethanol ablation as a first line therapy is considered or when the results of imaging procedures are equivocal. 11
• Note: It is important to consider and exclude Familial Hypocalciuric Hypercalcaemia (FHH) in mild cases of primary hyperparathyroidism. FHH does not require surgery and is a major cause of "failed" neck exploration in primary hyperparathyroidism.

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