Diagnostic Imaging Pathways - Hyperparathyroidism (Primary Suspected)
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This pathway provides guidance on the imaging of adult patients with suspected hyperparathyroidism.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: January 2012
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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
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| 1 |  |
Parathyroid Adenoma Image 1 (Ultrasound): A well circumscribed hypoechoic mass measuring up to 8mm is located deep to the inferior left thyroid pole. The appearances are consistent with a parathyroid adenoma. |
| 2a |  |
Parathyroid Adenoma Image 2a, 2b (Pertechnetate and Sestamibi Study), and 2c (SPECT): Initial pertechnetate images show uniform tracer distribution throughout both thyroid lobes apart from a small focal area of increased tracer uptake at the inferior pole of the left lobe of the thyroid gland. MIBI early and delayed images show increased uptake in the left and right lower poles of the thyroid. On subtraction images, there is an area of increased tracer activity near the inferior pole of the left lobe of the thyroid gland which represents abnormal parathyroid tissue (arrow). SPECT is used to help anatomically define the abnormal area. |
| 2b |  |
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| 2c |  |
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| 3 |  |
Parathyroid Adenoma Image 3 (H&E, x2.5): Histological section of a parathyroid adenoma showing sheets of monotonous oncocytic cells (blue arrows) and chief cells (green arrows) with no adipose tissue. |
Teaching Points
Teaching Points
- Imaging for preoperative localisation of the parathyroid glands remains controversial although it is generally recommended for minimally invasive or unilateral neck surgery
- Ultrasound and Sestamibi scans are sensitive methods used as first line investigations, frequently in combination
- CT and MRI have the advantage of superior anatomical localisation but are usually reserved for equivocal or negative ultrasound and nuclear medicine studies
- Preoperative imaging is required for recurrent or persistent hyperparathyroidism to minimise the risks of repeat surgery and to maximise the chances of successful treatment
ct
Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) of the Mediastinum
- CT and MRI of the neck and mediastinum are generally considered second line investigations in the assessment of primary hyperparathyroidism, following on from equivocal or negative ultrasound or nuclear medicine studies 24
- Their main advantage is superior spatial resolution and the detailed anatomical localisation of ectopic mediastinal lesions for surgical planning 24
- The sensitivity of CT for preoperative localisation of abnormal parathyroid tissue ranges from 78% to 86% 25,26, 27
- MRI demonstrates similar sensitivity ranging from 71% to 92% 28,29,30
- These modalities are particularly useful for persistent or recurrent hyperparathyroidism when more detailed surgical planning is required to minimise the risks associated with repeat surgery and to improve the chances of successful treatment 31
- The disadvantages of these studies include
- Exposure to ionising radiation with CT
- The use of intravenous contrast
hyp_para
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 preoperative 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 preoperative imaging are
- 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
nm_scan
Sestamibi Nuclear Medicine Scan and Subtraction Pertechnetate Scan
- Used for preoperative localisation of abnormal parathyroid glands in the following cases
- Includes the neck and the mediastinum for detection of ectopic abnormal parathyroid glands 9
- High sensitivity (50-75%) and specificity (>90%) for the detection of abnormal parathyroid glands 16,17,18,19
- Correlating the functional imaging provided by sestamibi scan with a technique with superior anatomical resolution such as SPECT, SPECT-CT, US, CT or MRI improves the sensitivity for detection of abnormal parathyroid tissue 12,13,16,17,22,23
- Sestamibi accumulates in both parathyroid tissue and thyroid nodules and anatomical localisation of the abnormality is based on washout properties 21
- 99mTc-pertechnetate is a thyroid selective radioisotope that can be used in combination with sestamibi. It is especially useful in patients with suspected or known thyroid disease or previous thyroid surgery. Digital subtraction methods can be used as an aid in identifying sestamibi accumulation due to abnormal parathyroid tissue 21,22,23
- Limitations
recurrent
Persistent or Recurrent Hyperparathyroidism
- The incidence of persistent or recurrent disease following surgery for hyperparathyroidism is 5-10% 31
- In such cases, the diagnosis of primary hyperparathyroidism should be re-confirmed and the indications for surgery should be reviewed 31
- Preoperative localisation is required in patients being considered for repeat surgery to more precisely define the site of abnormal parathyroid tissue and to minimsie the risks associated with repeat surgery due to fibrosis
- Preoperative localisation improves the success rate from 60 to more than 95% 32
- It is still debated which combination of imaging modalities represents the optimum assessment. However, most agree that at least two modalities should be performed, one of which should be a sestamibi scan 31
sampling
Selective Venous Sampling
- Selective venous sampling is an invasive procedure which is generally only considered in the preoperative localisation of abormal parathyroid tissue for recurrent or persistent hyperparathyroidism when non-invasive imaging methods have failed 33
- It involves selective cannulation of cervical and mediastinal veins to sample venous PTH levels. Local elevations of serum PTH compared to peripheral levels allow target areas to be defined for surgery (at least a two-fold gradient is required). Therefore, the effectiveness of this procedure depends upon production of PTH by the parathyroid glands and not on their size 33
- In the setting of recurrent or persistent hyperparathyroidism, the sensitivity for the localisation of abnormal parathyroid tissue ranges from 80 to 94% and the specificity from 85 to 100% 33,34
- The disadvantages of selective venous sampling include its
- Invasiveness with risks of haemorrhage and infection
- Exposure to ionising radiation and intravenous contrast
us
Ultrasound
- Used for identification and localisation of parathyroid adenomas in patients with primary hyperparathyroidism who undergo minimally invasive surgery 7,8,13
- Its sensitivity for detecting parathyroid neoplasms ranges between 36% to 78%. 8,13,16,17 In view of this, many authors now propose the use of ultrasound in combination with another imaging modality, most commonly scintigraphy 24
- Advantages 20
- Superior anatomical resolution (provides more detailed information of adenoma characteristics and relationships to other structures in the neck)
- Useful in evaluation of thyroid abnormalities
- Relatively inexpensive
- Does not emit ionising radiation
- Limitations 20,24
- Inability to localise the small percentage (2%) of parathyroid adenomas, particularly intrathyroidal, deeply located and ectopic mediastinal lesions
- Low sensitivity in recurrent or persistent primary hyperparathyroidism
- Operator depedent and subjective
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Loevner LA. Imaging of the parathyroid glands. Semin Ultrasound CT MR. 1996;17:563-75. (Review article)
- Howe JR. Minimally invasive parathyroid surgery. Surg Clin North Am. 2000;80:1399-426. (Review article)
- Numerow LM, Morita ET, Clark OH, et al. Persistent/recurrent hyperparathyroidism: a comparison of sestamibi scintigraphy, MRI, and ultrasonography. J Magn Reson Imaging. 1995;5:702-8. (Level III evidence)
- Mitchell BK, Merrell RC, Kinder BK. Localization studies in patients with hyperparathyroidism. Surg Clin North Am. 1995;75:483-98. (Review article)
- Wei JP, Burke GJ. Analysis of savings in operative time for primary hyperparathyroidism using localization with technetium 99m sestamibi scan. Am J Surg. 1995;170:488-91. (Level III evidence)
- Hindie E, Melliere D, Perlemuter L, et al. Primary hyperparathyroidism: higher success rate of first surgery after preoperative Tc-99m sestamibi-I-123 subtraction scanning. Radiology. 1997;204:221-8. (Level II evidence). View the reference
- Smit PC, Rinkes IHMB, van Dalen A, et al. Direct, minimally invasive adenomectomy for primary hyperparathyroidism: an alternative to conventional neck exploration? Ann Surg. 2000;231(4):559-65. (Level II evidence). View the reference
- Van Dalen A, Smit CP, van Vroonhoven TJM, et al. Minimally invasive surgery for solitary parathyroid adenomas in patients with primary hyperparathyroidism: role of US with supplemental CT. Radiology. 2001;220:631-9. (Level II evidence). View the reference
- Ishibashi M, Nishida H, Hiromatsu Y, et al. Localization of ectopic parathyroid glands using technetium-99m sestamibi imaging: comparison with magnetic resonance and computed tomographic imaging. Eur J Nucl Med.1997;24:197-201. (Level III evidence)
- Miller DL. Endocrine angiography and venous sampling. Radiol Clin North Am. 1993;31:1051-67. (Review article)
- Gritzmann N, Koischwitz D, Rettenbacher T. Sonography of the thyroid and parathyroid glands. Radiol Clin North Am. 2000;38(5):1131-45. (Review article)
- Gotway MB, Reddy GP, Webb WR, et al. Comparison between MR imaging and 99m-Tc MIBI scintigraphy in the evaluation of recurrent or persistent hyperparathyroidism. Radiology. 2001;218:783-90. (Level II evidence). View the reference
- Purcell GP, Dirbas FM, Jeffrey RB, et al. Parathyroid localization with high-resolution ultrasound and technetium Tc 99m sestamibi. Arch Surg. 1999;134:824-30. (Level II evidence). View the reference
- Borley NR, Collins RE, O'Doherty M, et al. Technetium-99m sestamibi parathyroid localization is accurate enough for scan-directed unilateral neck exploration. Br J Surg. 1996;83:989-91. (Level II/III evidence)
- Lee VS, Wilkinson RH Jr, Leight GS, et al. Hyperparathyroidism in high-risk surgical patients: evaluation with double-phase technetium 99m sestamibi imaging. Radiology. 1995;197:627-33. (Level III evidence)
- Krubsack AJ, Wilson SD, Lawson TL, et al. Prospective comparison of radionuclide, computed tomographic, sonographic, and magnetic resonance localization of parathyroid tumours. Surgery. 1989;106:639-46. (Level II evidence). View the reference
- De Feo ML, Colagrande S, Biagini C, et al. Parathyroid glands: combination of 99mTc MIBI scintigraphy and US for demonstration of parathyroid glands and nodules. Radiology. 2000;214:393-402. (Level II/III evidence)
- Ishibashi M, Nishida H, Hiromatsu Y, et al. Comparison of technetium-99m MIBI, technetium-99m-tetrofosmin, ultrasound and MRI for localization of abnormal parathyroid glands. J Nucl Med. 1998;39:320-4. (Level III evidence)
- Shaha AR, Sarkar S, Strashun A, et al. Sestamibi scan for preoperative localization in primary hyperparathyroidism. Head & Neck. 1997;19:87-91. (Level III evidence)
- Reeder SB, Desser TS, Weigel RJ, et al. Sonography in primary hyperparathyroidism: review with emphasis in scanning technique. J Ultrasound Med. 2002;21:539-52. (Review article)
- Smith JR, Oates ME. Radionuclide imaging of the parathyroid glands: patterns, pearls, and pitfalls. Radiographics. 2004;24:1101-15. (Review article)
- Lorberboym M, Minski I, Macadziob S, Nicolov G, Schachter P. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma. J Nucl Med. 2003;44:904-8. (Level II evidence). View the reference
- Neumann DR, Esselstyn CB Jr, Go RT, Wong CO, Rice TW, Obuchowski NA. Comparison of double-phase 99mTc-sestamibi with 123I-99mTc-sestamibi subtraction SPECT in hyperparathyroidism. AJR Am J Roentgenol. 1997;169:1671-4. (Level II evidence). View the reference
- Hindie E, Ugur O, Fuster D et al. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging. 2009;36(7);1201-16. (Clinical guidelines). View the guidelines
- Harari A, Zarnegar R, Lee J et al. Computed tomography can guide focused exploration in select patients with primary hyperparathyroidism and negative sestamibi scanning. Surgery. 2008;144(6);970-6;discussion 976-9. (Level III evidence). View the reference
- Mazzeo S, Cappelli C, Caramella D et al. Multidetector CT in diagnostic work-up of patients with primary hyperparathyroidism. La Radiologia Medica. 2007;112(5);763-75. (Level III evidence). View the reference
- Gross ND, Weissman JL, Veenker E et al. The diagnostic utility of computed tomography for preoperative localization in surgery for hyperparathyroidism. The Laryngoscope. 2004;114(2);227-31. (Level III evidence). View the reference
- Ruf J, Lopez Hanninen E, Steinmuller T et al. Preoperative localization of parathyroid glands. Use of MRI, scintigraphy, and image fusion. Nuklearmedizin. 2004;43(3);85-90. (Level III evidence). View the reference
- Lopez Hanninen E, Vogl TJ, Steinmuller T et al. Preoperative contrast-enhanced MRI of the parathyroid glands in hyperparathyroidism. Invest Radiol. 2000;35(7);426-30. (Level II evidence). View the reference
- Tziakouri C, Eracleous E, Skannavis S et al. Value of ultrasonography, CT and MR imaging in the diagnosis of primary hyperparathyroidism. Acta Radiol. 1996;37(5);720-6. (Level II evidence). View the reference
- Silverberg SJ and Fuleihan GE. Preoperative localization and surgical therapy of primary hyperparathyroidism. In: UpToDate, Basow, DS(Ed), UpToDate, Waltham, MA, 2009. (Review article)
- Shen W, Duren M, Morita E et al. Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg. 1996;131(8):861-7; discussion 867-9. (Level III evidence). View the reference
- Chaffanjon PC, Voirin D, Vasdev A et al. Selective venous sampling in recurrent and persistent hyperparathyroidism: indication, technique, and results. World J Surg. 2004;28(10):958-61. (Level III evidence). View the reference
- Reidel MA, Schilling T, Graf S et al. Localization of hyperfunctioning parathyroid glands by selective venous sampling in reoperation for primary or secondary hyperparathyroidism. Surgery. 2006;140(6):907-13; discussion 913. (Level II evidence). View the reference
Further Reading
- Gotway MB, Leung JWT, Gooding GA, et al. Hyperfunctioning parathyroid tissue: spectrum of appearances on non-invasive imaging. AJR Am J Roentgenol. 2002;179:495-502. (Review article)
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