© Borgis - Nowa Medycyna 2/2014, s. 77-80
*Marcin Gierach1,2, Agnieszka Skowrońska2, Cyprian Świętaszczyk3, Stanisław Pilecki3, Roman Junik1
Metody obrazowania pierwotnej nadczynności przytarczyc
Methods of imaging of primary hyperparathyroidism
1Department of Endocrinology and Diabetology with Laboratory of Nuclear Medicine, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz
Head of Department: prof. Roman Junik, MD, PhD
2Internal Ward, Hospital in Wąbrzeźno
Head of Internal Ward: Marcin Gierach, MD
3Regional Specialist Hospital in Grudziądz
Head of Nuclear Medicine Institute: Stanisław Pilecki, MD
Streszczenie
Pierwotna nadczynność przytarczyc to stan wzmożonego wydzielania parathormonu, którego przyczyną jest pierwotny defekt komórek przytarczyc, wyrażający się nadprodukcją PTH, nieadekwatną do potrzeb ustrojowych i niewrażliwą lub mało wrażliwą na supresyjne działanie hiperkalcemii. P-HTP jest trzecią co do częstości występowania chorobą endokrynologiczną (zaraz po cukrzycy i chorobach tarczycy) występującą z częstością 4-6/100 0000 rocznie, najczęściej u kobiet w okresie pomenopauzalnym.
Najczęstszą przyczyną P-HTP jest pojedyńczy gruczolak (75-85%), rzadziej występują mnogie gruczolaki (dwie zmiany: 2-12%; trzy: 1-2%; cztery i więcej: <1%) oraz rak przytarczyc <1%.
Introduction
Primary hyperparathyroidism (P-HTP) is characterized by an increased parathyroid hormone (PTH) secretion caused by a primary defect of parathyroid cells, PTH overproduction, which exceeds the needs of the organism and remains resistant to or poorly controlled by the suppressive effect of hypercalcaemia. P-HTP is the third most prevalent endocrine disorder (after diabetes and thyroid disorders), occurring in 4-6/100,000 people per year, most frequently in women in their post-menopausal stage.
The most common cause of P-HTP is a single gland adenoma (75-85%), less frequent are multigland adenomas (two lesions: 2-12%; three: 1-2%; four and more: <1%) and parathyroid cancer <1%. Few cases of primary hyperthyroidism may be due to the paraneoplastic production of parathyroid hormone by tumours not related with parathyroids (1).
Imaging techniques
In patients with clinical and biochemical signs indicative of hyperparathyroidism, medical imaging techniques should be used to enable the final diagnosis. The first essential examination employing such a technique is ultrasonography (US) of the thyroid. It should be conducted using a high-frequency linear probe; a 12-15 MHz probe may be used if other frequency ranges are unavailable. During the examination, the patient’s arms should be supported by a pillow. The assessment should cover the area between the carotid artery and the median line, and between the hyoid bone and the manubrium sterni. Lower parathyroids may be examined during the swallowing reflex. Usually the glands are not visible in routine examinations, since they are isoechoic to the thyroid tissue. During the US assessment, the tumour is described as homoechoic or hypoechoic, limited by tissue. It is oval- to bean-shaped. The sensitivity of tumour detection depends on the size of parathyroids; a normal gland has a size of 5 x 3 x 1 mm. The diameter of altered glands usually exceeds 5 mm. Among the correctly assessed glands weighing above 4,000 mg, 95% are detected as altered, while among those weighing below 1,500 mg, only 40% are detected as altered (2). Gland hyperplasia is rarely visualized and diagnosed, as the tumour size is smaller than in adenomas. The reactivity of inflamed lymph nodes may be confused with that of enlarged parathyroids and lead to the misidentification of the former as parathyroid adenomas or hyperplasias (1). US examinations are immediately available and relatively cheap. The sensitivity of this method reported in the literature can be as high as 91%. The parameter is highly dependent on the experience and the skills of the ultrasonographer. However, due to the ease, availability and noninvasiveness of the US technique, it may be a useful tool for the location of lesions in preoperative diagnostics (2). Additionally, the use of Color Doppler Ultrasonography (CDU) or Power Doppler Ultrasonography (PDU) has been reported in the assessment of blood flow through parathyroids. This permits the differentiation between adenomas and pathologies of the surrounding tissues (3). By using these techniques, pathology may be identified in the case of a lack of vascular blood flow in either central or peripheral parts of parathyroids, but also in the case of a uniformly increased vascular flow called the “spot of fire”. Blood vessels occurring in pathological lesions usually originate from the inferior thyroid artery. The sensitivity of the method is estimated at 97% (4).
Ultrasonography permits a precise assessment of the anatomical localization of parathyroid lesions, however, the assessment of ectopic glands or those located deeper using this technique is impossible. To properly assess those regions, a transoesophageal US examination may be conducted. Still, techniques such as computed tomography, magnetic resonance imaging or scintigraphy are more useful (5).
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Piśmiennictwo
1. Shaheen F, Chowdry N, Gojwari T et al.: Role of cervical ultrasonography in primary hyperparathyroidism. Indian J Radiol Imaging 2008; 18(4): 302-305. 2. Mohammadi A, Moloudi F, Ghasemi-rad M: The role of colour Doppler ultrasonography in the preoperative localization of parathyroid adenomas. Endocrine Journal 2012; 59(5): 375-382. 3. Bhasali A, Masoodi SR, Bhadada S et al.: Ultrasonography in detection of single and multiple abnormal parathyroid glands in PHPT: Comparison with radionuclide scintigraphy and surgery. Clin Endocrinol (Oxf) 2006; 65: 340-345. 4. Gough I: Reoperative parathyroid surgery: the importance of ectopic location and multigland disease. ANZ J Surg 2006; 76: 1048-1050. 5. Hunter GJ, Schellingerhout D, Vu TH, Hamberg LM et al.: Accuracy of four-dimensional CY for the localization of abnormal parathyroid glands in patients with primary hyperparathyroidism. Radiology 2012; 264(3): 789-795. 6. Kawata R, Kotetsu L, Takamaki A et al.: Ultrasonography for preoperative localization of enlarged parathyroid glands in secondary hyperparathyroidism. Auris Nasus Larynx 2009; 36: 461-465. 7. Piciucchi S, Barone D, Gavelli G et al.: Primary hyperparathyroidism: Imaging to Pathology. J Clin Imaging Sci 2012; 2: 59. 8. Wakamatsu H, Noguchi S, Yamashita H et al.: Technetium-99m tetrofosmin for parathyroid scintigraphy: a direct comparison with 99mTc-MIBI, 201TI, MRI and US. Eur J Nucl Med 2001; 28: 1817-1827. 9. Froberg AC, Valkema R, Bonjer HJ, Krenning EP: 99mTc-tetrofosmin or 99mTc-sestamibi for double phase parathyroid scintigraphy? Eur J Nucl Med Mol Imaging 2003; 30: 193-196. 10. Greenspan BS, Dillehay G, Intenzo CH: SNM Practice Guideline for Parathyroid Scintigraphy 4.0. Journal of Nuclear Medicine Technology 2012; 40(2): 1-8. 11. Gawrychowski J, Buła G: Imaging diagnostics for primary hyperparathyroidism. Endokrynologia Polska 2013; 64, 5: 404-408.
12. Kronenberg HM, Melmed S, Polonsky KS. Williams Textbook of Endocrinology. 10th ed. Philadelphia, Pa: Saunders 2003; 1303-1372. 13. Ferlin G, Borsato N, Camerani M et al.: New perspectives in localizing enlarged parathyroids by technetium-thallium subtraction scan. J Nucl Med 1983; 24: 438-441. 14. Coakley AJ, Kettle AG, Wells CP et al.: 99Tcm sestamibi- a new agent for parathyroid imaging. Nucl Med Commun 1989; 10: 791-794. 15. Ishbashi M, Nishida H, Kumabe T et al.: Tc-99m tetrofosmin. A new diagnostic tracer for parathyroid imaging. Cil Nucl Med 1996; 37: 551-556. 16. Wakamatsu H, Noguchi S, Yamashita H et al.: Technetium-99m tetrofosmin for parathyroid scintigraphy: A direct comparison with (99m)Tc-MIBI,(201)Tl, MRI and US. Eur J Nucl Med 2001; 28: 1817-1827.
