PARATHYROID

IMAGING:
PREOPERATIVE
LOCALISATION

INDRATI SUROYO
HEAD AND NECK DIVISION RADIOLOGY DEPARTMENT
CIPTOMANGUNKUSUMO/ FKUI

NOVEMBER 7, 2020
 Parathyroid
Imaging

• Localizing abnormal gland  primary function

• Accurate pre op identification
• Directed parathyroid surgery Effective vs
traditional neck exploration
• Reduced surgical time, hospital time, improve
cosmetic result
• No risk of permanent hypoparathyroidism
 Parathyroid
Imaging

Pathology :
• Adenoma  88% single, 4% double adenoma
• Multiple gland hyperplasia 6%
• Rare : Parathyroid Carcinoma <1%, Familial
hypocalcinic hypercalcemia

Information to surgeon :
- Number of lesion
- Site of lesion
- Size of lesion
 Parathyroid Imaging

Neck USG  anatomical study (precise for eutopic)

Tc99m Sestamibi Scintigraphy/ SPECT  functional study

4D CT  eutopic & ectopic excellent anatomy

Note : Biochemical testing should be conducted

Parathyroid
Imaging
 PARATHYROID
ANATOMY
• Usually located between
posterior border of thyroid
gland
• 5 x 3 x 1 mm in diameter
• 30-40 mg of weight
• Normal : 4 glands
• 5% fewer
• 3-13% supernumery glands
PARATHYROID
ANATOMY
 • Thyrothymic ligament
• Tracheoesophageal groove
• Retroesophageal space
• Retropharyngeal/ high cervical
• Carotid sheath
• Intrathyroid
• Anterior/ posterior superior
mediastinum
• Intrathymic
• Aortopulmonary window

ECTOPIC GLANDS
LOCATIONS
Parathyroid
Location
 USG

• Safe, available, lack of

ionizing radiation, short
duration study, potential
cost saving
• Limitation : operator
variability and experience
• Normal non enlarge gland
cannot be visualized
• Enlarge gland can be
visualized > 1cm in
diameter
 • Hypoechogenicity oval/ bean shape
(multilobulated in larger case)
• Color Doppler  arc of rim vascularity
USG OF (tend to be in the periphery before
penetrating deeper), polar, peripheral
PARATHYROID distribution
GLAND • Sensitivity : single adenoma 72-89%,
double adenoma 44%, hyperplasia 30%
USG OF PARATHYROID Pitfalls :
GLAND • Hyperplasia is more
difficult  size <
adenoma
• Cervical LN  benign
LN : echogenic fatty
hilum, Doppler supply
by small hilar
• Concomitant thyroid
disease: enlarge
multinodular thyroid
distorted anatomy 
mimic parathyroid
• Intrathyroid gland 
impossible to
distinguish
 USG OF
PARATHYROID
GLAND
 ADENOMA :
• Mostly single
• Hypoechoic to thyroid gland, extra
thyroid well defined margin
• Doppler : hypervascular, polar arterial,
vascular arc  typical finding
USG • Mostly located posterior/ inferior to
thyroid lobe
• 3% ectopic
• Few cases atypical parathyroid finding :
heterogen, calcification or cystic
component
USG
 Polar type vascularization
USG
 Mild heterogenous isoechoic with cystic component,
USG Polar type color Doppler
 • Double adenoma hypoechoic and iso with hypoechoic rim
USG extrathyroid capsule. CDFI polar type/ arc of rim
vascularization
USG Atypical finding adenoma
USG
 • Precisely located : 90% solitary adenoma, 73 % double
adenoma, 45% hyperplastic glands
• Most common radiotracer : Sestamibi with Tc99m
• Dual Phase technique :
Scintigraphy - Initial image  shortly after administration :
uptake both thyroid and parathyroid.
Asymmetric uptake abnormal tissue
- Delayed image 2 hours  retain radiotracer
characteristic of hyperfunction
 • Retain radio tracer up take on right inferoposterior thyroid
SCINTIGRAPHY lobe
SCINTIGRAPHY • Retain up take in left thyroid  adenoma parathyroid
SCINTIGRAPHY
SCINTIGRAPHY • Ectopic mediastinal parathyroid
 • 4D
– First 3D : axial, coronal, sagittal  anatomical information
– Last D : multiphase contrast (C)  perfusion information
(No C, arterial phase, delayed phase)
• 4D  plain, early arterial, late arterial, delayed
4D CT •
phase
Excellent anatomy (eutopic and ectopic)
• DD/ from LN and thyroid nodule
• Improve localization : minimally invasive surgery
• Non visualized on normal condition
 • Scan view : angle of mandible – mediastinum
(carina)
• Characteristic finding : peak enhancement
arterial phase, washed out from arterial to
4D CT delayed, low attenuation on non C
• Indication :
- Second investigation/ alternative fail to
investigate
- Patient undergoing repeat surgery
 4D CT information :
• Number, size and specific location
• Surgical landmark : thyroid gland (contact/ no),
carotid artery, inferior thyroid artery

4D CT • Presence and absence : ectopic/

supernumerary
• Concurrent thyroid pathologic condition

Note : false +/- for thyroid node and LN (level VI)  C

characteristic
4D CT
4D CT
4D CT
4D CT
4D CT
4D CT
4D CT
 Summary :

• Imaging is not for diagnosis

Parathyroi •
•
Imaging does not identify normal gland
Imaging should detect abnormal gland
d Imaging • Imaging should identify ectopic gland
• Imaging should be able to identify
thyroid nodules that may require
concurrent surgical resection
THANK YOU