1991, The British Journal of Radiology, 64, 679-682
Ultrasonic detection of parathyroid adenomas By J. Murchison, MRCP, C. Mclntosh, FRCS, A. G. F. Aitken, FRCR, J. Logie, FRCS and A. Munro, FRCS Departments of Radiology and Surgery, Raigmore Hospital, Inverness {Received July 1990 and in final form March 1991)
Keywords: Parathyroid adenomas, Hyperparathyroidism, Ultrasound
Abstract. High-resolution real time sonography was used to evaluate patients with suspected primary hyperparathyroidism. A total of 12 consecutive patients was scanned pre-operatively. The sensitivity of the procedure was 92% and the specificity 97%. In our hospital sonography is the procedure of choice for localizing enlarged parathyroid glands prior to surgical exploration.
With the increased use and availability of multichannel autoanalysers for biochemical determination, hypercalcaemia and primary hyperparathyroidism are now recognized to be much more common than previously appreciated (Heath et al, 1980). The treatment of choice in symptomatic patients, whose laboratory and clinical studies support the diagnosis of primary hyperparathyroidism, is exploration of the neck by an experienced parathyroid surgeon (Hodgson & Heath, 1981; Scholz & Purnell, 1981). Surgical exploration is also indicated in asymptomatic individuals to cure hypercalcaemia and to avoid metabolic complications such as bone demineralization, urolithiasis and nephrocalcinosis (Gaz & Wang, 1984). A wide variety of imaging techniques have been advocated for localization. These have included oesophageal cine radiography (Stevens & Jackson, 1967), computed tomography (Adams et al, 1981; Whitley et al, 1981; Stark et al, 1983; Krubsack et al, 1986), radio-isotope imaging (Gooding et al, 1986), high resolution real time ultrasound (Sample et al, 1978; Moreau et al, 1980; Barraclough et al, 1981; Jarhult et al, 1985), thermography (Samuels et al, 1972) and arteriography and selective venous sampling (Eisenberg et al, 1974; Hjern et al, 1975). Ultrasonography is considered by many to be the imaging investigation of choice (Crocker, 1986; Davidson et al, 1988) and has been reported to be a specific and sensitive test (Simeone etal, 1981; Heerden et al, 1982; Stark et al, 1985; Buchwach et al, 1987). We describe our recent experience with high resolution real time sonography in patients with primary hyperparathyroidism.
(Advanced Technology Labs, Bellevue, WA) with a high resolution 7.5 MHz transducer. Scans were obtained with the patient in the supine position and the neck slightly extended. Multiple planes were scanned covering the thyroid gland and adjacent internal jugular and carotid vessels to the level of the clavicles. Views inferior and posterior to the clavicle were obtained as far as possible by angling the transducer. The average examination time was 10 min. The examination was considered positive if an oval or elongated discrete mass was found located along the posterior surface of the thyroid gland or related to the adjacent carotid artery. (Figs 1, 2, 3). At operation, the side indicated by the scan was explored first. The tumour was sent for frozen section examination while the remaining glands were inspected. Results
A total of 13 parathyroid adenomas (PTAs) were identified in 12 patients with primary hyperparathyroidism. Adenomas seen ranged in size from 6 to 40 mm and included one bilateral PTA, one predominantly cystic PTA (Fig. 4), one intrathyroid PTA (Fig. 5)
Materials and methods
During a 14 month period 12 patients with biochemical evidence of primary hyperparathyroidism and with raised serum parathyroid hormone levels were scanned before surgical exploration. The ultrasound examinations were performed using a real time ultrasound unit Address for correspondence: A. G. F. Aitken, Department of Radiology, Raigmore Hospital, Inverness. Vol. 64, No. 764
Figure 1. Transverse section of left neck demonstrates a 1 cm PTA (arrows) lying posterior to the thyroid (t) and common carotid artery (cc). Jugular vein (j).
679
/ . Murchison, C. Mclntosh, A. G. F. Aitken, J. Logie and A. Munro
Figure 2. Longitudinal section through the right thyroid lobe showing a 2.5 cm PTA (arrows) lying posterior to the thyroid (t). Strap muscles (sm).
Figure 5. Longitudinal section showing a PTA (crosses) lying within the thyroid capsule. Thyroid (t).
false negative examination result in one patient. At operation this patient was found to have a pedunculated thyroid adenoma at the lower pole of the right thyroid lobe which was interpreted as a PTA, and a PTA at the left lower thyroid pole which was interpreted as a thyroid adenoma. Thirty-one normal parathyroid glands were identified at operation. The sensitivity of ultrasound investigation was 92%, specificity 97% and accuracy 95%. Duration of operation ranged from 55 to 150 min (mean 79 min). All patients were rendered normocalcaemic by surgery and remained normocalcaemic for at least 3 months post-operatively. Figure 3. Transverse section of right neck just inferior to the lower pole of the thyroid. A 0.6 cm hypoechoic mass (crosses) consistent with a PTA lies adjacent to the common carotid artery (cc). Jugular vein (j); sterno-cleidomastoid muscle (s).
Figure 4. Longitudinal section through the right thyroid lobe (t) shows a cystic PTA (crosses), containing internal echoes and showing some posterior acoustic enhancement.
and one PTA lying between the trachea and the oesophagus. Twelve of the 13 PTAs were correctly identified by ultrasound. There was one false positive and one 680
Discussion The results of our study compare favourably with those of other studies, which variously reported sensitivities of 63-85% (Butch et al, 1985; Jarhult et al, 1985; Gooding et al, 1986; Buchwach et al, 1987; Davidson et al, 1988; Krubsack et al, 1989; Lloyd et al, 1990) and show that these tumours can be located accurately using high resolution ultrasound. Difficulty was occasionally encountered in differentiating PTAs from thyroid adenomas protruding from the posterior surface of the thyroid, a problem which has been encountered by other authors (Sample et al, 1978; Reading et al, 1982; Jarhult et al, 1985). Identification of a PTA was facilitated if a plane of cleavage or an echogenic line could be seen between the mass and the thyroid. The choice of pre-operative imaging technique in primary hyperparathyroidism is ultimately dependent on the expertise and equipment available. Parathyroid ultrasound in particular is heavily dependent on the experience of the operator (Lloyd et al, 1990). Oesophageal cine radiography and thermography are of historical interest only. Selective venous sampling and selective arteriography are technically difficult, expensive, time consuming and potentially hazardous, but have a place in localizing PTAs in cases of failed neck exploration. Radio-itosope imaging using thalliumtechnetium computer subtraction scanning may identify 70-90% of parathyroid tumours (Fine, 1987; Carmalt The British Journal of Radiology, August 1991
Ultrasonic detection of parathyroid adenomas
et al, 1988). False negative results may be obtained with isotope scanning if the glands are small, and false positive results can arise in patients with thyroid nodules (Fine, 1987). The procedure is minimally invasive but does expose the patient to radiation (Duh et al, 1987). Initial attempts using computed tomography (CT) for parathyroid tumour localization were not particularly sensitive, detecting 50 to 60% of tumours (Adams et al, 1981; Whitley et al, 1981). A major problem is streak artefact caused by shoulder positioning but this can be overcome by employing a shoulder positioning device (Stark et al, 1983). More recent reports have shown that 70 to 80% of parathyroid tumours can be detected using CT (Krubsack et al, 1989). CT has the advantage of being able to locate ectopic glands in the mediastinum where ultrasonic visualization is poor (Duh et al, 1987). Several recent reports have advocated chemical ablation of PTAs under radiological guidance particularly for patients who are unfit for surgery, those who refuse surgery (Karstrup et al, 1987) and for those who have previously undergone unsuccessful surgery. Methods proposed include injection of ethanol under ultrasound control (Solbiati et al, 1985; Karstrup et al, 1990) and angiographic ablation by infusion of ionic contrast agents (Miller et al, 1987). The emergence of these techniques illustrates the importance of pre-therapy imaging and in particular the role of ultrasound as a method of localization. An experienced parathyroid surgeon can successfully cure 90-95% of patients with hyperparathyroidism without the pre-operative use of a localization procedure (Satava et al, 1975; Rossoff, 1985). Because of this some clinicians consider pre-operative localization unnecessary. However, using pre-operative localization a cure rate of 98.8% has been achieved (Lloyd et al, 1990) suggesting that even with an experienced parathyroid surgeon the results may be improved with preoperative imaging. Ultrasound has undoubtedly modified the pre-operative management and operative strategy in patients with primary hyperparathyroidism in our hospital. By first exploring the side of the lesion indicated by the scan we have achieved shorter operating times than those commonly reported (Brewer et al, 1983). Shorter operating times should enable the surgical team to make more efficient use of the operating room and by minimizing the extent of tissue dissection should reduce the risk of operative complications. In conclusion we consider ultrasound to be the imaging technique of choice for detecting PTAs because of its high accuracy, ease of application, lack of radiation and relatively low cost. Pre-operative localization of PTAs in our practice facilitates surgical exploration for primary hyperparathyroidism.
R. H., 1981. The localisation of parathyroid tissue by ultrasound scanning prior to surgery in patients with hyperparathyroidism. World Journal of Surgery, 5, 91-95. BREWER, W. H., WALSH, J. W. & NEWSOME, H. H., 1983.
Impact of sonography on surgery for primary hyperparathyroidism. American Journal of Surgery, 145, 270-272. BUCHWACH, K. A., MANGUM, W. B. & HAHN, F. W., 1987.
Pre-operative localisation Laryngoscope, 97, 13-15.
of
parathyroid
adenomas.
BUTCH, R. J., SIMEONE, J. F. & MUELLER, P. R., 1985. Thyroid
and parathyroid ultrasonography. Radiological Clinics of North America, 23, 57-71. CARMALT, H. L., GILLETT, D. J., CHU, J., EVANS, R. A. & Kos,
S., 1988. Prospective comparison of radionuclide, ultrasound and computed tomography in the preoperative localisation of parathyroid glands. World Journal of Surgery, 12, 830-834. CROCKER, E. F., 1986. The pursuit of the parathyroid. Medical Journal of Australia, 144, 506-507. DAVIDSON, J., NOYEK, A. M., GOTTESMAN, I., CHAPNIK, J. S., FRIEDBERG, J., KIRSH, J. C , JAFFER, N., ROTHBERG, R. &
WORTZMAN, G., 1988. The parathyroid adenoma—an imaging/surgical perspective. Journal of Otolaryngology, 17, 282-287. DUH, Q.-Y., SANCHO, J. J. & CLARK, O. H., 1987. Parathyroid
localisation. Ada Chirurgica Scandinavica, 153, 241-245. EISENBERG, H., PALLOTTA, J. & SHERWOOD, L., 1974. Selective
arteriography, venography and venous hormone assay in diagnosis and location of parathyroid lesions. American Journal of Medicine, 56, 810-821. FINE, E. J., 1987. Parathyroid imaging: its current status and future role. Seminars in Nuclear Medicine, 17, 350-359. GAZ, R. D., WANG, C , 1984. Management of asymptomatic hyperparathyroidism. American Journal of Surgery, 147, 498-501. GOODING, G. A. W., OKERLUND, M. D., STARK, D. D. &
CLARK, O. H., 1986. Parathyroid imaging: comparison of double tracer (Tl 201), Tc99m scintigraphy and high resolution US. Radiology, 161, 57-64. HEATH, H., HODGSON, S. F. & KENNEDY, M. A., 1980. Primary
hyperparathyroidism. New England Journal of Medicine, 302, 189-193. HIERN, B., ALMQVIST, S., CRANBERG, P., LINOVALL, N. &
WASTHED, B., 1975. Operative localisation of parathyroid tissue by selective neck vein catheterisation and radioimmunoassay or parathyroid hormone. Ada Chirurgica Scandinavica, 141, 31-39. HODGSON, S. F. & HEATH, H., 1981. Asymptomatic primary
hyperparathyroidism. Treat Proceedings, 56, 521-522.
or follow?
Mayo
Clinic
JARHULT, J., KRISTOFFERSSON, A., LUNDSTROM, B. & OBERG, L.,
1985. Comparison of ultrasonography and computed tomography in pre-operative location of parathyroid adenomas. Ada Chirurgica Scandinavica, 151, 583-587. KARSTRUP, S., HOLM, H. H., GLENTHOJ, A. & HEGEDUS, L.,
1990. Non-surgical treatment of primary hyperparathyroidism with sonographically guided percutaneous injection of ethanol. Results in a selected series of patients. American Journal of Roentgenology, 154, 1087-1090. KARSTRUP, S., HOLM, H. H., SOREN, T. P. & HEGEDUS, L.,
References ADAMS, J. E., ADAMS, P. H., MAMTORA, H. & ISHERWOOD, I.,
1981. Computed tomography and the localisation of parathyroid tumours. Clinical Radiology, 32, 251-254. BARRACLOUGH, B. H., REEVE, T. S., DUFFY, P. J. & PICKER,
Vol. 64, No. 764
1987. Ultrasonically guided percutaneous inactivation of parathyroid tumours. British Journal of Radiology, 60, 667-670. KRUBSACK, A. J., ARNOLD, J., WILSON, S. D., LAWSON, T. L., KNEELAN, J. B., THORSEN, H. K., COOLIER, B. D., HELLMAN,
R. S. & ISITMAN, A. T., 1989. Prospective comparison of radionuclide, computed tomography, sonographic and
681
/ . Murchison, C. Mclntosh, A. G. F. Aitken, J. Logie and A. Munro magnetic resonance localisation of parathyroid tumours. Surgery, 106, 639-646. KRUBSACK, A. J., WILSON, S. D., LAWSON, T. L., COLLIER, B. D., HELLMAN, R. S. & ISITMAN, A. T., 1986. Prospective
comparison of radionuclide, computed tomographic and sonographic localisation of parathyroid tumours. World Journal of Surgery, 10, 579-585. LLOYD, M. N. H., LEES, W. R. & MILROY, E. J. G., 1990.
Preoperative localisation in primary hyperparathyroidism. Clinical Radiology, 41, 239-243. MILLER, D. L., DOPPMAN, J. L., CHANG, R., SIMMONS, J. T., O'LEARY, T., NORTON, J. A., SPIEGEL, A. M., MARX, S. J. &
SCHOLZ, D. A. & PURNELL, D. C ,
1981. Asymptomatic
primary hyperparathyroidism—10 year prospective study. Mayo Clinic Proceedings, 56, 473-478. SIMEONE, J. F., MUELLER, P. R., FERRUCCI, J. T., VANSONNENBERG, E., WANG, C.-A., HALL, D. A. &
WITTENBURG, J., 1981. High resolution real time sonography of the parathyroid. Radiology, 141, 745-751. SOLBIATI, L., GlAGRANDE, A . , D E PRA, L., BELLOTTIE, E.,
CANTU, P. & RAVETTO, C , 1985. Percutaneous
ethanol
injection of parathyroid tumours under U/S guidance. Treatment for secondary hyperparathyroidism. Radiology, 155, 607-610.
AURBACH, G. D., 1987. Angiographic ablation of parathyroid adenomas—lessons from a 10-year experience. Radiology, 165, 601-607.
STARK, D. D., GOODING, G. A. W. & CLARK, O. H., 1985.
MOREAU, J. F., ULMANN, A., DRUEKE, T., HAMIDOU, S. &
STARK, D. D., GOODING, G. A. W., Moss, A. A., CLARK, O. H.
DUPOST, C , 1980. Localisation of parathyroid tumours by ultrasonography. New England Journal of Medicine, 302, 582-583.
& OVENSFORS, C. O., 1983. Parathyroid imaging: comparison of high resolution CT and high resolution sonography. American Journal of Roentgenology, 141, 633-683.
READING, C. C , CHARBONEAU, J. W., JAMES, E. M., KARSELL, P. R., PURNELL, D. C , GRANT, C. S. et al, 1982. High
STEVENS, A. C. & JACKSON, C. E., 1967. Localisation of
resolution parathyroid sonography. American Journal of Radiology, 139, 539-546. ROSSOFF, L., 1985. Hyperparathyroidism, hypergraphic and just plain hype. Surgery, 98, 989-994. SAMPLE, W. F., MITCHELL, S. P. & BLEDSOE, R. C ,
1978.
Parathyroid ultrasonography. Radiology, 127, 485-490. SAMUELS, B. I., DOWDY, A. H. & LECKY, J. W.,
Non-invasive parathyroid imaging. Seminars in Ultrasound,
CTandMR, 6, 310-320.
parathyroid adenomas by oesophageal cineroentgenography. American Journal of Roentgenology, 99, 233-237. VAN HEERDEN, J. A., JAMES, E. M., KARSELL, P. R., CHARONEAU, J.W., GRANT, C. S. & PURNELL, D. C , 1982.
Small-part ultrasonography in primary thyroidism. Annals of Surgery, 195, 774-779.
hyperpara-
1972.
WHITLEY, N. O., BOHLAM, M., CONNER, T. B., MCCREA, E. S., MASON, G. R. & WHITLEY, J. E., 1981. Computed
SATAVA, R. M., BEAHRS, O. H. & SCHOLZ, D. A., 1975. Success
tomography for localisation of parathyroid adenomas. Journal of Computer Assisted Tomography, 5, 812-817.
Parathyroid thermography. Radiology, 104, 575-578. rate of cervical exploration for hyperparathyroidism. Archives of Surgery, 110, 625-628.
682
The British Journal of Radiology, August 1991
Ultrasonic detection of parathyroid adenomas By J. Murchison, MRCP, C. Mclntosh, FRCS, A. G. F. Aitken, FRCR, J. Logie, FRCS and A. Munro, FRCS Departments of Radiology and Surgery, Raigmore Hospital, Inverness {Received July 1990 and in final form March 1991)
Keywords: Parathyroid adenomas, Hyperparathyroidism, Ultrasound
Abstract. High-resolution real time sonography was used to evaluate patients with suspected primary hyperparathyroidism. A total of 12 consecutive patients was scanned pre-operatively. The sensitivity of the procedure was 92% and the specificity 97%. In our hospital sonography is the procedure of choice for localizing enlarged parathyroid glands prior to surgical exploration.
With the increased use and availability of multichannel autoanalysers for biochemical determination, hypercalcaemia and primary hyperparathyroidism are now recognized to be much more common than previously appreciated (Heath et al, 1980). The treatment of choice in symptomatic patients, whose laboratory and clinical studies support the diagnosis of primary hyperparathyroidism, is exploration of the neck by an experienced parathyroid surgeon (Hodgson & Heath, 1981; Scholz & Purnell, 1981). Surgical exploration is also indicated in asymptomatic individuals to cure hypercalcaemia and to avoid metabolic complications such as bone demineralization, urolithiasis and nephrocalcinosis (Gaz & Wang, 1984). A wide variety of imaging techniques have been advocated for localization. These have included oesophageal cine radiography (Stevens & Jackson, 1967), computed tomography (Adams et al, 1981; Whitley et al, 1981; Stark et al, 1983; Krubsack et al, 1986), radio-isotope imaging (Gooding et al, 1986), high resolution real time ultrasound (Sample et al, 1978; Moreau et al, 1980; Barraclough et al, 1981; Jarhult et al, 1985), thermography (Samuels et al, 1972) and arteriography and selective venous sampling (Eisenberg et al, 1974; Hjern et al, 1975). Ultrasonography is considered by many to be the imaging investigation of choice (Crocker, 1986; Davidson et al, 1988) and has been reported to be a specific and sensitive test (Simeone etal, 1981; Heerden et al, 1982; Stark et al, 1985; Buchwach et al, 1987). We describe our recent experience with high resolution real time sonography in patients with primary hyperparathyroidism.
(Advanced Technology Labs, Bellevue, WA) with a high resolution 7.5 MHz transducer. Scans were obtained with the patient in the supine position and the neck slightly extended. Multiple planes were scanned covering the thyroid gland and adjacent internal jugular and carotid vessels to the level of the clavicles. Views inferior and posterior to the clavicle were obtained as far as possible by angling the transducer. The average examination time was 10 min. The examination was considered positive if an oval or elongated discrete mass was found located along the posterior surface of the thyroid gland or related to the adjacent carotid artery. (Figs 1, 2, 3). At operation, the side indicated by the scan was explored first. The tumour was sent for frozen section examination while the remaining glands were inspected. Results
A total of 13 parathyroid adenomas (PTAs) were identified in 12 patients with primary hyperparathyroidism. Adenomas seen ranged in size from 6 to 40 mm and included one bilateral PTA, one predominantly cystic PTA (Fig. 4), one intrathyroid PTA (Fig. 5)
Materials and methods
During a 14 month period 12 patients with biochemical evidence of primary hyperparathyroidism and with raised serum parathyroid hormone levels were scanned before surgical exploration. The ultrasound examinations were performed using a real time ultrasound unit Address for correspondence: A. G. F. Aitken, Department of Radiology, Raigmore Hospital, Inverness. Vol. 64, No. 764
Figure 1. Transverse section of left neck demonstrates a 1 cm PTA (arrows) lying posterior to the thyroid (t) and common carotid artery (cc). Jugular vein (j).
679
/ . Murchison, C. Mclntosh, A. G. F. Aitken, J. Logie and A. Munro
Figure 2. Longitudinal section through the right thyroid lobe showing a 2.5 cm PTA (arrows) lying posterior to the thyroid (t). Strap muscles (sm).
Figure 5. Longitudinal section showing a PTA (crosses) lying within the thyroid capsule. Thyroid (t).
false negative examination result in one patient. At operation this patient was found to have a pedunculated thyroid adenoma at the lower pole of the right thyroid lobe which was interpreted as a PTA, and a PTA at the left lower thyroid pole which was interpreted as a thyroid adenoma. Thirty-one normal parathyroid glands were identified at operation. The sensitivity of ultrasound investigation was 92%, specificity 97% and accuracy 95%. Duration of operation ranged from 55 to 150 min (mean 79 min). All patients were rendered normocalcaemic by surgery and remained normocalcaemic for at least 3 months post-operatively. Figure 3. Transverse section of right neck just inferior to the lower pole of the thyroid. A 0.6 cm hypoechoic mass (crosses) consistent with a PTA lies adjacent to the common carotid artery (cc). Jugular vein (j); sterno-cleidomastoid muscle (s).
Figure 4. Longitudinal section through the right thyroid lobe (t) shows a cystic PTA (crosses), containing internal echoes and showing some posterior acoustic enhancement.
and one PTA lying between the trachea and the oesophagus. Twelve of the 13 PTAs were correctly identified by ultrasound. There was one false positive and one 680
Discussion The results of our study compare favourably with those of other studies, which variously reported sensitivities of 63-85% (Butch et al, 1985; Jarhult et al, 1985; Gooding et al, 1986; Buchwach et al, 1987; Davidson et al, 1988; Krubsack et al, 1989; Lloyd et al, 1990) and show that these tumours can be located accurately using high resolution ultrasound. Difficulty was occasionally encountered in differentiating PTAs from thyroid adenomas protruding from the posterior surface of the thyroid, a problem which has been encountered by other authors (Sample et al, 1978; Reading et al, 1982; Jarhult et al, 1985). Identification of a PTA was facilitated if a plane of cleavage or an echogenic line could be seen between the mass and the thyroid. The choice of pre-operative imaging technique in primary hyperparathyroidism is ultimately dependent on the expertise and equipment available. Parathyroid ultrasound in particular is heavily dependent on the experience of the operator (Lloyd et al, 1990). Oesophageal cine radiography and thermography are of historical interest only. Selective venous sampling and selective arteriography are technically difficult, expensive, time consuming and potentially hazardous, but have a place in localizing PTAs in cases of failed neck exploration. Radio-itosope imaging using thalliumtechnetium computer subtraction scanning may identify 70-90% of parathyroid tumours (Fine, 1987; Carmalt The British Journal of Radiology, August 1991
Ultrasonic detection of parathyroid adenomas
et al, 1988). False negative results may be obtained with isotope scanning if the glands are small, and false positive results can arise in patients with thyroid nodules (Fine, 1987). The procedure is minimally invasive but does expose the patient to radiation (Duh et al, 1987). Initial attempts using computed tomography (CT) for parathyroid tumour localization were not particularly sensitive, detecting 50 to 60% of tumours (Adams et al, 1981; Whitley et al, 1981). A major problem is streak artefact caused by shoulder positioning but this can be overcome by employing a shoulder positioning device (Stark et al, 1983). More recent reports have shown that 70 to 80% of parathyroid tumours can be detected using CT (Krubsack et al, 1989). CT has the advantage of being able to locate ectopic glands in the mediastinum where ultrasonic visualization is poor (Duh et al, 1987). Several recent reports have advocated chemical ablation of PTAs under radiological guidance particularly for patients who are unfit for surgery, those who refuse surgery (Karstrup et al, 1987) and for those who have previously undergone unsuccessful surgery. Methods proposed include injection of ethanol under ultrasound control (Solbiati et al, 1985; Karstrup et al, 1990) and angiographic ablation by infusion of ionic contrast agents (Miller et al, 1987). The emergence of these techniques illustrates the importance of pre-therapy imaging and in particular the role of ultrasound as a method of localization. An experienced parathyroid surgeon can successfully cure 90-95% of patients with hyperparathyroidism without the pre-operative use of a localization procedure (Satava et al, 1975; Rossoff, 1985). Because of this some clinicians consider pre-operative localization unnecessary. However, using pre-operative localization a cure rate of 98.8% has been achieved (Lloyd et al, 1990) suggesting that even with an experienced parathyroid surgeon the results may be improved with preoperative imaging. Ultrasound has undoubtedly modified the pre-operative management and operative strategy in patients with primary hyperparathyroidism in our hospital. By first exploring the side of the lesion indicated by the scan we have achieved shorter operating times than those commonly reported (Brewer et al, 1983). Shorter operating times should enable the surgical team to make more efficient use of the operating room and by minimizing the extent of tissue dissection should reduce the risk of operative complications. In conclusion we consider ultrasound to be the imaging technique of choice for detecting PTAs because of its high accuracy, ease of application, lack of radiation and relatively low cost. Pre-operative localization of PTAs in our practice facilitates surgical exploration for primary hyperparathyroidism.
R. H., 1981. The localisation of parathyroid tissue by ultrasound scanning prior to surgery in patients with hyperparathyroidism. World Journal of Surgery, 5, 91-95. BREWER, W. H., WALSH, J. W. & NEWSOME, H. H., 1983.
Impact of sonography on surgery for primary hyperparathyroidism. American Journal of Surgery, 145, 270-272. BUCHWACH, K. A., MANGUM, W. B. & HAHN, F. W., 1987.
Pre-operative localisation Laryngoscope, 97, 13-15.
of
parathyroid
adenomas.
BUTCH, R. J., SIMEONE, J. F. & MUELLER, P. R., 1985. Thyroid
and parathyroid ultrasonography. Radiological Clinics of North America, 23, 57-71. CARMALT, H. L., GILLETT, D. J., CHU, J., EVANS, R. A. & Kos,
S., 1988. Prospective comparison of radionuclide, ultrasound and computed tomography in the preoperative localisation of parathyroid glands. World Journal of Surgery, 12, 830-834. CROCKER, E. F., 1986. The pursuit of the parathyroid. Medical Journal of Australia, 144, 506-507. DAVIDSON, J., NOYEK, A. M., GOTTESMAN, I., CHAPNIK, J. S., FRIEDBERG, J., KIRSH, J. C , JAFFER, N., ROTHBERG, R. &
WORTZMAN, G., 1988. The parathyroid adenoma—an imaging/surgical perspective. Journal of Otolaryngology, 17, 282-287. DUH, Q.-Y., SANCHO, J. J. & CLARK, O. H., 1987. Parathyroid
localisation. Ada Chirurgica Scandinavica, 153, 241-245. EISENBERG, H., PALLOTTA, J. & SHERWOOD, L., 1974. Selective
arteriography, venography and venous hormone assay in diagnosis and location of parathyroid lesions. American Journal of Medicine, 56, 810-821. FINE, E. J., 1987. Parathyroid imaging: its current status and future role. Seminars in Nuclear Medicine, 17, 350-359. GAZ, R. D., WANG, C , 1984. Management of asymptomatic hyperparathyroidism. American Journal of Surgery, 147, 498-501. GOODING, G. A. W., OKERLUND, M. D., STARK, D. D. &
CLARK, O. H., 1986. Parathyroid imaging: comparison of double tracer (Tl 201), Tc99m scintigraphy and high resolution US. Radiology, 161, 57-64. HEATH, H., HODGSON, S. F. & KENNEDY, M. A., 1980. Primary
hyperparathyroidism. New England Journal of Medicine, 302, 189-193. HIERN, B., ALMQVIST, S., CRANBERG, P., LINOVALL, N. &
WASTHED, B., 1975. Operative localisation of parathyroid tissue by selective neck vein catheterisation and radioimmunoassay or parathyroid hormone. Ada Chirurgica Scandinavica, 141, 31-39. HODGSON, S. F. & HEATH, H., 1981. Asymptomatic primary
hyperparathyroidism. Treat Proceedings, 56, 521-522.
or follow?
Mayo
Clinic
JARHULT, J., KRISTOFFERSSON, A., LUNDSTROM, B. & OBERG, L.,
1985. Comparison of ultrasonography and computed tomography in pre-operative location of parathyroid adenomas. Ada Chirurgica Scandinavica, 151, 583-587. KARSTRUP, S., HOLM, H. H., GLENTHOJ, A. & HEGEDUS, L.,
1990. Non-surgical treatment of primary hyperparathyroidism with sonographically guided percutaneous injection of ethanol. Results in a selected series of patients. American Journal of Roentgenology, 154, 1087-1090. KARSTRUP, S., HOLM, H. H., SOREN, T. P. & HEGEDUS, L.,
References ADAMS, J. E., ADAMS, P. H., MAMTORA, H. & ISHERWOOD, I.,
1981. Computed tomography and the localisation of parathyroid tumours. Clinical Radiology, 32, 251-254. BARRACLOUGH, B. H., REEVE, T. S., DUFFY, P. J. & PICKER,
Vol. 64, No. 764
1987. Ultrasonically guided percutaneous inactivation of parathyroid tumours. British Journal of Radiology, 60, 667-670. KRUBSACK, A. J., ARNOLD, J., WILSON, S. D., LAWSON, T. L., KNEELAN, J. B., THORSEN, H. K., COOLIER, B. D., HELLMAN,
R. S. & ISITMAN, A. T., 1989. Prospective comparison of radionuclide, computed tomography, sonographic and
681
/ . Murchison, C. Mclntosh, A. G. F. Aitken, J. Logie and A. Munro magnetic resonance localisation of parathyroid tumours. Surgery, 106, 639-646. KRUBSACK, A. J., WILSON, S. D., LAWSON, T. L., COLLIER, B. D., HELLMAN, R. S. & ISITMAN, A. T., 1986. Prospective
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