Inconclusive preoperative imaging is a strong predictor of multiglandular parathyroid disease (MGD) in patients with primary hyperparathyroidism (PHPT). MGD was investigated in a cohort of 17 patients with PHPT (mean age 64.9 years, total calcium 2.75 mmol/l and parathyroid hormone (PTH) 113.3 ng/l) who underwent 18F-fluorocholine PET/CT (FCH) imaging before surgery. The initial MIBI SPECT scintigraphy (MIBI) and/or neck ultrasound were not conclusive or did not localize all pathological parathyroid glands, and PHPT persisted after surgery. Sporadic MGD was present in 4 of 17 patients with PHPT (24 %). In 3 of 4 patients with MGD, FCH correctly localized 6 pathological parathyroid glands and surgery was successful. Excised parathyroid glands were smaller (p <0.02) and often hyperplastic in MGD than in single gland disease. In two individuals with MGD, excision of a hyperplastic parathyroid gland led to a false positive decline in intraoperative PTH and/or postoperative serum calcium. Although in one patient it was associated with partial false negativity, parathyroid imaging with FCH seemed to be superior to neck ultrasound and/or MIBI scintigraphy in MGD.

Institute of Nuclear Medicine 1st Faculty of Medicine Charles University and the General University Hospital Prague Czech Republic

Zobrazit více v PubMed

Barczyński M, Bränström R, Dionigi G, Mihai R. Sporadic multiple parathyroid gland disease--a consensus report of the European Society of Endocrine Surgeons (ESES) Langenbecks Arch Surg. 2015;400(8):887–905. doi: 10.1007/s00423-015-1348-1. PubMed DOI PMC

Mihai R, Sitges-Serra A. Multigland primary hyperparathyroidism—frequently considered, seldom encountered. Langenbeck’s Arch Surg. 2015;400(8):863–866. doi: 10.1007/s00423-016-1373-8. PubMed DOI

Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, et al. The American Association of Endocrine Surgeons Guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151(10):959. doi: 10.1001/jamasurg.2016.2310. PubMed DOI

Caldwell M, Laux J, Clark M, Kim L, Rubin J. Persistently Elevated PTH after parathyroidectomy at one year: experience in a tertiary referral center. J clin Endocrinol Metab. 2019;104(10):4473–4480. doi: 10.1210/jc.2019-00705. PubMed DOI PMC

Trébouet E, Bannani S, Wargny M, Leux C, Caillard C, Kraeber-Bodéré F, Renaudin K, Chaillous L, Mirallié É, Ansquer C. Mild sporadic primary hyperparathyroidism: high rate of multiglandular disease is associated with lower surgical cure rate. Langenbeck’s Archives of Surgery. 2019;404(4):431–438. doi: 10.1007/s00423-019-01782-1. PubMed DOI

Pandian TK, Lubitz CC, Bird SH, Kuo LE, Stephen AE. Normocalcemic hyperparathyroidism: A collaborative endocrine surgery quality improvement program analysis. Surgery. 2020;167(1):168–172. doi: 10.1016/j.surg.2019.06.043. PubMed DOI

Kuzminski SJ, Sosa JA, Hoang JK. Update in parathyroid imaging. Magnetic Resonance Imaging Clinics of North America. 2018;26(1):151–166. doi: 10.1016/j.mric.2017.08.009. PubMed DOI

Nichols KJ, Tronco GG, Palestro CJ. Influence of Multigland Parathyroid Disease on 99mTc-Sestamibi SPECT/CT. Clin Nuclear Med. 2016;41(4):282–288. doi: 10.1097/rlu.0000000000001115. PubMed DOI

Thier M, Daudi S, Bergenfelz A, Almquist M. Predictors of multiglandular disease in primary hyperparathyroidism. Langenbeck’s Arch Surgery. 2018;403(1):103–109. doi: 10.1007/s00423-017-1647-9. PubMed DOI PMC

Zajickova K, Zogala D, Kubinyi J. Parathyroid imaging by (18)F-fluorocholine PET/CT in patients with primary hyperparathyroidism and inconclusive conventional methods: clinico-pathological correlations. Physiol Res. 2018;67(Suppl 3):S551–S557. doi: 10.33549/physiolres.934029. PubMed DOI

Irvin GL, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg. 2004;28(12):1287–1292. doi: 10.1007/s00268-004-7708-6. PubMed DOI

Krátký J, Vítková H, Bartáková J, Telička Z, Antošová M, Límanová Z, Jiskra J. Thyroid nodules: pathophysiological insight on oncogenesis and novel diagnostic techniques. Physiol Res. 2014;63(Suppl 2):S26–S275. doi: 10.33549/physiolres.932818. PubMed DOI

Kebebew E. Predictors of Single-Gland vs Multigland parathyroid disease in primary hyperparathyroidism. Arch Surg. 2006;141(8):777. doi: 10.1001/archsurg.141.8.777. PubMed DOI

Hughes DT, Miller BS, Doherty GM, Gauger PG. Intraoperative parathyroid hormone monitoring in patients with recognized multiglandular primary hyperparathyroidism. World J Surg. 2010;35(2):336–341. doi: 10.1007/s00268-010-0887-4. PubMed DOI

Thakur A, Sebag F, Slotema E, Ippolito G, Taïeb D, Henry JF. Significance of biochemical parameters in differentiating uniglandular from multiglandular disease and limiting use of intraoperative parathormone assay. World J Surg. 2009;33(6):1219–1223. doi: 10.1007/s00268-009-0029-z. PubMed DOI

Shi Y, Azimzadeh P, Jamingal S, Wentworth S, Ferlitch J, Koh J, Balenga N, Olson JA., Jr Polyclonal origin of parathyroid tumors is common and is associated with multiple gland disease in primary hyperparathyroidism. Surgery. 2018;163(1):9–14. doi: 10.1016/j.surg.2017.04.038. PubMed DOI PMC

Carneiro-Pla DM, Romaguera R, Nadji M, Lew JI, Solorzano CC, Irvin GL. Does histopathology predict parathyroid hypersecretion and influence correctly the extent of parathyroidectomy in patients with sporadic primary hyperparathyroidism? Surgery. 2007;142(6):930–935. doi: 10.1016/j.surg.2007.09.019. PubMed DOI

Lawrence DA. A histological comparison of adenomatous and hyperplastic parathyroid glands. J Clin Pathol. 1978;31(7):626–632. doi: 10.1136/jcp.31.7.626. PubMed DOI PMC

Yavuz S, Simonds WF, Weinstein LS, Collins MT, Kebebew E, Nilubol N, Phan GQ, Libutti SK, Remaley AT, Van Deventer M, Marx SJ. Sleeping parathyroid tumor: rapid hyperfunction after removal of the dominant tumor. J Clin Endocrinol Metab. 2012;97(6):1834–1841. doi: 10.1210/jc.2011-3030. PubMed DOI PMC

Marx SJ, Menczel J, Campbell G, Aurbach GD, Spiegel AM, Norton JA. Heterogeneous size of the parathyroid glands in familial multiple endocrine neoplasia type 1. Clin Endocrinol. 1991;35(6):521–526. doi: 10.1111/j.1365-2265.1991.tb00938.x. PubMed DOI

Zofkova I. Hypercalcemia. pathophysiological aspects. Physiol Res. 2016:1–10. doi: 10.33549/physiolres.933059. PubMed DOI

Marini F, Cianferotti L, Giusti F, Brandi ML. Molecular genetics in primary hyperparathyroidism: the role of genetic tests in differential diagnosis, disease prevention strategy, and therapeutic planning. A 2017 update. Clin Cases Miner Bone Metab. 2017;14(1):60–70. doi: 10.11138/ccmbm/2017.14.1.060. PubMed DOI PMC

Ferrari C, Santo G, Mammucci P, Pisani AR, Sardaro A, Rubini G. Diagnostic Value of Choline PET in the preoperative localization of hyperfunctioning parathyroid gland(s): A Comprehensive Overview. Biomedicines. 2021;9(3):231. doi: 10.3390/biomedicines9030231. PubMed DOI PMC

Grimaldi S, Young J, Kamenicky P, Hartl D, Terroir M, Leboulleux S, Berdelou A, Hadoux J, Hescot S, Remy H, Baudin E, Schlumberger M, Deandreis D. Challenging pre-surgical localization of hyperfunctioning parathyroid glands in primary hyperparathyroidism: the added value of (18)F-Fluorocholine PET/CT. Eur J Nucl Med Mol Imaging. 2018;45(10):1772–1780. doi: 10.1007/s00259-018-4018-z. PubMed DOI