Diagnosis of Parathyroid Adenomas with New Ultrasound Imaging Modalities

• Ultrasound technology:
  • Is becoming an integral part of diagnosing parathyroid adenomas
  • Careful ultrasound evaluation with:
    • B-mode
    • Shear wave elastography
    • Three-dimensional (3D) of parathyroid adenomas:
      • May improve localization and outcome
• Introduction:
  • A 60-year-old woman was referred for the evaluation of hyperparathyroidism.
  • This patient gave her informed consent.
  • She had a history of hypothyroidism and thyroid nodules.
  • She was being treated with levothyroxine 50 mcg daily.
  • Routine testing revealed hypercalcemia:
    • The serum calcium was 11.2 (nL range 8.7–10.2 mg/dL), creatinine was 0.69 (nL range 0.57–1.00 mg/dL), intact parathyroid hormone (PTH) was 70 (nL range 15–65 pg/mL), phosphorus was 2.7 (nL range 2.5–4.5 mg/ dL), vitamin D was 38.7 (30–100 ng/mL), and 24 hours urine calcium was 362.9 (100–300 mg/24 hour).
  • The neck ultrasound showed:
    • Two lesions one superior/posterior and the other in the inferior/posterior aspect of the right thyroid lobe measuring 11.6 · 4.4 · 9.7 mm and 14.6 · 5.0 · 10.0 mm, respectively.
    • Both lesions resembled parathyroid adenomas.
    • Shear wave velocity (SWV) measurements for the superior and inferior lesions were 1.67 and 1.77 m/second, respectively.
    • For the adjacent thyroid tissue SWV was 2.3 m/second, significantly higher.
    • 3D ultrasound examination demonstrated a polar artery in both lesions.
  • A sestamibi scan showed a probable right parathyroid adenoma and she was referred for surgery.
  • She was found to have two right parathyroid adenomas in the superior and inferior poles corresponding with the ultrasound finding.
  • Intraoperative PTH level decreased from 139.9 to 17 pg/mL postresection.
  • Six weeks after surgery, her calcium and PTH were normal.

• Materials and Methods:
  • This patient was evaluated with ultrasound imaging, including:
    • B- mode
    • Shear wave elastography (SWE)
    • 3D ultrasound

• Discussion:
  • Most patients with primary hyperparathyroidism have a single parathyroid adenoma:
    • Other causes include:
      • Glandular hyperplasia
      • Multiple adenomas
      • Parathyroid carcinoma
        
  • The role of ultrasound in diagnosing parathyroid adenomas:
    • Is becoming more prominent because of:
      • Improved technology
      • Low cost
      • Noninvasive nature
  • SWE can be an added value to b-mode ultrasound in diagnosing parathyroid adenomas:
    • Previous publications have reported that SWV measurement of parathyroid adenomas:
      • May enhance other sonographic parameters to predict the diagnosis of parathyroid adenomas:
        • Parathyroid adenomas appear to have:
          • A more homogenous texture when compared with the thyroid gland
          • Lower tissue stiffness when compared with the thyroid gland
  • It can be challenging to differentiate:
    • Parathyroid adenomas from lymph nodes (LNs) and ectopic thyroid tissue at level VI, with b-mode ultrasound
    • A combination of 3D ultrasound images with 3D color Doppler (CD):
      • Might improve our ability to:
        • Identify the polar artery and enhance differentiation from LN
    • 3D technology might improve the view:
      • By adding coronal view to current b-mode that comprises of transverse and longitudinal views
• Conclusion:
  • Combining multiple image modalities, including:
    • B-mode, shear wave elastography, and 3D technology:
      • May improve our ability to identify parathyroid adenomas.
  • Parathyroid adenomas have:
    • A lower SWV compared with thyroid tissue
  • 3D ultrasound technology may enhance view of the polar artery when adding 3D CD. 

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