Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism.
BACKGROUND
Four-dimensional computed tomography (4D-CT) utilizes multiplanar images and perfusion characteristics to identify abnormal parathyroid glands. We assessed the role of 4D-CT in patients with inconclusive preoperative ultrasound and sestamibi localization studies.


METHODS
Adult patients with primary hyperparathyroidism with negative or discordant standard imaging who underwent both localization with 4D-CT and operative intervention for curative intent were included. Patient characteristics, 4D-CT scan results compared with operative findings, and curative proportion were assessed.


RESULTS
Of the 60 patients, 4D-CT accurately lateralized 73% and localized 60% of abnormal glands found at operation. Single candidate lesions (46/60) were confirmed at operation in 70%. When multiple lesions were identified on 4D-CT (14/60), accuracy dropped to 29% (P = .03). The accuracy of 4D-CT was not different between primary and reoperative cases (P = .79). Of the 8 patients with multigland disease diagnosed perioperatively, 5 had multiple candidate lesions noted on 4D-CT. In 94% (48/51) of patients, a >50% drop in intraoperative parathormone (IOPTH) level was achieved after resection and 87% (48/55) had long-term cure with a median follow-up of 221 days.


CONCLUSIONS
4D-CT identifies the more than half of abnormal parathyroids missed by traditional imaging and should be considered in cases with negative or discordant sestamibi and ultrasound. Bilateral exploration is warranted when multiple candidate lesions are reported on 4D-CT. Multigland disease remains a challenging entity.
Department of Surgery, Massachusetts General Hospital, Boston, MA, USA. clubitz@partners.org
Carrie C
CC
Lubitz
George J
GJ
Hunter
Leena M
LM
Hamberg
Sareh
S
Parangi
Daniel
D
Ruan
Atul
A
Gawande
Randall D
RD
Gaz
Gregory W
GW
Randolph
Francis D
FD
Moore
Richard A
RA
Hodin
Antonia E
AE
Stephen
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002118:Calcium / Q000097:blood; D003287:Contrast Media; D005260:Female; D056973:Four-Dimensional Computed Tomography / Q000379:methods*; D007839:Functional Laterality; D006801:Humans; D006980:Hyperthyroidism / Q000000981:diagnostic imaging*; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D010282:Parathyroid Neoplasms / Q000000981:diagnostic imaging* / Q000601:surgery*; D057234:Preoperative Period; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon / Q000379:methods; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014463:Ultrasonography
D003287:Contrast Media; D010281:Parathyroid Hormone; D017256:Technetium Tc 99m Sestamibi; D002118:Calcium