Clinical review: Parathyroid localization and implications for clinical management.
METHODS
The prevalence of hyperparathyroidism, especially primary hyperparathyroidism, has increased in recent decades due to improvements in diagnostic techniques with a corresponding surge in parathyroid surgery, leading to the development of focused, minimally invasive surgical approaches. Focused parathyroidectomy is predicated on preoperative localization of suspected parathyroid pathology. As a result, there has been a proliferation of parathyroid imaging modalities and protocols, resulting in confusion about their indications and applications.


METHODS
Bibliographies from clinical trials and review articles published since 2000 were reviewed and supplemented with targeted searches using biomedical databases. We also employed our extensive clinical experience.


RESULTS
The best-studied modalities for parathyroid localization are nuclear scintigraphy and sonography and are widely applied as initial studies. Multiple variations exist, and several additional noninvasive imaging techniques, such as computed tomography and magnetic resonance, are described. The exquisite anatomical detail of 4-dimensional computed tomography must be balanced with significant radiation exposure to the thyroid gland. Invasive venous PTH sampling and parathyroid arteriography have important roles in remedial cases. Due to considerable heterogeneity in imaging, multidisciplinary collaboration between endocrinologists, surgeons, and radiologists is beneficial.


CONCLUSIONS
Parathyroid localization is indicated in surgical candidates. Crucial considerations when selecting an imaging study include availability, cost, radiation exposure, local expertise, and accuracy. Additional factors include the patient's anticipated pathology and whether it is de novo or refractory disease. An approach to imaging for patients with primary hyperparathyroidism is presented.
Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06520-8062, USA.
John W
JW
Kunstman
Jonathan D
JD
Kirsch
Amit
A
Mahajan
Robert
R
Udelsman
D006801:Humans; D006961:Hyperparathyroidism / Q000175:diagnosis* / Q000601:surgery*; D008279:Magnetic Resonance Imaging; D016105:Parathyroidectomy; D011300:Preoperative Care; D011877:Radionuclide Imaging; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography