Ultrasound examination in diagnosis of morphological variants of parathyroid hyperplasia in patients with secondary hyperparathyroidism

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1 Ultrasound examination in diagnosis of morphological variants of parathyroid hyperplasia in patients with secondary hyperparathyroidism Poster No.: C-0304 Congress: ECR 2015 Type: Authors: Keywords: DOI: Scientific Exhibit E. Polukhina 1, A. Vasil'ev 2 ; 1 Khabarovsk/RU, 2 Moscow/RU Thyroid / Parathyroids, Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Spectral Doppler, Experimental investigations, Surgery, Teleradiology, Endocrine disorders, Hyperplasia / Hypertrophy /ecr2015/C-0304 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 7

2 Aims and objectives Secondary hyperparathyroidism (shpt) induced by chronic renal failure is one of the most serious complications in dialysis patients. Prolonged parathyroid stimulation leads initially to diffuse polyclonal hyperplasia followed by nodular hyperplasia. Cells in nodular hyperplasia have reduced numbers of vitamin D receptor and calcium-sensing receptor, which results in diminished responsiveness of parathyroid glands (PTG) with nodular hyperplasia to medical treatment. This aim of this study was to evaluate the role of ultrasound examination in assessment of PTG changes in patients with shpt and establish noninvasive ultrasound diagnostic criteria of morphological variants of parathyroid hyperplasia to improve the effectiveness of treatment. Methods and materials Two hundred patients with end stage renal disease on dialysis were examined (mean age 50.5 years). Duration of dialysis was 61 months on average ( ). Parameters to be considered for the assessment of shpt progression include quantity, size, echogenicity of the PTG, homogeneity and vascularization. In 28 patients subjected to parathyroidectomy, the comparison of morphological and ultrasound data was performed. Results The PTG enlargement was revealed in 62.5 % of cases. There were identified 249 glands (including 10 ectopic PTG). The quantity of PTG varied from 1 to 5 among the patients. The size of PTG varied from 0.4 through 3.4 #m; the volume - from 0.02 through 5.39 #m³. In all cases echogenicity of detected PTG was lower than that of thyroid gland tissue. In 43.8 % of cases structure of PTG was nonhomogeneous because of areas of increased echogenicity, calcifications and anechogenic inclusions. Relationship was noted between quantity of the PTG and duration of dialysis (R = 0,267; p < 0,001). The correlation was also detected between parathyroid hormone level and the volume of the most enlarged gland (R = 0,542; p < 0,001). There was correlation found between degree of vascularization and glandular volume (R = 0,462; p < 0,001), parathyroid hormone level (R = 0,263; p = 0,017) and calcium-phosphorus product level (R = 0,236; p = 0,036). Page 2 of 7

3 Morphologic examination of 69 removed PTG revealed diffuse hyperplasia in 26 (37.8%) glands, nodular hyperplasia in 43 (62.3%) glands. Ultrasound data in patients subjected to parathyroidectomy are presented in Table 1. For each sonographic feature, diagnostic performance was calculated, and values are presented in Table 2. The nodular parathyroid hyperplasia can be assumed at presence of heterogeneous structure (accuracy of 84.1%), resistive index value in glandular arteries more than 0.65 (accuracy of 88.4 %), systolic velocity value in the peripheral arteries > 30 cm/s (accuracy of 78.3 %) and maximal size of PTG more than 1.5 cm (accuracy of 72.5%). Images for this section: Page 3 of 7

4 Table 1: Table.1. Ultrasound data in patients subjected to parathyroidectomy Page 4 of 7

5 Conclusion Ultrasound imaging plays a significant role in the assessment of PTG changes in patients with shpt. Regular ultrasound exams allow timely detection of changes in parathyroid glands, to evaluate degree and the morphological variants of parathyroid hyperplasia. Personal information Elena Polukhina, MD, PhD., associate professor of the Radiology Diagnostics Department, Postgraduate Institute For Public Health Workers, Khabarovsk, Russia, polukhina@inbox.ru Aleksandr Vasil'ev, MD, PhD., corresponding member of RAMS, professor, head of Department of Radiology of Moscow State Medical University of Medicine and Density named after A.I. Evdokimov, Moscow, Russia, auv62@mail.ru References 1. Canadillas S., Canalejo A., Santamaria R. et al. Calcium-sensing receptor expression and parathyroid hormone secretion in hyperplastic parathyroid glands from humans // J. Am. Soc. Nephrol V. 16. P Cunningham J., Locatelli F., Rodriguez M. Secondary Hyperparathyroidism: Pathogenesis, Disease Progression, and Therapeutic Options // Clin. J. Am. Soc. Nephrol V. 6. P Demiralay E., Altaca G. Comparison of proliferative activity in parathyroid glands in primary and secondary hyperparathyroidism // Acta Endocrinologica V. 7. # 4. P Drueke T.B. Cell biology of parathyroid gland hyperplasia in chronic renal failure // J. Am. Soc. Nephrol V.11. P Floege J., Kim J., Ireland E. et al. Serum ipth, calcium and phosphate, and the risk of mortality in a European haemodialysis population // Nephrol. Dial. Transplant V. 26. # 6. P Fukagawa M., Nakanishi S., Kazama J.J. Basic and clinical aspects of parathyroid hyperplasia in chronic kidney diseases // Kidney Int V.70. Suppl.102. P.S3-7. Page 5 of 7

6 7. Hirai T., Nakashima A., Takasugi N. et al. Response of Secondary Hyperparathyroidism to Cinacalcet Depends on Parathyroid Size // Nephron Clin. Pract V P Kitaoka M. Ultrasonographic diagnosis of parathyroid glands and percutaneous ethanol injection therapy // Nephrol. Dial. Transplant V.18. Suppl.3. P Matsuoka S., Tominaga Y., Sato T. et al. Relationship between the dimension of parathyroid glands estimated by ultrasonography and the hyperplastic pattern in patients with renal hyperparathyroidism // Ther. Apher. Dial V.12. P Meola M., Petrucci I. Cupisti A. Ultrasound in clinical setting of secondary hyperparathyroidism // J. Nephrol V. 26. # 5. P Okuno S., Ishimura E., Kitatani K., et al. Relationship between parathyroid gland size and responsiveness to maxacalcitol therapy in patient with secondary HPT // Nephrol. Dial. Transplant P Onoda N., Kurihara S., Sakurai Y. et al. Evaluation of blood supply to the parathyrpud glands in secondary hyperparathyroidism compared with histopathology // Nephrol. Dial. Transplant V.18. Suppl.3. P Onoda N., Fukagawa M., Tominaga Y. et al. New clinical guidelines for selective direct injection therapy of the parathyroid glands in chronic dialysis patients // Nephrol. Dial. Transplant. Plus V.1. Suppl.3. P Pavlovic D., Tomic Brzac H. Ultrasonographic evaluation of parathyroid hyperplasia in dialysis patients // Scientific World Journal V. 6. P Rodriguez M., Canadillas S., Lopez I. et al. Regulation of parathyroid function in chronic renal failure // J. Bone Miner. Metab V.24. P Tominaga Y., Matsuoka S., Sato T. et al. Clinical features and hyperplastic pattern of parathyroid glands in hemodialysis patients with advanced secondary hyperparathyroidism refractory to maxacalcitol treatment and required parathyroidectomy // Ther. Dial. Apher V.11. P Vulpio C., Bossola M., De Gaetano A. et al. Ultrasound patterns of parathyroid glands in chronic hemodialysis patients with secondary HPT // Am. J. Nephrol V.28. P Uhlig K., Berns J.S., Kestenbaum B. KDOQI US commentary on the 2009 KDIGO Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of CKD-Mineral and Bone Disorder (CKD-MBD) // Am. J. Kidney Dis V. 55. # 5. P Page 6 of 7

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