Spectrum of Radiological Findings in Primary Hyperparathyroidism

Transcription

1 Spectrum of Radiological Findings in Primary Hyperparathyroidism Poster No.: C-0904 Congress: ECR 2015 Type: Educational Exhibit Authors: F. Abubacker Sulaiman, R. Kalaiarasan; Chennai/IN Keywords: Thyroid / Parathyroids, Ultrasound, CT, MR, Molecular imaging, Hyperplasia / Hypertrophy DOI: /ecr2015/C-0904 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 32

2 Learning objectives Diagnosis of primary hyper parathyroidism using various imaging modalities. To describe the difference between each modality in diagnosing primary hyper parathyroidism. To get familiarize with spectrum of Radiological images and findings in primary hyper parathyroidism. Background Primary hyperparathyroidism (PHP) is a disease in which one or more hyperactive parathyroid glands constantly make too much parathyroid hormone (PTH). In primary hyperparathyroidism, the "thermostat" controlling the calcium is always on high. This leads to calcium being taken out of the bones (leading to weakening of the bones or osteoporosis) and gastrointestinal tract and put into the blood stream. This increases the blood levels of calcium. Since the blood is cleaned (filtered) by the kidneys, this leads to the kidneys being exposed to high levels of calcium, which can lead to kidney stones, kidney damage, and other problems. In most patients with primary hyperparathyroidism (80%), only one of the four parathyroid glands is diseased - these people have what is called a "single adenoma." In about 10% of affected people, two or three glands are hyperactive- called "double or triple adenoma." Finally, in 10% of patients, all four glands are hyperacitve- called "four gland hyperplasia." About 28 out of 100,000 people will have this disease and it is twice as common in women [3,4] than men. The disease becomes more common as people get older and most [5] commonly occurs after age 45 with an average age of 65. Primary hyperparathyroidism is the most common cause of abnormally high blood calcium levels in the general population. Findings and procedure details Page 2 of 32

3 Plain radiographic findings may include resorption and sclerosis of numerous sites in the skeletal system. X-Ray: The most common radiologic finding in primary hyperparathyroidism is osteopenia, which may be generalized or asymmetric. Fine trabeculations are initially lost, with resultant coarse and thickened trabeculae. The disease may progress with further destruction that results in a groundglass appearance in the trabeculae. About 30-50% of the bone density must [19] be lost to show changes on radiographs. Other methods for the quantification of bone density, such as QCT scanning and DEXA, are more sensitive in the evaluation of osteopenia. Additional findings include bone resorption, which may occur at many different anatomic sites. Bone resorption may be classified as subperiosteal, intracortical, trabecular, endosteal, subchondral, subligamentous, or subtendinous. Subperiosteal bone resorption is an early and virtually pathognomonic sign of hyperparathyroidism. Although subperiosteal bone resorption can affect many sites, the most common site in hyperparathyroidism is the middle phalanges of the index and middle fingers, primarily on the radial aspect. Page 3 of 32

4 Fig. 1: This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption. Also, note the subperiosteal and intracortical resorption. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 4 of 32

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6 Fig. 2: Distal femur shows scalloped defects along the inner margin of the cortex, which denote endosteal resorption. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Fig. 3: Radiograph of the shoulder depicts sub-periosteal distal clavicular resorption. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 6 of 32

7 Fig. 4: In the skull, areas of decreased radio opacity are intermingled with sclerotic radio opaque areas, resulting in a classic appearance called the salt-and-pepper skull. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Brown tumor : Brown tumors are well-circumscribed lytic lesions of bone that represent the osteoclastic resorption of a confluent area of bone with subsequent fibrous replacement. The lesions may be single or multiple, with expansion of overlying bone, and they may be present in any site, although the lesions usually occur in cortical bone. Common sites include the mandible, clavicle, ribs, pelvis, and femur. Page 7 of 32

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9 Fig. 5: Humerus- osseous expansion and lucency of the proximal humerus. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 9 of 32

10 Fig. 6: Radiograph of the mid femoral diaphysis -eccentric (arrowheads) and central positions (arrow) of the lesions. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Ultrasonography: Ultrasonography is one of the primary modalities used to localize parathyroid tumors.the size of the adenoma is usually correlated with the degree of parathyroid elevation. Adenomas appear as well-defined hypoechoic lesions with potential cystic or necrotic areas. Ultrasonography offers the advantage of depicting potential concomitant thyroid disease, which is present in approximately 40% of patients with parathyroid disease. [25] Fig. 8: Parathyroid Gland References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 10 of 32

11 Fig. 9: In renal imaging, ultrasonography can demonstrate bilateral hyperechoic medullary pyramids that are consistent with medullary nephrocalcinosis,anyhow it is a nonspecific finding. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Nuclear Imaging (Sestambi scan): Sestamibi scans involve injecting a small amount of special radioactive material into a vein and taking an X-ray image of the chest, neck, and head. Sestamibi scans have an accuracy rate of about 80 to 95%. The accuracy of the test is very institution-specific and depends on the quality of the equipment used, the technique used to perform the test, and the skill of the interpreter. Centers that perform a lot of parathyroid surgery typically have more accurate sestamibi scans. The advantages of sestamibi scans are its wide availability and the ability to evaluate for diseased glands outside of the neck at the same [29,30] time. Page 11 of 32

12 Fig. 10: Sestamibi scan References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Page 12 of 32

13 Fig. 11: Scintigraphic manifestation of the "salt-and-pepper" sign of the skull in hyperparathyroidism. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN MRI: MRI is one diagnostic modality that can be used to evaluate ectopic parathyroid adenomas. On T1-weighted images, adenomas appear as low-signal-intensity masses, whereas intermediate or high signal intensity is seen on T2-weighted images. Gadolinium enhancement with fat suppression results in diffuse enhancement of the adenoma. Page 13 of 32

14 Fig. 12: MRI scan with parathyoid adenoma identified low in the neck. References: Radiology and Imaging Sciences, Chettinad Hospital and Research Institute, Chettinad Hospital and Research Institute - Chennai/IN Images for this section: Page 14 of 32

15 Fig. 1: This image demonstrates subperiosteal resorption that has resulted in severe tuftal resorption. Also, note the subperiosteal and intracortical resorption. Page 15 of 32

16 Fig. 3: Radiograph of the shoulder depicts sub-periosteal distal clavicular resorption. Page 16 of 32

17 Fig. 4: In the skull, areas of decreased radio opacity are intermingled with sclerotic radio opaque areas, resulting in a classic appearance called the salt-and-pepper skull. Page 17 of 32

18 Fig. 7: Brown tumor in pelvis Page 18 of 32

19 Fig. 8: Parathyroid Gland Page 19 of 32

20 Fig. 9: In renal imaging, ultrasonography can demonstrate bilateral hyperechoic medullary pyramids that are consistent with medullary nephrocalcinosis,anyhow it is a nonspecific finding. Page 20 of 32

21 Fig. 10: Sestamibi scan Page 21 of 32

22 Fig. 11: Scintigraphic manifestation of the "salt-and-pepper" sign of the skull in hyperparathyroidism. Page 22 of 32

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24 Fig. 2: Distal femur shows scalloped defects along the inner margin of the cortex, which denote endosteal resorption. Page 24 of 32

25 Fig. 6: Radiograph of the mid femoral diaphysis -eccentric (arrowheads) and central positions (arrow) of the lesions. Page 25 of 32

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27 Fig. 5: Humerus- osseous expansion and lucency of the proximal humerus. Fig. 12: MRI scan with parathyoid adenoma identified low in the neck. Page 27 of 32

28 Conclusion Radiographic findings of subperiosteal resorption are most specific for the disease and should prompt consideration of the primary hyperparathyroidism. Ultrasonography is approximately 75% sensitive in identifying adenomas, but this technique has low sensitivity in identifying ectopic lesions. The advantages of sestamibi scans are its wide availability and the ability to evaluate for diseased glands outside of the neck at the same time. MRI findings of brown tumors are nonspecific. Bony expansion can be visualized, and the extent of the lesion can be determined. The imaging characteristics depend on the amount of fibrous tissue, hemorrhage, and cystic changes that are present in the lesion. Lack of an associated softtissue mass is a pertinent negative finding that can be demonstrated on MRI. MRI is one diagnostic modality that can be used to evaluate ectopic parathyroid adenomas Personal information Dr.F.Abuabacker Sulaiman, MD.RD Associate Professor Department of Radiology and Imaging Sciences Chettinad Hospital and Research Institute Kelambakkam Kanchipuram District Tamilnadu India Dr.Ramya Kalaiarasan 1st year Post graduate student Page 28 of 32

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