Radionuclide Parathyroid Imaging: Book and Atlas

Description

This atlas, compiled by experienced specialists in the field, is designed as a ready reference on the use of parathyroid scintigraphy in patients with hyperparathyroidism, both for the localisation of parathyroid pathology and as an aid to surgery. The introductory chapters review the basic core knowledge on the subject. Eighty case reviews are then presented, covering gamma camera planar imaging, SPECT, hybrid SPECT-CT, and also PET-CT. In total, 240 illustrations are included, comprising 160 grey-scale photos depicting nuclear medicine and CT images and 80 dual-modality fusion colour photos. This compilation of illustrative clinical cases will greatly assist clinicians and imaging specialists in image interpretation in different settings. The images replicate normal conventional formats used for routine reporting and hence facilitate fast and reliable diagnosis. Each of the case reviews includes documentation of the procedure, findings, and conclusions with relevant commentary. Surgeons, nuclear medicine physicians, and radiologists will find the Radionuclide Parathyroid Imaging: Book and Atlas to be a valuable practical tool and learning aid. Preface Acknowledgements Contents Contributors 1: Parathyroid Anatomy, Embryology and Histology 1.1 Introduction 1.1.1 Historical Perspective 1.2 Morphology 1.3 Embryology 1.4 Histology References 2: Physiology 2.1 Introduction 2.2 Parathyroid Hormone 2.3 Calcium Physiology and Homeostasis References 3: Hyperparathyroid Disorders 3.1 Introduction 3.2 Symptoms and Signs of Hypercalcaemia 3.3 Causes of Hypercalcaemia 3.4 Primary Hyperparathyroidism (PHPT) 3.4.1 Hereditary PHPT 3.4.2 Sporadic PHPT 3.4.3 Parathyroid Adenoma 3.4.3.1 Solitary Adenoma 3.4.3.2 Double or Multiple Adenomas 3.4.3.3 Microadenoma 3.4.3.4 Lipoadenomas 3.4.3.5 Cystic Adenoma (Functional Parathyroid Cyst) 3.4.4 Parathyroid Hyperplasia 3.4.4.1 Chief Cell Hyperplasia 3.4.4.2 Water-Clear Cell Hyperplasia 3.4.5 Parathyroid Carcinoma References 4: Diagnostic Imaging: Structural Modalities 4.1 Introduction 4.2 Ultrasonography 4.3 Computed Tomography (CT) 4.4 Magnetic Resonance Imaging (MRI) 4.5 Angiography 4.6 Selective Venous Sampling 4.7 Conclusion References 5: Parathyroid Scintigraphy 5.1 Introduction 5.2 Single-Photon Emitting Radiotracers for Thyroid and Parathyroid Imaging 5.2.1 123Iodine-Sodium Iodide 5.2.2 99mTc-Pertechnetate 5.2.3 Thallium-201 5.2.4 99mTc-Sestamibi (Cardiolite) 5.2.5 99mTc-Tetrofosmin 5.3 Imaging Protocols 5.3.1 Dual-Tracer Subtraction Technique 5.3.2 Dual-Phase Subtraction Imaging 5.3.3 SPECT or SPECT/CT Protocols 5.3.4 Image Processing and Optimisation 5.3.4.1 Negative Image Transformation 5.3.4.2 Inverse Logarithmic Greyscale Transformation 5.3.4.3 Colour Scale Hybrid Image Display 5.4 Clinical Aspects 5.4.1 Sensitivity and Specificity 5.4.2 False-Positive and False-Negative Scans 5.4.3 Factors Affecting Uptake 5.4.4 Thallium Parathyroid Scintigraphy: Current Role References 6: Parathyroid PET 6.1 Introduction 6.2 18F-Fluorodeoxyglucose (18F-FDG) 6.3 11C-Methionine 6.4 Choline PET 6.5 Clinical Context References 7: Nuclear Medicine Cases 7.1 Case 7.1. Palpable Neck Nodule (Parathyroid Adenoma) 7.1.1 Background 7.1.2 Procedure 7.1.3 Findings 7.1.4 Conclusion 7.1.5 Comments and Teaching Points 7.2 Case 7.2. Water-Clear Cell Parathyroid Adenoma + Thyroid Adenoma 7.2.1 Background 7.2.2 Procedure 7.2.3 Findings 7.2.4 Conclusion 7.2.5 Comments and Teaching Points 7.3 Case 7.3. Ectopic Supernumerary Left Upper Parathyroid Gland Hyperplasia 7.3.1 Background 7.3.2 Procedure 7.3.3 Findings 7.3.4 Conclusion 7.3.5 Comments and Teaching Points 7.4 Case 7.4. Right Upper Parathyroid Adenoma + Ectopic Mediastinal Parathyroid Adenoma 7.4.1 Background 7.4.2 Procedure 7.4.3 Findings 7.4.4 Conclusion 7.4.5 Comments and Teaching Points 7.5 Case 7.5. Ectopic Right Superior Parathyroid Adenoma 7.5.1 Background 7.5.2 Procedure 7.5.3 Findings 7.5.4 Conclusion 7.5.5 Comments and Teaching Points 7.6 Case 7.6. Left Lower Parathyroid Adenoma 7.6.1 Background 7.6.2 Procedure 7.6.3 Findings 7.6.4 Conclusion 7.6.5 Comments and Teaching Points 7.7 Case 7.7. Right Lower Parathyroid Adenoma 7.7.1 Background 7.7.2 Procedure 7.7.3 Findings 7.7.4 Conclusion 7.8 Case 7.8. Failed Thallium/Technetium Subtraction Scan. Single Adenoma on Dual-Phase Planar Sestamibi Scan with Tertiary Hyperparathyroidism 7.8.1 Background 7.8.2 Procedure 7.8.3 Findings 7.8.4 Conclusion 7.8.5 Comments and Teaching Points 7.9 Case 7.9. Left Intrathyroidal Parathyroid Adenoma 7.9.1 Background 7.9.2 Procedure 7.9.3 Findings 7.9.4 Conclusion 7.9.5 Comments and Teaching Points 7.10 Case 7.10. Sestamibi-negative, Thallium-positive Right Parathyroid Adenoma 7.10.1 Background 7.10.2 Procedure 7.10.3 Findings 7.10.4 Conclusion 7.10.5 Comments and Teaching Points 7.11 Case 7.11. Sestamibi-Negative and Thallium-Positive Left Parathyroid Adenoma 7.11.1 Background 7.11.2 Procedures 7.11.3 Findings 7.11.4 Conclusion 7.11.5 Comments and Teaching Points 7.12 Case 7.12. Sestamibi-Negative, Thallium-Positive Double Parathyroid Adenomas 7.12.1 Background 7.12.2 Procedures 7.12.3 Findings 7.12.4 Conclusion 7.12.5 Comments and Teaching Points 7.13 Case 7.13. Sestamibi-Negative, Weakly Thallium Positive Left Lower Parathyroid Adenoma 7.13.1 Background 7.13.2 Procedures 7.13.3 Findings 7.13.4 Conclusion 7.13.5 Comments and Teaching Points 7.14 Case 7.14. Intact Parathyroid Hormone-Secreting Bone Metastasis from Breast Cancer 7.14.1 Background 7.14.2 Procedure 7.14.3 Findings 7.14.4 Conclusion 7.14.5 Comments and Teaching Points 7.15 Case 7.15. Large Right Parathyroid Adenoma and a Small Ectopic Left Lower Adenoma 7.15.1 Background 7.15.2 Procedure 7.15.3 Findings 7.15.4 Conclusion 7.15.5 Comments and Teaching Points 7.16 Case 7.16. Left Upper Parathyroid Adenoma 7.16.1 Background 7.16.2 Procedure 7.16.3 Findings 7.16.4 Conclusion 7.16.5 Comments and Teaching Points 7.17 Case 7.17. Left Lower Parathyroid Adenoma 7.17.1 Background 7.17.2 Procedure 7.17.3 Findings 7.17.4 Conclusion 7.17.5 Comments and Teaching Points 7.18 Case 7.18. Pertechnetate- and Sestamibi-Avid Right Lower Intrathyroidal Parathyroid Adenoma 7.18.1 Background 7.18.2 Procedure 7.18.3 Findings 7.18.4 Conclusion 7.18.5 Comments and Teaching Points 7.19 Case 7.19. Multinodular Goitre with Left Lower Parathyroid Adenoma 7.19.1 Background 7.19.2 Procedure 7.19.3 Findings 7.19.4 Conclusion 7.19.5 Comments and Teaching Points 7.20 Case 7.20. Left Lower Parathyroid Gland Cancer with Brown Tumours 7.20.1 Background 7.20.2 Procedures 7.20.3 Findings 7.20.4 Conclusion 7.20.5 Comments and Teaching Points 7.21 Case 7.21. Parathyroid Adenoma Positive on Both Sestamibi and Thallium Scans 7.21.1 Background 7.21.2 Procedures 7.21.3 Findings 7.21.4 Conclusion 7.21.5 Comments and Teaching Points 7.22 Case 7.22. Two-Gland Parathyroid Hyperplasia 7.22.1 Background 7.22.2 Procedure 7.22.3 Findings 7.22.4 Conclusion 7.22.5 Comments and Teaching Points 7.23 Case 7.23. Three-Gland Parathyroid Hyperplasia 7.23.1 Background 7.23.2 Procedure 7.23.3 Findings 7.23.4 Conclusion 7.23.5 Comments and Teaching Points 7.24 Case 7.24. Single Left Lower Parathyroid Adenoma 7.24.1 Background 7.24.2 Procedure 7.24.3 Findings 7.24.4 Conclusion 7.25 Case 7.25. Single Ectopic Retrosternal Parathyroid Adenoma 7.25.1 Background 7.25.2 Procedure 7.25.3 Findings 7.25.4 Conclusion 7.26 Case 7.26. Double Ectopic Parathyroid Adenomas (Left Intrathyroidal + Ectopic Right Lower) 7.26.1 Background 7.26.2 Procedure 7.26.3 Findings 7.26.4 Conclusion 7.26.5 Comments and Teaching Points 7.27 Case 7.27. A Case of Sagliker Syndrome 7.27.1 Background 7.27.2 Procedures 7.27.3 Findings (Parathyroid Scintigraphy) 7.27.4 Findings (Skeletal Scintigraphy) 7.27.5 Conclusion 7.27.6 Comments and Teaching Points 7.28 Case 7.28. Synchronous Parathyroid Adenoma and Papillary Thyroid Carcinoma 7.28.1 Background 7.28.2 Procedure 7.28.3 Findings 7.28.4 Conclusion 7.28.5 Comments and Teaching Points 7.29 Case 7.29. Left Lower Parathyroid Adenoma + Sestamibi-Avid Thyroid Adenoma (Papillary Thyroid Carcinoma) 7.29.1 Background 7.29.2 Procedure 7.29.3 Findings 7.29.4 Conclusion 7.29.5 Comments and Teaching Points 7.30 Case 7.30. 18F-FDG and 99mTc-Sestamibi  Positive Parathyroid Adenoma Without Hyperparathyroidism 7.30.1 Background 7.30.2 Procedures 7.30.3 Findings 7.30.4 Conclusion 7.30.5 Comments and Teaching Points 7.31 Case 7.31. 99mTc-Pertechnetate-Avid and 99mTc-Sestamibi-Avid Bilateral Parathyroid Gland Hyperplasia 7.31.1 Background 7.31.2 Procedure 7.31.3 Findings 7.31.4 Conclusion 7.31.5 Comments and Teaching Points 7.32 Case 7.32. Four-Gland Parathyroid Hyperplasia with Incidental Dextrocardia 7.32.1 Background 7.32.2 Procedure 7.32.3 Findings 7.32.4 Conclusion 7.32.5 Comments and Teaching Points 7.33 Case 7.33. Parathyroid Adenoma + Sestamibi-Avid Thyroid Nodule (Hurthle Cell Carcinoma) 7.33.1 Background 7.33.2 Procedure 7.33.3 Findings 7.33.4 Conclusion 7.33.5 Comments and Teaching Points 7.34 Case 7.34. Single Parathyroid Adenoma Associated with Transient Renal Failure 7.34.1 Background 7.34.2 Procedure 7.34.3 Findings 7.34.4 Conclusion 7.34.5 Comments and Teaching Points 7.35 Case 7.35. Bilateral Upper Parathyroid Gland Hyperplasia 7.35.1 Background 7.35.2 Procedure 7.35.3 Findings 7.35.4 Conclusion 7.35.5 Comments and Teaching Points 7.36 Case 7.36. Concomitant Multinodular Goitre and Parathyroid Adenoma 7.36.1 Background 7.36.2 Procedure 7.36.3 Findings 7.36.4 Conclusion 7.36.5 Comments and Teaching Points 7.37 Case 7.37. Resected Parathyroid Adenoma with Possible Recurrence 7.37.1 Background 7.37.2 Procedure 7.37.3 Findings 7.37.4 Conclusion 7.37.5 Comments and Teaching Points 7.38 Case 7.38. Papillary Thyroid Carcinoma Masquerading as an Intrathyroidal Parathyroid Adenoma 7.38.1 Background 7.38.2 Procedure 7.38.3 Findings 7.38.4 Conclusion 7.38.5 Comments and Teaching Points 7.39 Case 7.39. Synchronous Parathyroid Adenoma and Papillary Thyroid Carcinoma (Oncocytic Variant) 7.39.1 Background 7.39.2 Procedure 7.39.3 Findings 7.39.4 Conclusion 7.39.5 Comments and Teaching Points 7.40 Case 7.40. Single Parathyroid Adenoma with Reversible Renal Damage 7.40.1 Background 7.40.2 Procedure 7.40.3 Findings 7.40.4 Conclusion 7.40.5 Comments and Teaching Points 7.41 Case 7.41. Ectopic Non-oncocytic Cell Parathyroid Adenoma 7.41.1 Background 7.41.2 Procedure 7.41.3 Findings 7.41.4 Conclusion 7.41.5 Comments and Teaching Points 7.42 Case 7.42. Three-Gland Parathyroid Hyperplasia with Incidental Unsuspected Dilated Cardiomyopathy 7.42.1 Background 7.42.2 Procedure 7.42.3 Findings 7.42.4 Conclusion 7.42.5 Comments and Teaching Points 7.43 Case 7.43. Six-Gland Parathyroid Hyperplasia 7.43.1 Background 7.43.2 Procedure 7.43.3 Findings 7.43.4 Conclusion 7.43.5 Comments and Teaching Points 7.44 Case 7.44. Concurrent Hyperthyroidism Due to Graves’ Disease and Vitamin D Deficiency-Induced Normocalcaemic Primary Hyperparathyroidism with a Sestamibi-Negative but Thallium-Positive Parathyroid Adenoma 7.44.1 Background 7.44.2 Procedure (99mTc-Pertechnetate Thyroid Scan + 99mTc-Sestamibi Parathyroid Scan) 7.44.3 Procedure (201Tl-Thallous Chloride Parathyroid Scan) 7.44.4 Findings 7.44.5 Conclusion 7.44.6 Comments and Teaching Points 7.45 Case 7.45. Double Parathyroid Adenomas: (1) One Thallium-Avid but Sestamibi-Non-avid and (2) Other Both Sestamibi- and Thallium-Avid 7.45.1 Background 7.45.2 Procedure (99mTc-Sestamibi Parathyroid Scan) 7.45.3 Procedure (201Tl-Thallous Chloride Parathyroid Scan) 7.45.4 Findings 7.45.5 Conclusion 7.45.6 Comments and Teaching Points 7.46 Case 7.46. Four-Gland Parathyroid Hyperplasia 7.46.1 Background 7.46.2 Procedure 7.46.3 Findings 7.46.4 Conclusion 7.46.5 Comments and Teaching Points 7.47 Case 7.47. Brown Tumour Associated with Parathyroid Adenocarcinoma Mimicking a Mediastinal Parathyroid Adenoma 7.47.1 Procedure 7.47.2 Findings 7.47.3 Conclusion 7.47.4 Comments and Teaching Points 7.48 Case 7.48. Normocalcaemic Primary Hyperparathyroidism and Bilateral Upper Parathyroid Gland Hyperplasia 7.48.1 Background 7.48.2 Procedure 7.48.3 Findings 7.48.4 Conclusion 7.48.5 Comments and Teaching Points 7.49 Case 7.49. Normocalcaemic Primary Hyperparathyroidism and Five-Gland Hyperplasia 7.49.1 Background 7.49.2 Procedure 7.49.3 Findings 7.49.4 Conclusion 7.49.5 Comments and Teaching Points 7.50 Case 7.50. Right Upper Parathyroid Adenoma Pre- and Post-surgery 7.50.1 Background 7.50.2 Procedure 7.50.3 Findings 7.50.4 Conclusion 7.50.5 Comments and Teaching Points 7.51 Case 7.51. Probable Non-oncogenic Cell Parathyroid Adenoma 7.51.1 Background 7.51.2 Procedure 7.51.3 Findings 7.51.4 Conclusion 7.51.5 Comments and Teaching Points 7.52 Case 7.52. Pertechnetate- and Sestamibi-Avid Intrathyroidal Parathyroid Adenoma 7.52.1 Background 7.52.2 Procedure 7.52.3 Findings 7.52.4 Conclusion 7.52.5 Comments and Teaching Points 7.53 Case 7.53. Bilateral Lower Parathyroid Gland Hyperplasia 7.53.1 Background 7.53.2 Procedure 7.53.3 Findings 7.53.4 Conclusion 7.53.5 Comments and Teaching Points 7.54 Case 7.54. Double Parathyroid Adenomas 7.54.1 Background 7.54.2 Procedure 7.54.3 Findings 7.54.4 Conclusion 7.54.5 Comments and Teaching Points 7.55 Case 7.55. Double Parathyroid Hyperplasia: One with Early Sestamibi Washout and One with Sestamibi Retention 7.55.1 Background 7.55.2 Procedure 7.55.3 Findings 7.55.4 Conclusion 7.55.5 Comments and Teaching Points 7.56 Case 7.56. Unsuspected Primary Hyperparathyroidism Diagnosed on FDG Scan Confirmed by Sestamibi Scan 7.56.1 Background 7.56.2 Procedure 7.56.3 Findings 7.56.4 Conclusion 7.56.5 Comments and Teaching Points 7.57 Case 7.57. Cystic and Non-cystic Parathyroid Adenomas 7.57.1 Background 7.57.2 Procedure 7.57.3 Findings 7.57.4 Conclusion 7.57.5 Comments and Teaching Points 7.58 Case 7.58. Cystic Ectopic Parathyroid Adenoma 7.58.1 Background 7.58.2 Procedure 7.58.3 Findings 7.58.4 Conclusion 7.58.5 Comments and Teaching Points 7.59 Case 7.59. Ectopic Parathyroid Adenoma + an Apparent Ectopic Cystic Mediastinal Parathyroid Adenoma (Thymic Neoplasm with Functional Parathyroid Tissue) 7.59.1 Background 7.59.2 Procedure 7.59.3 Findings 7.59.4 Conclusion 7.59.5 Comments and Teaching Points 7.60 Case 7.60. Tertiary Hyperparathyroidism with Five Adenomatous Parathyroid Glands 7.60.1 Background 7.60.2 Procedure 7.60.3 Findings 7.60.4 Conclusion 7.60.5 Comments and Teaching Points 7.61 Case 7.61. Sestamibi-Avid Cold Thyroid Nodule Suggesting Thyroid Neoplasm + Ectopic Parathyroid Adenoma 7.61.1 Background 7.61.2 Procedure 7.61.3 Findings 7.61.4 Conclusion 7.61.5 Comments and Teaching Points 7.62 Case 7.62. Autonomous Thyroid Nodule + Bilateral Lower Parathyroid Gland Hyperplasia/Adenoma with Primary Hyperparathyroidism 7.62.1 Background 7.62.2 Procedure 7.62.3 Findings 7.62.4 Conclusion 7.62.5 Comments and Teaching Points 7.63 Case 7.63. Ectopic Midline Retrosternal Parathyroid Adenoma 7.63.1 Background 7.63.2 Procedure 7.63.3 Findings 7.63.4 Conclusion 7.63.5 Comments and Teaching Points 7.64 Case 7.64. Right Lower Parathyroid Adenoma Pre- and Post-surgery 7.64.1 Background 7.64.2 Procedure 7.64.3 Findings 7.64.4 Conclusion 7.64.5 Comments and Teaching Points 7.65 Case 7.65. Tertiary Hyperparathyroidism with Four Adenomatous Parathyroid Glands 7.65.1 Background 7.65.2 Procedures 7.65.3 Findings 7.65.4 Conclusion 7.65.5 Comments and Teaching Points 7.66 Case 7.66. Thyroiditis + Ectopic Left Lower Parathyroid Adenoma 7.66.1 Background 7.66.2 Procedure 7.66.3 Findings 7.66.4 Conclusion 7.66.5 Comments and Teaching Points 7.67 Case 7.67. Triple Modality (Scintigraphy, contrast CT and US) Imaging of a Solitary Parathyroid Adenoma 7.67.1 Background 7.67.2 Procedure 7.67.3 Findings 7.67.4 Conclusion 7.67.5 Comments and Teaching Points 7.68 Case 7.68. Water-Clear Cell Right Lower Adenoma 7.68.1 Background 7.68.2 Procedure 7.68.3 Findings 7.68.4 Conclusion 7.68.5 Comments and Teaching Points 7.69 Case 7.69. Giant Right Lower Parathyroid Gland Cancer 7.69.1 Background 7.69.2 Procedure 7.69.3 Findings 7.69.4 Conclusion 7.69.5 Comments and Teaching Points 7.70 Case 7.70. Dual-Tracer (99mTc-Sestamibi and 201Tl-Thallous Chloride) Avid Parathyroid Adenoma 7.70.1 Background 7.70.2 Procedure 7.70.3 Findings 7.70.4 Conclusion 7.70.5 Comments and Teaching Points 7.71 Case 7.71. Four-Gland Parathyroid Hyperplasia: Two Sestamibi-Avid Glands and all Four Thallium-Avid Glands 7.71.1 Background 7.71.2 Procedure 7.71.3 Findings 7.71.4 Conclusion 7.71.5 Comments and Teaching Points 7.72 Case 7.72. Sestamibi-Negative Thallium-Positive 3-Gland Parathyroid Hyperplasia 7.72.1 Background 7.72.2 Procedure 7.72.3 Findings 7.72.4 Conclusion 7.72.5 Comments and Teaching Points References 8: PET/CT Cases 8.1 Case 8.1. 18F-Choline PET/CT Scan: Normal Physiological Distribution 8.1.1 Background 8.1.2 Procedure 8.1.3 Findings 8.1.4 Conclusion 8.1.5 Comments and Teaching Points 8.2 Case 8.2. 18F-Choline PET/CT Scan: Left Lower Parathyroid Adenoma 8.2.1 Background 8.2.2 Procedure 8.2.3 Findings 8.2.4 Conclusion 8.2.5 Comments and Teaching Points 8.3 Case 8.3. 18F-Choline PET/CT Scan: Ectopic Right Lower Parathyroid Adenoma 8.3.1 Background 8.3.2 Procedure 8.3.3 Findings 8.3.4 Conclusion 8.3.5 Comments and Teaching Points 8.4 Case 8.4. 18F-Choline PET/CT Scan: Ectopic Retrosternal Parathyroid Adenoma 8.4.1 Background 8.4.2 Procedure 8.4.3 Findings 8.4.4 Conclusion 8.4.5 Comments and Teaching Points 8.5 Case 8.5. 18F-Choline PET/CT Scan + 99mTc-Sestamibi SPECT/CT: Cystic and Non-cystic Parathyroid Adenomas (Oncogenic Type) 8.5.1 Background 8.5.2 Procedure 8.5.3 Findings 8.5.4 Conclusion 8.5.5 Comments and Teaching Points 8.6 Case 8.6. 18F-Choline PET/CT Scan + 99mTc-Sestamibi SPECT/CT: Four Glands Parathyroid Hyperplasia on Choline, Two Positive on Sestamibi 8.6.1 Background 8.6.2 Procedure 8.6.3 Findings 8.6.4 Conclusion 8.6.5 Comments and Teaching Points 8.7 Case 8.7. 18F-Choline PET/CT Scan + 18F-FDGC PET/CT Scan + 99mTc-Sestamibi SPECT/CT: Tertiary Hyperparathyroidism Due to Three-Gland Parathyroid Adenomas with Brown Tumours 8.7.1 Background 8.7.2 Procedure 8.7.3 Findings 8.7.4 Conclusion 8.7.5 Comments and Teaching Points 8.8 Case 8.8. 18F-Choline PET/CT Scan: Left Lower Parathyroid Adenoma – Incidental Finding 8.8.1 Background 8.8.2 Procedure 8.8.3 Findings 8.8.4 Conclusion 8.8.5 Comments and Teaching Points Further Readings