Giri Somdatta, Nagarajan Krishnan, Krishnaraj Balamourougan, Gochhait Debasis, Ponnusamy Madhusudhanan, Sebastian Anitha, Sriviruthi Baskararaj, Sahoo Jayaprakash, Kamalanathan Sadishkumar, Naik Dukhabandhu
Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, IND.
Endocrinology and Metabolism, All India Institute of Medical Sciences, Kalyani, Kalyani, IND.
Cureus. 2025 Jul 31;17(7):e89110. doi: 10.7759/cureus.89110. eCollection 2025 Jul.
Background The accurate preoperative localization of parathyroid adenomas is crucial for minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (PHPT). This study assessed the diagnostic performance of four-dimensional computed tomography (4D CT) in detecting parathyroid adenomas, compared with ultrasound (USG) and technetium methoxy isobutyl isonitrile single photon emission computed tomography (99mTc-sestamibi SPECT/CT). Methods We retrospectively analyzed 53 patients with biochemically confirmed PHPT who underwent all three preoperative imaging modalities, followed by parathyroidectomy from January 2020 to January 2025. Imaging findings were validated against intraoperative localization, histopathology, and intraoperative parathyroid hormone (PTH) dynamics. Multi-gland diseases were excluded. Sensitivity, positive predictive value (PPV), and concordance were calculated. Percentage arterial enhancement (PAE) was analyzed as a radiological marker. Results The mean age was 42.7 ± 14.7 years, with 29 (54.7%) women. Forty-nine (88.7%) patients had typical adenomas, three (0.05%) had carcinoma, and one (0.01%) had an atypical adenoma. The majority of lesions (24, 45%) were located in the right inferior parathyroid gland, followed by the left inferior (16, 30%). Overall, preoperative imaging was able to localize 50/53 (94.3%) lesions correctly. 4D CT correctly localized 45 lesions, outperforming USG and 99mTc-sestamibi SPECT/CT by identifying eight and 12 additional lesions, respectively. Sensitivity was highest for 4D CT (88.2%), followed by 99mTc-sestamibi SPECT/CT (82.4%) and USG (72.6%), with all three modalities showing high PPV (>94%). Among small adenomas (<20 mm), 4D CT demonstrated superior detection (21/21, 100%) compared to USG (16/21, 76.2%) and 99mTc-sestamibi SPECT/CT (15/21, 71.4%). Dynamic enhancement patterns on 4D CT distinguished adenomas from mimickers. However, applying a fixed PAE cutoff (128.9%), as previously proposed, yielded limited sensitivity (75%) and specificity (31.6%). Conclusion 4D CT outperformed USG and 99mTc-sestamibi SPECT/CT in localizing parathyroid adenomas in PHPT and was particularly useful when USG or 99mTc-sestamibi SPECT/CT results were inconclusive. While all three modalities showed high positive predictive value, 4D CT localized additional lesions missed by others. Its dynamic contrast patterns effectively differentiated adenomas from mimics. However, the utility of a fixed PAE cutoff was limited by protocol-dependent variability, indicating a need for tailored thresholds.
背景 甲状旁腺腺瘤的准确术前定位对于原发性甲状旁腺功能亢进症（PHPT）的微创甲状旁腺切除术（MIP）至关重要。本研究评估了四维计算机断层扫描（4D CT）在检测甲状旁腺腺瘤方面的诊断性能，并与超声（USG）和锝甲氧基异丁基异腈单光子发射计算机断层扫描（99mTc-司他米比SPECT/CT）进行了比较。方法 我们回顾性分析了2020年1月至2025年1月期间53例经生化确诊的PHPT患者，这些患者均接受了上述三种术前成像检查，随后接受了甲状旁腺切除术。成像结果通过术中定位、组织病理学和术中甲状旁腺激素（PTH）动态变化进行验证。排除多腺体疾病。计算敏感性、阳性预测值（PPV）和一致性。分析动脉强化百分比（PAE）作为一种影像学标志物。结果 患者平均年龄为42.7±14.7岁，其中29例（54.7%）为女性。49例（88.7%）患者患有典型腺瘤，3例（0.05%）患有癌，1例（0.01%）患有非典型腺瘤。大多数病变（24例，45%）位于右下甲状旁腺，其次是左下甲状旁腺（16例，30%）。总体而言，术前成像能够正确定位53个病变中的50个（94.3%）。4D CT正确定位了45个病变，分别比USG和99mTc-司他米比SPECT/CT多识别出8个和12个病变。4D CT的敏感性最高（88.2%），其次是99mTc-司他米比SPECT/CT（82.4%）和USG（72.6%），三种检查方法的PPV均较高（>94%）。在小腺瘤（<20 mm）中，4D CT的检测能力优于USG（16/21，76.2%）和99mTc-司他米比SPECT/CT（15/21，71.4%）（21/21，100%）。4D CT上的动态强化模式可将腺瘤与类似病变区分开来。然而，按照先前提出的固定PAE阈值（128.9%），敏感性（75%）和特异性（31.6%）有限。结论 在PHPT患者甲状旁腺腺瘤的定位方面，4D CT优于USG和99mTc-司他米比SPECT/CT，当USG或99mTc-司他米比SPECT/CT结果不明确时尤其有用。虽然三种检查方法的阳性预测值都很高，但4D CT能定位其他方法遗漏的额外病变。其动态对比模式能有效区分腺瘤与类似病变。然而，固定PAE阈值的效用受到协议相关变异性的限制，这表明需要制定个性化阈值。
