The Use of Parathyroid 4D-MRI in Localizing Ectopic Parathyroid Glands in Renal Hyperparathyroidism
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Renal hyperparathyroidism (RHPT), seen in the setting of end stage renal disease (ESRD) is associated with four gland hyperplasia. If refractory to medical management, patients are referred for surgical evaluation for parathyroidectomy. Ectopic parathyroid glands are more common in patients with RHPT and can be found in 26%–46% of patients, sometimes representing a diagnostic imaging challenge. If not accurately distinguished on imaging, they may not be found during neck exploration, which could result in recurrent disease or failure to obtain surgical cure. Different imaging modalities such as ultrasound, 99m-technetium sestamibi scan, or dynamic contrast-enhanced parathyroid computed tomography scan are available to attempt localization of parathyroid glands prior to surgery to help direct surgical exploration. More recently, dynamic, contrast-enhanced parathyroid magnetic resonance imaging (4D-MRI) has been shown to be a useful alternative imaging modality, particularly in patients with ESRD avoiding the use of iodinated contrast. Here we report two cases of ectopic parathyroid glands detected using 4D-MRI in the setting of parathyroidectomy for RHPT. Patient A is a 35-year-old female with a history of ESRD secondary to nephrotic syndrome whose 4th parathyroid gland was identified on 4D-MRI in the right inferior pole of the thyroid. Patient B is a 42-year-old male with a history of ESRD secondary to membranous nephropathy who had a parathyroid lesion identified on 4D-MRI near the left common carotid artery. In both cases, 4D-MRI proved to be a useful tool for localization of the missing parathyroid gland.
Abstract
Renal hyperparathyroidism (RHPT), seen in the setting of end stage renal disease (ESRD) is associated with four gland hyperplasia. If refractory to medical management, patients are referred for surgical evaluation for parathyroidectomy. Ectopic parathyroid glands are more common in patients with RHPT and can be found in 26%–46% of patients, sometimes representing a diagnostic imaging challenge. If not accurately distinguished on imaging, they may not be found during neck exploration, which could result in recurrent disease or failure to obtain surgical cure. Different imaging modalities such as ultrasound, 99m-technetium sestamibi scan, or dynamic contrast-enhanced parathyroid computed tomography scan are available to attempt localization of parathyroid glands prior to surgery to help direct surgical exploration. More recently, dynamic, contrast-enhanced parathyroid magnetic resonance imaging (4D-MRI) has been shown to be a useful alternative imaging modality, particularly in patients with ESRD avoiding the use of iodinated contrast. Here we report two cases of ectopic parathyroid glands detected using 4D-MRI in the setting of parathyroidectomy for RHPT. Patient A is a 35-year-old female with a history of ESRD secondary to nephrotic syndrome whose 4th parathyroid gland was identified on 4D-MRI in the right inferior pole of the thyroid. Patient B is a 42-year-old male with a history of ESRD secondary to membranous nephropathy who had a parathyroid lesion identified on 4D-MRI near the left common carotid artery. In both cases, 4D-MRI proved to be a useful tool for localization of the missing parathyroid gland.
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