Annals of Surgical Oncology

, Volume 25, Issue 5, pp 1403–1409 | Cite as

4D-CT is Superior to Ultrasound and Sestamibi for Localizing Recurrent Parathyroid Disease

  • Moska Hamidi
  • Michael Sullivan
  • George Hunter
  • Leena Hamberg
  • Nancy L. Cho
  • Atul A. Gawande
  • Gerard M. Doherty
  • Francis D. MooreJr.
  • Matthew A. Nehs
Endocrine Tumors



Recurrent primary hyperparathyroidism (PHPT) presents a diagnostic challenge in localizing a hyperfunctioning gland. Although several imaging modalities are available for preoperative localization, 4D-CT is increasingly utilized for its ability to locate both smaller and previously unlocalized lesions. Currently, there is a paucity of data evaluating the utility of 4D-CT in the reoperative setting compared with ultrasound (US) and sestamibi. We aimed to determine the sensitivity of 4D-CT in localizing parathyroid adenomas in recurrent or persistent PHPT.


We performed a retrospective review of prospectively collected data from a tertiary-care hospital, and identified 58 patients who received preoperative 4D-CT with US and/or sestamibi between May 2008 and March 2016. Data regarding the size, shape, and number of parathyroid lesions were collected for each patient.


A total of 62 lesions were identified intraoperatively among the 58 patients (6 with multigland disease) included in this investigation. 4D-CT missed 13 lesions identified intraoperatively, compared with 32 and 22 lesions missed by US and sestamibi, respectively. Sensitivity for correct lateralization of culprit lesions was 77.4% for 4D-CT, 38.5% for US, and 46% for sestamibi. 4D-CT was superior in lateralizing adenomas (49/62) compared with US (20/52; p < 0.001) and sestamibi (18/47; p < 0.001). The overall cure rate (6-month postoperative calcium < 10.7 mg/dL) was 89.7%. All patients with lesions correctly lateralized by 4D-CT were cured at 6 months.


4D-CT localized parathyroid adenomas with higher sensitivity among patients with recurrent or persistent PHPT compared with sestamibi or US-based imaging.





  1. 1.
    Liddy S, Worsley D, Torreggiani W, Feeney J. Preoperative imaging in primary hyperparathyroidism: literature review and recommendations. Can Assoc Radiol J. 2017;68(1):47–55.CrossRefPubMedGoogle Scholar
  2. 2.
    Griffith B, Chaudhary H, Mahmood G, Carlin AM, Peterson E, Singer M, Patel SC. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Am J Neuroradiol. 2015;36(12):2373–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh Q, et al. The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg. 2016;151(10):959–68.CrossRefPubMedGoogle Scholar
  4. 4.
    Lebastchi AH, Donovan PI, Udelsman R. Paradigm shift in the surgical management of multigland parathyroid hyperplasia an individualized approach. JAMA Surg. 2014;149(11):1133–137.CrossRefPubMedGoogle Scholar
  5. 5.
    Udelsman R, Donovan P, Sokoll L. One hundred consecutive minimally invasive parathyroid explorations. Ann Surg. 2000; 232(3):331–9.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002;235(5):665–70; discussion 670–2.CrossRefGoogle Scholar
  7. 7.
    Beyer T, Solorzano C, Starr F, Nilubol N, Prinz R. Parathyroidectomy outcomes according to operative approach. Am J Surg. 2007;193(3):368–72; discussion 372–3.CrossRefPubMedGoogle Scholar
  8. 8.
    Morris LF, Zanocco K, Ituarte PH, Ro K, Duh QY, Sturgeon C, et al. The value of intraoperative parathyroid hormone monitoring in localized primary hyperparathyroidism: a cost analysis. Ann Surg Oncol. 2010;17(3):679–85.CrossRefPubMedGoogle Scholar
  9. 9.
    Lubitz C, Hunter G, Hamberg L, Parangi S, Ruan D, Gawande A, et al. Accuracy of 4-dimensional computed tomography in poorly localized patients with primary hyperparathyroidism. Surgery. 2010;148 (6):1129–37.CrossRefPubMedGoogle Scholar
  10. 10.
    Mortenson MM, Evans DB, Lee JE, Hunter GJ, Shellingerhout D, Vu D, et al. Parathyroid exploration in the reoperative neck: improved preoperative localization with 4D-computed tomography. J Am Coll Surg. 2008;206(5):889–95; discussion 895–6.CrossRefGoogle Scholar
  11. 11.
    Karakas E, Müller HH, Schlosshauer T, et al. Reoperations for primary hyperparathyroidism: improvement of outcome over 2 decades. Langenbecks Arch Surg. 2013;398(1):99–106.CrossRefPubMedGoogle Scholar
  12. 12.
    Thompson GB, Grant CS, Perrier ND, Harman R, Hodgson SF, Ilstrup D, et al. Reoperative parathyroid surgery in the era of sestamibi scanning and intraoperative parathyroid hormone monitoring. Arch Surg. 1999;134(7):699–05.CrossRefPubMedGoogle Scholar
  13. 13.
    Beland MD, Mayo-Smith WW, Grand DJ, Machan JT, Monchik JM. Dynamic MDCT for localization of occult parathyroid adenomas in 26 patients with primary hyperparathyroidism. AJR Am J Roentgenol. 2011;196(1):61–5.CrossRefPubMedGoogle Scholar
  14. 14.
    Kuo L, Wachtel H, Fraker D, Kelz R. Reoperative parathyroidectomy: who is at risk and what is the risk? J Surg Res. 2014;191(2):256–61.CrossRefPubMedGoogle Scholar
  15. 15.
    Kuhel WI, Kutler DI, Cohen M, Heineman T. Response to “parathyroid surgery: getting it right the first time”: parathyroid surgery: primum non nocere. Otolaryngol Head Neck Surg. 2016;154(2):397.CrossRefPubMedGoogle Scholar
  16. 16.
    Day KM, Elsayed M, Beland MD, Monchik JM. The utility of 4-dimensional computed tomography for preoperative localization of primary hyperparathyroidism in patients not localized by sestamibi or ultrasonography. Surgery. 2015;157(3):534–39.CrossRefPubMedGoogle Scholar
  17. 17.
    Galvin L, Oldan J, Bahl M, Eastwood J, Sosa J, Hoang J. Parathyroid 4D CT and scintigraphy: what factors contribute to missed parathyroid lesions? Otolaryngol Head Neck Surg. 2016;154 (5):847–53.CrossRefPubMedGoogle Scholar
  18. 18.
    Hinson AM, Lee DR, Hobbs BA, Fitzgerald RT, Bodenner DL, Stack BC Jr. Preoperative 4D CT localization of nonlocalizing parathyroid adenomas by US and SPECT-CT. Otolaryngol Head Neck Surg. 2015;153(5):775–78.CrossRefPubMedGoogle Scholar
  19. 19.
    Wagh ST, Razvi NA. Marascuilo method of multiple comparisons (an analytical study of caesarean section delivery). Int J Contemp Med Res. 2016;3(4):1137–40.Google Scholar
  20. 20.
    Suh YJ, Choi JY, Kim SJ, Chun IK, Yun TJ, Lee KE, et al. Comparison of 4D CT, ultrasonography, and sestamibi SPECT/CT in localizing single-gland primary hyperparathyroidism. Otolaryngol Head Neck Surg. 2015;152(3):438–43.CrossRefPubMedGoogle Scholar
  21. 21.
    Ginsburg M, Christoforidis GA, Zivin SP, Obara P, Wroblewski K, Angelos P, et al. Adenoma localization for recurrent or persistent primary hyperparathyroidism using dynamic four-dimensional CT and venous sampling. J Vasc Interv Radiol. 2015;26(1):79–86.CrossRefPubMedGoogle Scholar
  22. 22.
    Starker LF, Mahajan A, Björklund P, et al. 4D parathyroid CT as the Initial localization study for patients with de novo primary hyperparathyroidism. Ann Surg Oncol. 2011;18(6):1723–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery. 2006;140:932–40.CrossRefPubMedGoogle Scholar
  24. 24.
    Bahl M, Sepahdari A, Sosa J, Hoang J. Parathyroid adenomas and hyperplasia on four-dimensional CT scans: three patterns of enhancement relative to the thyroid gland justify a three-phase protocol. Radiology. 2015;277(2):454–62.CrossRefPubMedGoogle Scholar
  25. 25.
    Wang T, Cheung K, Farrokhyar F, Roman S, Sosa J. Would scan, but which scan? A cost-utility analysis to optimize preoperative imaging for primary hyperparathyroidism. Surgery. 2011;150(6):1286–94.CrossRefPubMedGoogle Scholar
  26. 26.
    Cham S, Sepahdari AR, Hall KE, Yeh MW, Harari A. Dynamic parathyroid computed tomography (4dct4d-ct) facilitates reoperative parathyroidectomy and enables cure of missed hyperplasia. Ann Surg Oncol. 2015;22(11):3537–42.CrossRefPubMedGoogle Scholar
  27. 27.
    Morris L, Lee S, Warneke C, Abadin S, Suliburk J, Romero Arenas M, et al. Fewer adverse events after reoperative parathyroidectomy associated with initial minimally invasive parathyroidectomy. Am J Surg. 2014;208(5):850–5.CrossRefPubMedGoogle Scholar
  28. 28.
    Duke W, Vernon H, Terris D. Reoperative parathyroidectomy: overly descended superior adenoma. Otolaryngol Head Neck Surg. 2016;154(2):268–71.CrossRefPubMedGoogle Scholar
  29. 29.
    McIntyre CJ, Allen JLY, Constantinides VA, Jackson JE, Tolley NS, Palazzo FF. Patterns of disease in patients at a tertiary referral centre requiring reoperative parathyroidectomy. Ann R Coll Surg Engl. 2015;97(8):598–02.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Society of Surgical Oncology 2018

Authors and Affiliations

  • Moska Hamidi
    • 1
  • Michael Sullivan
    • 2
  • George Hunter
    • 3
  • Leena Hamberg
    • 4
  • Nancy L. Cho
    • 4
  • Atul A. Gawande
    • 4
  • Gerard M. Doherty
    • 4
  • Francis D. MooreJr.
    • 4
  • Matthew A. Nehs
    • 4
    • 5
  1. 1.Division of General SurgeryLondon Health Sciences CenterLondonCanada
  2. 2.Division of General SurgeryJersey Shore University Medical CenterNeptune CityUSA
  3. 3.Department of RadiologyMassachusetts General HospitalBostonUSA
  4. 4.Department of SurgeryBrigham and Women’s HospitalBostonUSA
  5. 5.General and Endocrine Surgery, Brigham and Women’s HospitalHarvard Medical SchoolBostonUSA

Personalised recommendations