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CT in identifying within a calcific thyroid nodule the parathyroid responsible for primary hyperparathyroidism”
Letters to the Editor 837
Surgery Volume 140, Number 5
Y.Koike
Fig. Use of an internal thoracic artery holder.
ITA holder should prove to be a good tool during pancreaticojejunostomy training. Sohei Satoi, MD Hideyoshi Toyokawa, MD Hiroaki Yanagimoto, MD Yoichi Matsui, MD Soichiro Takai, MD Yasuo Kamiyama, MD Department of Surgery Kansai Medical University 2-3-1 Shi-machi, Hirakata Osaka 573-1191, Japan doi:10.1016/j.surg.2006.04.011
art in preoperative parathyroid localization in patients affected by hyperparathyroidism, in particular when conventional imaging procedures failed for intrinsic reasons. We report a case of a symptomatic hyperparathyroid patient in whom the parathyroid was located in a thyroid calcific mass, which was previously considered an old and negligible nodule in a multinodular goiter. A 74-year-old woman was hospitalized with a 1-week history of dyspnea. Physical examination revealed palpable nodules on both lower thyroid poles. A radiograph of the thorax showed a left compression of the trachea attributable to a partially plunged goiter. Thyroid color-Doppler ultrasonography revealed the presence of a multinodular goiter with a complex calcific mass and undetectable intranodular flow in the right lobe, and an isoechogenic nodule with prevalent perinodular flow in the partially plunged left lobe. Associated levels of free triiodothyronine, free thyroxine, and thyroid-stimulating hormone were normal, whereas serum concentrations of parathyroid hormone (PTH) and calcium were concomitantly increased (458 pg/mL and 11.6 mg/dL). Primary hyperparathyroidism was confirmed, and diagnostic fine-needle aspiration of the left nodule under direct ultrasonography guidance was performed. The result was inconclusive for nondiagnostic specimens for both cytology and PTH determination. Fineneedle aspiration was not practicable on the right calcific nodule. A parathyroid scan was performed after intravenous injection of 370 MBq of MIBI. Planar acquisition revealed two areas of focal MIBI uptake on both lower thyroid poles. The subsequent SPECT/CT performed with the use of a hybrid gamma camera (Infinia Hawkey-General Electrics, Milwaukee, Minn) identified the complex composition of the calcific mass characterized by an inhomogeneous cyst with a subtotal calcific wall (Fig 1, A); an area of increased MIBI uptake (Fig 1, B) was located in the dorsal side. The second MIBI-positive nodule was confirmed on the lower pole of the contralateral thyroid lobe. Examination of the right specimen after total thyroidectomy revealed the presence of a calcific cyst in partial necrotic/ haemorrhagic involution with a “clear cell” parathyroid carcinoma with capsular invasion in it. The presence of a multicentric follicular carcinoma was revealed by histologic tests of the left thyroid nodule.2 After thyroid resection both PTH serum and calcium levels returned to normal (13 pg/mL and 7.5 mg/dL at 6 days postsurgery). This scenario suggests that MIBI SPECT/CT can be considered the best procedure in identifying and locating the normotopic or ectopic glands in patients affected by hyperparathyroidism even when these glands are hidden within “stone walls.”
“Decisive presurgical role of MIBI SPECT/CT in identifying within a calcific thyroid nodule the parathyroid responsible for primary hyperparathyroidism”
Mario Piga, MD Alessandra Serra, MD Department of Nuclear Medicine Policlinico Universitario Cagliari, Italy
To the Editors: 99mTc-Sestamibi (MIBI) single-photon emission computed tomography (SPECT) combined with computed tomographic (CT)1 scanning represents the state of the
Alessandro Uccheddu, MD Department of Surgery Policlinico Universitario Cagliari, Italy
838 Letters to the Editor
Surgery November 2006
Fig 1. Parathyroid MIBI SPECT/CT in a 74-year-old woman with primary hyperparathyroidism. Transaxial CT image shows the calcific cyst located in the lower pole of the right thyroid lobe (A). Image fusion SPECT/CT (B) precisely defined the characteristics of the inhomogeneous cyst with a calcific wall; an area of increased MIBI uptake located in the dorsal side was shown histologically as a parathyroid carcinoma. Maria Letizia Lai, MD Gavino Faa, MD Department of Cytomorphology San Giovanni di Dio Hospital Cagliari, Italy
mary, recurrent, and persistent hyperparathyroidism. Surgery 2004;135:157-62. 2. Boi F, Lai ML, Deias C, et al. The usefulness of 99mTc-SestaMIBI scan in the diagnostic evaluation of thyroid nodules with oncocytic cytology. Eur J Endocrinol 2003;149:493-8.
1. Profanter C, Wetscher GJ, Gabriel M, et al. CT-MIBI image fusion: a new preoperative localization technique for pri-
doi:10.1016/j.surg.2006.04.009
References
Surgery Volume 140, Number 5
Y.Koike
Fig. Use of an internal thoracic artery holder.
ITA holder should prove to be a good tool during pancreaticojejunostomy training. Sohei Satoi, MD Hideyoshi Toyokawa, MD Hiroaki Yanagimoto, MD Yoichi Matsui, MD Soichiro Takai, MD Yasuo Kamiyama, MD Department of Surgery Kansai Medical University 2-3-1 Shi-machi, Hirakata Osaka 573-1191, Japan doi:10.1016/j.surg.2006.04.011
art in preoperative parathyroid localization in patients affected by hyperparathyroidism, in particular when conventional imaging procedures failed for intrinsic reasons. We report a case of a symptomatic hyperparathyroid patient in whom the parathyroid was located in a thyroid calcific mass, which was previously considered an old and negligible nodule in a multinodular goiter. A 74-year-old woman was hospitalized with a 1-week history of dyspnea. Physical examination revealed palpable nodules on both lower thyroid poles. A radiograph of the thorax showed a left compression of the trachea attributable to a partially plunged goiter. Thyroid color-Doppler ultrasonography revealed the presence of a multinodular goiter with a complex calcific mass and undetectable intranodular flow in the right lobe, and an isoechogenic nodule with prevalent perinodular flow in the partially plunged left lobe. Associated levels of free triiodothyronine, free thyroxine, and thyroid-stimulating hormone were normal, whereas serum concentrations of parathyroid hormone (PTH) and calcium were concomitantly increased (458 pg/mL and 11.6 mg/dL). Primary hyperparathyroidism was confirmed, and diagnostic fine-needle aspiration of the left nodule under direct ultrasonography guidance was performed. The result was inconclusive for nondiagnostic specimens for both cytology and PTH determination. Fineneedle aspiration was not practicable on the right calcific nodule. A parathyroid scan was performed after intravenous injection of 370 MBq of MIBI. Planar acquisition revealed two areas of focal MIBI uptake on both lower thyroid poles. The subsequent SPECT/CT performed with the use of a hybrid gamma camera (Infinia Hawkey-General Electrics, Milwaukee, Minn) identified the complex composition of the calcific mass characterized by an inhomogeneous cyst with a subtotal calcific wall (Fig 1, A); an area of increased MIBI uptake (Fig 1, B) was located in the dorsal side. The second MIBI-positive nodule was confirmed on the lower pole of the contralateral thyroid lobe. Examination of the right specimen after total thyroidectomy revealed the presence of a calcific cyst in partial necrotic/ haemorrhagic involution with a “clear cell” parathyroid carcinoma with capsular invasion in it. The presence of a multicentric follicular carcinoma was revealed by histologic tests of the left thyroid nodule.2 After thyroid resection both PTH serum and calcium levels returned to normal (13 pg/mL and 7.5 mg/dL at 6 days postsurgery). This scenario suggests that MIBI SPECT/CT can be considered the best procedure in identifying and locating the normotopic or ectopic glands in patients affected by hyperparathyroidism even when these glands are hidden within “stone walls.”
“Decisive presurgical role of MIBI SPECT/CT in identifying within a calcific thyroid nodule the parathyroid responsible for primary hyperparathyroidism”
Mario Piga, MD Alessandra Serra, MD Department of Nuclear Medicine Policlinico Universitario Cagliari, Italy
To the Editors: 99mTc-Sestamibi (MIBI) single-photon emission computed tomography (SPECT) combined with computed tomographic (CT)1 scanning represents the state of the
Alessandro Uccheddu, MD Department of Surgery Policlinico Universitario Cagliari, Italy
838 Letters to the Editor
Surgery November 2006
Fig 1. Parathyroid MIBI SPECT/CT in a 74-year-old woman with primary hyperparathyroidism. Transaxial CT image shows the calcific cyst located in the lower pole of the right thyroid lobe (A). Image fusion SPECT/CT (B) precisely defined the characteristics of the inhomogeneous cyst with a calcific wall; an area of increased MIBI uptake located in the dorsal side was shown histologically as a parathyroid carcinoma. Maria Letizia Lai, MD Gavino Faa, MD Department of Cytomorphology San Giovanni di Dio Hospital Cagliari, Italy
mary, recurrent, and persistent hyperparathyroidism. Surgery 2004;135:157-62. 2. Boi F, Lai ML, Deias C, et al. The usefulness of 99mTc-SestaMIBI scan in the diagnostic evaluation of thyroid nodules with oncocytic cytology. Eur J Endocrinol 2003;149:493-8.
1. Profanter C, Wetscher GJ, Gabriel M, et al. CT-MIBI image fusion: a new preoperative localization technique for pri-
doi:10.1016/j.surg.2006.04.009
References