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have&#160;supernumerary parathyroid glands&#46; In the latter case the&#160;glands are usually ectopic&#46;&#160;This variation in number and location is due to&#160;differences in embryological development&#46; The upper&#160;parathyroid glands originate in the fourth pharyngeal&#160;pouch of the thyroid gland and little displacement is&#160;required for them to adopt their definitive position&#44; while&#160;the lower glands develop from the third pharyngeal&#160;pouch and migrate towards the pole&#46; As a result of this&#160;greater embryological migration&#44; the lower parathyroid&#160;glands may be more likely to adopt an ectopic position&#160;than the upper parathyroid glands&#46;&#160;On average the parathyroid glands are 2-7mm long and 2-&#160;4mm wide&#44; and 0&#46;5-2mm thick&#46;&#160;The imaging techniques available for evaluating the&#160;parathyroid glands in patients with SHPT include the&#160;following &#40;figure 1&#41;&#58;</p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">CERVICAL ECHOGRAPHY</span></p><p class="elsevierStylePara">Cervical echography was the first imaging technique&#160;used to study the parathyroid glands and it continues to be a test we can recommend&#44; particularly in view of the&#160;fact that it is an economical and innocuous alternative&#44;&#160;although it has the disadvantage of being very dependent&#160;on technical expertise and&#44; consequently&#44; its sensitivity&#160;can vary considerably&#46;&#160;Colour Doppler linear multifrequency transducers &#40;7&#46;5-&#160;12MHz&#41; are used for studies of the parathyroid glands&#44;&#160;although in patients who are obese or who have a&#160;multinodular goitre transducers with lower frequencies&#160;&#40;5-7&#46;5MHz&#41; are employed&#46;</p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">Exploration Technique</span></p><p class="elsevierStylePara">When a scan is performed&#44; the neck of the patient must&#160;be slightly stretched&#46; Images are taken of each side of&#160;the neck in longitudinal and transversal sections&#44; as well&#160;as from front to back and also with the head rotated&#160;sideways 45&#186;&#46;&#160;The thyroid gland is used as an anatomical reference&#44;&#160;given that most pathological parathyroid glands will be&#160;found behind&#44; at the sides of or below the thyroid gland&#46;&#160;Other anatomical points of reference are the long muscle&#160;of the neck&#44; the lower neurovascular bundle &#40;lower&#160;thyroid artery and recurrent laryngeal nerve&#41; and the&#160;oesophagus&#46; The scan must cover the area from the&#160;submandibular gland to the subclavian vein and laterally&#160;from the tracheal midline to the carotid artery and&#160;jugular vein&#44; as well as the area corresponding to the&#160;aortic arch&#44; in order to exclude the presence of ectopic&#160;pathological glands&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ECHOGRAPHIC DIAGNOSIS&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Mode B Echography</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span>While the first echographic scanners only permitted onedimensional&#160;images &#40;mode A&#41;&#44; with the development of&#160;brightness modulation &#40;mode B&#41;&#44; in which variations in the&#160;amplitude of pulsations are represented at each point by&#160;different shades of grey&#44; it was possible to view an&#160;anatomical image&#46;&#160;Normal parathyroid glands are not visible in mode B&#160;echography&#46; This is due to their small size and the fact&#160;that their echogenicity is very similar to that of the&#160;thyroid gland&#46;&#160;Enlarged parathyroid glands are perceived as a nodular&#44;&#160;hypoechoic&#44; homogenous image&#44; which is rounded or&#160;oval in shape with smooth contours delimited by a fine&#160;echogenic line corresponding to the glandular capsule&#46;&#160;When they are oval&#44; their longitudinal axis is parallel to the longitudinal axis of the thyroid gland&#46; In about 15-&#160;20&#37; of cases&#44; the glandular echostructure may be&#160;heterogeneous&#44; owing to the presence of necrosis and&#47;or&#160;haemorrhage or even calcification&#44; especially in very&#160;enlarged parathyroid glands&#46;&#160;Various studies have demonstrated an excellent&#160;correlation between echographic measurements and the&#160;weight of resected glands and some of them have shown a&#160;correlation between glandular size and the severity and&#160;prognosis for secondary hyperparathyroidism and its&#160;response to treatment&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;Doppler and Colour Doppler Echography</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span>Pulsed Doppler</p><p class="elsevierStylePara">The combination of echography and the Doppler technique&#160;enabled vascular structures to be studied&#44; which allows&#160;velocities and flows to be estimated&#46;</p><p class="elsevierStylePara">Colour Doppler</p><p class="elsevierStylePara">When colour-Doppler is used the data on velocities and&#160;frequencies can be converted to produce a colour image&#46;&#160;Flow direction is expressed in red if it is positive and in blue&#160;if it is negative&#44; irrespective of whether the vessel in question&#160;is an artery or a vein&#46;&#160;With the colour Doppler technique pathological glands&#160;usually demonstrate a hypervascular pattern&#44;<span class="elsevierStyleSup">4 </span>the increase in&#160;vascularization showing an intraparenchymal distribution&#44;&#160;with no perinodular component&#44; although the latter is not&#160;always observed&#46;</p><p class="elsevierStylePara">Power-Doppler Echography</p><p class="elsevierStylePara">This technique is based on the analysis of the amplitude&#160;of mobile echoes inside blood vessels&#44; yielding contrasted&#160;vascular structures&#44; and enabling smaller vessels to be&#160;identified&#44; which not only facilitates their identification&#160;but also evaluates any vascularization&#46;&#160;In this case the vascular pattern is the characteristic of&#160;an arterial bed with low resistance and a continuous flow&#160;is observed during diastolic movements&#46;&#160;A recent study<span class="elsevierStyleSup">5 </span>demonstrated that 60&#37; of glands with no&#160;power Doppler result corresponded to diffuse hyperplasia&#160;or hyperplasia with initial nodularity&#44; while 83&#46;7&#37; of&#160;glands which produced power Doppler readings&#160;presented nodular hyperplasia&#44; even in parathyroid&#160;glands weighing 0&#46;5g or less&#46;&#160;An absence of vascularization has been described in&#160;approximately 10&#37; of pathological parathyroid glands&#44;&#160;owing to&#58; <span class="elsevierStyleItalic">1&#41; </span>size less than 1cm&#59; <span class="elsevierStyleItalic">2&#41; </span>deep location&#59; <span class="elsevierStyleItalic">3&#41; </span>location&#160;close to large vessels&#44; meaning there are transmission&#160;artefacts&#44; and <span class="elsevierStyleItalic">4&#41; </span>the existence of areas of necrosis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIAGNOSTIC PROBLEMS</span></p><p class="elsevierStylePara">In general&#44; the sensitivity and specificity of echography&#160;in parathyroid pathology studies are conditioned by&#160;various factors&#46;&#160;The diagnostic sensitivity of echography is influenced&#160;by&#58; <span class="elsevierStyleItalic">a&#41; </span>the location of the pathological gland &#40;atypical&#160;location&#44; ectopic glands&#41;&#59; <span class="elsevierStyleItalic">b&#41; </span>their size &#40;&#60; 1cm&#41;&#59; <span class="elsevierStyleItalic">c&#41; </span>the&#160;coexistence of goitre and <span class="elsevierStyleItalic">d&#41; </span>a history of cervical&#160;surgery&#46;&#160;With respect to specificity&#44; as well as the diagnostic&#160;problems which may occur with adenopathies of the&#160;cervical spine and thyroid nodules&#44; there are two&#160;problems which are related to anatomical structures&#58; the&#160;thyroid vein &#40;it may cross the lower third of the thyroid&#160;lobe and be mistaken for an enlarged parathyroid gland&#41;&#160;and the long muscle of the neck&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INDICATIONS</span></p><p class="elsevierStylePara">The classic indication for mode B echography in SHPT&#160;studies is the pre-surgical location of pathological glands&#160;&#40;figure 2&#41;&#46;&#160;Although in SHPT more than one gland is affected and&#44;&#160;consequently&#44; minimally invasive surgery is not applicable&#44;&#160;the localization of the glands enables surgical exploration to&#160;be curtailed&#44; thus reducing intervention time and surgical&#160;trauma&#46;&#160;Colour Doppler imaging proves useful when&#44; in mode B&#160;studies&#44; there are diagnostic problems with thyroid nodules&#160;or cervical adenopathies&#46;&#160;With power Doppler imaging arterial flow can be assessed&#160;and&#44; consequently&#44; to some extent&#44; the degree of activity and&#160;then&#44; from this&#44; probably the response to treatment&#44; although&#160;for this purpose gammagraphy would seem more advisable&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Echography-guided Interventions</span></p><p class="elsevierStylePara">The applications of echography as a guide to intervention&#160;procedures in SHPT include&#58;&#160;1&#46; Fine-needle puncture aspiration &#40;FNPA&#41;&#160;2&#46; Percutaneous ablative treatment of adenomas or&#160;parathyroid gland hyperplasia&#160;FNPAs are of interest for characterizing nodular cervical&#160;lesions&#44; when there is reason to suspect intrathyroid&#160;parathyroid glands&#46;&#160;Percutaneous ablation with alcohol or even calcitriol<span class="elsevierStyleSup">6-8&#160;</span>consists of percutaneous injection of ethanol or calcitriol into&#160;the hyperplastic glands&#47;adenomas&#44; with the aim of reducing&#160;the PTH-producing mass&#46;&#160;It may be indicated in patients with medical problems where&#160;surgery is contraindicated&#46; In some centres it is currently&#160;used as an adjuvant to medical therapy&#46; The size of the gland&#160;amenable to percutaneous ablation varies from one centre to&#160;another &#40;generally &#62; 5-10mm&#41;&#46;&#160;The results described in recently published studies are much&#160;better than in early studies&#46; Normal long-term serum PTH&#160;levels &#40;1-3 years&#41; have been described in approximately 80&#37;&#160;of the patients who have been treated and the smaller the&#160;number of enlarged glands the better the results&#46;&#160;Greater effectiveness has been reported for the alcoholization&#160;of less vascularized parathyroid glands than for glands which&#160;demonstrate a significant initial Doppler reading&#46;&#160;The complications which may be associated with the&#160;procedure are primarily paralysis of the recurrent nerve&#44;&#160;which is usually temporary&#44; and peri-glandular fibrosis&#44;&#160;which may make subsequent surgery difficult&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RADIONUCLIDE STUDIES</span></p><p class="elsevierStylePara">Gammagraphy</p><p class="elsevierStylePara">The first studies of parathyroid tissue functionality were&#160;conducted at the beginning of the 1980s using potassium&#160;analogues&#44; such as thallium-201&#46;<span class="elsevierStyleSup">9-11&#160;</span>Although gammagraphy using thallium-201 is still in use&#44;&#160;nowadays other radiodrugs such as technetium-99m metoxyisobutyl-&#160;isonitrile &#40;MIBI&#41; or technetium-99m tetrofosmin&#160;&#40;TTF&#41; are used&#44; chiefly because of the better physical&#160;properties of technetium-99m&#46; In fact&#44; MIBI is in the process&#160;of becoming the main radiodrug employed in the majority of&#160;nuclear medicine departments&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Radionuclides</span></p><p class="elsevierStylePara">Gammagraphy using Thallium &#40;thallium-201&#41;</p><p class="elsevierStylePara">Thallium is an analogue of potassium&#46; It reaches the tissues&#160;in a manner which is proportionate to blood flow and it&#160;enters the cell actively&#44; being transported across the cell&#160;membrane by the Na-K-ATPase pump&#46;&#160;When gammagraphy with thallium is performed&#44; the&#160;simultaneous thyroid uptake measured by technetium-99m&#160;thyroid gammagraphy needs to be subtracted from the results&#160;to avoid interferences from thyroid tissue&#46;<span class="elsevierStyleSup">10&#160;</span>Although some initial studies have reported that thallium-&#160;201 demonstrates good sensitivity in the identification of&#160;hyperplastic parathyroid glands&#44;<span class="elsevierStyleSup">9&#44;11 </span>the quality of the images&#160;is substantially poorer than images obtained using TTF and&#160;MIBI&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Double-phase MIBI Gammagraphy</p><p class="elsevierStylePara">Parathyroid double-phase MBI gammagraphy is the most&#160;widely used nuclear medicine technique for visualizing&#160;abnormal parathyroid glands&#46; The compound used is hexakis&#160;isobutyl isonitrile &#40;sestamibi&#41; &#40;MIBI&#41;&#46;&#160;MIBI uses <span class="elsevierStyleSup">99m</span>Tc as a marker&#44; a radionuclide with a very short&#160;half-life&#44; enabling high doses to be administered without&#160;exposing patients to high levels of radioactivity&#44; which at the&#160;same time ensures better imaging quality and lower&#160;absorption by other tissues&#46;<span class="elsevierStyleSup">12&#160;</span>The procedure entails the intravenous injection of 20mCi&#160;&#40;740MBq&#41; of MIBI&#46;&#160;The images are obtained with the patient lying down&#44; if&#160;possible with their neck stretched&#46; Frontal images are&#160;obtained of an area which includes the neck and upper&#160;thorax&#46;&#160;MIBI is taken up by both hyperfunctioning parathyroid and&#160;thyroid tissue&#44; but&#44; unlike thallium&#44; there is a difference in its&#160;elimination from the hyperfunctioning thyroid and&#160;parathyroid glands&#44; the process being more rapid in the&#160;thyroid glands&#46;&#160;In a gammagraphy study an initial phase &#40;thyroid phase&#41; is&#160;obtained at 15 minutes and a late phase &#40;parathyroid phase&#41; at&#160;60 minutes&#46; Thyroid tissue has a physiological affinity during&#160;the initial phase&#44; but clearance is rapid and normally any&#160;thyroid gland activity disappears&#46; Normal parathyroid tissue&#160;shows no uptake in either of the two phases&#46; Abnormal glands&#160;have a tendency to retain the tracer&#44; which is visualized in the&#160;late phase&#46; Thus&#44; in cases of hyperplasia&#47;adenoma&#44; images are&#160;obtained of areas of hyperactive uptake activity&#44; which are&#160;marked to a greater or lesser extent and are sometimes visible&#160;even in the initial phase image&#46;&#160;Athyroid gland gammagraphy which is complementary to the&#160;MIBI gammagraphy is recommended in regions where goitre&#160;is endemic&#44; in order to avoid false positives&#46; The possibility of&#160;clearances in similar times for both tissues&#44; which could lead to&#160;false negatives&#44; has also been described&#46;<span class="elsevierStyleSup">13&#44;14&#160;</span>In MIBI gammagraphy&#44; qualitative&#44; quantitative or semiquantitative&#160;methods can be used to calculate the uptake&#160;index of pathological parathyroid glands&#58;&#160;1&#46; Qualitative methods merely confirm the presence or&#160;absence of hyperfunctioning glands&#46;&#160;2&#46; Quantitative methods include digital visualization&#44; which&#160;corresponds to the late or parathyroid phase&#46; The image&#160;is used to create a ROI &#40;<span class="elsevierStyleItalic">region of interest</span>&#41; in the&#160;parathyroid gland&#44; which exhibits high uptake&#44; and in the&#160;thyroid gland&#46; The activity&#47;pixel average in the&#160;parathyroid lesion is divided by the activity&#47;pixel average&#160;of the thyroid gland to determine the increase in the&#160;activity of the parathyroid gland&#46;&#160;3&#46; Semi-quantitative methods employ different grading&#160;options&#46; Our experience using a semi-quantitative system&#160;has shown it to be very useful&#46; The system awards a&#160;score of &#8220;0&#8221; to a lack of uptake&#44; a score of &#8220;1&#8221; &#40;mild&#41; if&#160;uptake is similar to that of bone or soft tissue&#44; a score of&#160;&#8220;2&#8221; &#40;moderate&#41; if the level of uptake is between 1 and&#160;that of the salivary glands&#44; and a score of &#8220;3&#8221; &#40;intense&#41; if&#160;it is similar or higher than the salivary glands&#46;<span class="elsevierStyleSup">15&#160;</span>This semi-quantitative system has been useful in helping us&#160;to decide which gland should be left in place or employed&#160;for an auto-transplant &#40;the one with the least uptake&#41; when a&#160;partial parathyroidectomy or a parathyroidectomy with an&#160;auto-transplant&#44; respectively&#44; is performed&#46; It has also been&#160;very useful for evaluating the efficacy of the medical&#160;treatment of SHPT&#44; both with vitamin D analogues and&#160;calcimimetic agents&#46; And&#44; finally&#44; it has served as a means of&#160;predicting the results of medical treatment and for deciding&#160;whether to perform a parathyroidectomy &#40;it is unlikely that a&#160;patient with an intense level of uptake will respond to&#160;medical treatment&#41;&#46;<span class="elsevierStyleSup">15-17</span></p><p class="elsevierStylePara">Gammagraphy with Tetrofosmin</p><p class="elsevierStylePara">Tetrofosmin &#40;TTF&#41; is a molecule which is similar to MIBI&#160;and it has been proposed as a tracer for the pre-surgical&#160;detection and screening of abnormal parathyroid glands&#44;&#160;although it is cleared more slowly in thyroid tissue than&#160;MIBI and the interpretation of double-phase images is more&#160;complex&#46;<span class="elsevierStyleSup">18&#44;19</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">SPECIAL TECHNIQUES FOR OBTAINING IMAGES&#160;GAMMAGRAPHY USING A PINHOLE COLLIMATOR</span></p><p class="elsevierStylePara">Gammagraphic images are usually visible in one plane &#40;twodimensional&#41;&#44;&#160;but there are special techniques which enable&#160;their definition and sensitivity to be improved&#46; One of them&#160;involves using a Pinhole collimator&#44; which takes the form of&#160;a cone and has the unique ability to produce a magnified&#160;inverted image&#46;&#160;The addition of Pinhole images during the late phase of&#160;<span class="elsevierStyleSup">99m</span>Tc-MIBI gammagraphy can increase the rate of detection&#160;of adenomas in indeterminate or initially negative studies&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Gammagraphy combined with the SPECT &#40;Singlephoton&#160;Emission Computed Tomography&#41; Technique</span></p><p class="elsevierStylePara">Gammagraphy with SPECT&#44; which enables 360&#186; images&#160;in three spatial planes to be obtained &#40;three-dimensional&#160;images&#41;&#44; has increased the ability of the method to locate&#160;the parathyroid glands and has permitted the detection of&#160;small lesions&#44; which has given the technique greater&#160;precision&#46;&#160;Some groups use SPECT together with the <span class="elsevierStyleItalic">pin-hole&#160;</span>technique&#44; which results in a significant increase in&#160;sensitivity&#46;<span class="elsevierStyleSup">20&#44;21 </span>However&#44; the use of this technique in clinical&#160;practice is controversial&#44; given that the <span class="elsevierStyleItalic">pin-hole </span>method is&#160;not suitable for the detection of ectopic glands located in the&#160;mediastinum&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Factors which Influence Radiotracer Uptake</span></p><p class="elsevierStylePara">Although the main factor affecting the localization of&#160;hyperfunctional parathyroid glands by nuclear medicine&#160;techniques seems to be related to their size&#44; the comparison&#160;of morphological and functional data suggests that either&#160;TTF or MIBI gammagraphy not only reveals an increase in&#160;the size of glands but also identifies the presence of&#160;hyperfunction in parathyroid tissue&#46;&#160;Small adenomas have been easy to identify but the downside&#160;is that false negatives have been described in fairly enlarged&#160;glands&#46; Consequently&#44; size is not the only factor which&#160;decides ease of detection&#46;&#160;The mechanism by means of which the radionuclide remains&#160;for a long period of time in hyperfunctional glands is&#160;unknown&#44; but it is probably the result of one or several&#160;circumstances&#44; such as the phase of the cell cycle&#44; the type of&#160;cell&#44; mitochondrial density&#44; the presence&#47;absence of&#160;expression proteins&#44; such as P-glycoprotein&#44; and specific&#160;biochemical markers like PTHi and calcaemia&#46;<span class="elsevierStyleSup">22&#160;</span>In general&#44; the uptake of both MIBI and TTF is&#160;considered to be greater in cases of nodular hyperplasia&#160;than in diffuse hyperplasia&#46; In patients with SHPT the&#160;intensity of the focal uptake of MIBI in the parathyroid&#160;glands was considered to be directly related to the&#160;phase of the cell cycle&#46; Higher uptake levels correlate&#160;with the active phase of cell growth&#44; indicating that&#160;MIBI gammagraphy reflects the functional state of the&#160;gland&#46;<span class="elsevierStyleSup">23&#160;</span>The radiotracer seems to show more intense accumulation in&#160;glands that have large areas of oxyphilic cells which are rich&#160;in mitochondria than in areas with normal cell types&#46;<span class="elsevierStyleSup">24&#160;</span>Some authors have found a correlation between serum&#160;calcium levels&#44; PTH levels and numbers of oxyphilic cells in&#160;tissues&#44; as well as between calcium levels and initial tracer&#160;uptake&#46;<span class="elsevierStyleSup">24 </span>Thus&#44; serum calcium levels could play an important&#160;role in modifying the kinetic properties of MIBI by&#160;influencing membrane potentials&#46;&#160;The level of radiotracer uptake has shown a significant&#160;correlation with the presence of greater numbers of&#160;mitochondria in the glands&#46;<span class="elsevierStyleSup">25 </span>The link which exists between&#160;MIBI uptake and retention and the number of mitochondria&#160;could also explain why uptake is greater in abnormal&#160;parathyroid tissue&#44; this constituting an indicator of metabolic&#160;activity within cells&#46;&#160;The relationship between the uptake of radiotracers and the&#160;expression of P-glycoprotein has been studied in&#160;hyperfunctional parathyroid glands&#46; It has been noted that&#160;radiotracers are rapidly eliminated from parathyroid glands&#160;which contain P-glycoprotein and&#44; therefore&#44; the uptake seen&#160;in images will be negative&#46; In parathyroid glands which do&#160;not contain P-glycoprotein the radiotracer stays in the cells&#44;&#160;which makes it easier to detect them by gammagraphy&#46;<span class="elsevierStyleSup">26-28&#160;</span>An increase in the expression of P-glycoprotein could be&#160;responsible for some false negatives in parathyroid&#160;gammagraphy&#46; Similar results have been obtained using&#160;TTF&#46;&#160;There is a significant correlation between MIBI uptake and&#160;serum PTHi values&#44; but not with serum calcium&#44; phosphorus&#44;&#160;25-OH vitamin D or 1&#46;25-OH vitamin D levels&#46;<span class="elsevierStyleSup">29&#160;</span>Calcium channel blockers&#44; which are normally prescribed to&#160;treat hypertension&#44; have been shown to reduce the secretion&#160;of PTH <span class="elsevierStyleItalic">in vitro </span>and to have an effect on the membrane&#160;potential of parathyroid cells&#44; which could reduce their&#160;sensitivity to MIBI&#46;<span class="elsevierStyleSup">30</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgery Radioguided by MIBI Gammagraphy</span></p><p class="elsevierStylePara">By means of a gamma radiation detection probe which&#160;permits acoustic signals to be obtained and by measuring&#160;radioactive activity&#44; a surgeon can be guided during an&#160;operation involving the excision of pathological thyroid&#160;glands&#46;&#160;The technique is recommended for single adenomas which&#160;are visible in MIBI images without the presence of active&#160;thyroid nodules that could interfere with their detection&#44;&#160;when there is no previous history of cervical irradiation or a&#160;family history of MEN&#46;<span class="elsevierStyleSup">31 </span>This technique is also indicated in&#160;patients who have been operated on more than once due to&#160;the persistence or recurrence of their hyperparathyroidism&#160;and when there is reason to suspect ectopic glands&#46;&#160;Its most obvious advantages are the reduction in surgery&#160;time and the possibility of verifying the correct excision of&#160;parathyroid tissue&#44; given that the radioactive activity of the&#160;tissue which has been surgically removed can be measured&#160;<span class="elsevierStyleItalic">ex vivo&#46;</span><span class="elsevierStyleSup">32 <br></br></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Positron Emission Tomography &#40;PET&#41;</span></p><p class="elsevierStylePara">PET is a non-invasive technique which enables images that&#160;reflect the metabolic activity of the parathyroid glands to be&#160;obtained&#46;&#160;This technique employs isotopes which emit positrons&#160;&#40;positive electrons&#41;&#46; These isotopes generally have a very&#160;short average-life&#44; which also means a reduction in the period&#160;of exposure and exploration&#46; The agents used for PET offer&#160;better definition than those that are used for gammagraphy&#46;&#160;Carbon-11 labelled with methionine is recommended for&#160;studying the parathyroid glands&#46;&#160;Some studies have demonstrated a good correlation between&#160;<span class="elsevierStyleSup">11</span>C-methionine uptake and PTH and calcium levels&#46;<span class="elsevierStyleSup">33-35&#160;</span>PET using <span class="elsevierStyleSup">11</span>C-methionine can be a useful method in patients&#160;with secondary hyperparathyroidism when the results of&#160;echography and gammagraphy have proved negative or&#160;inconclusive&#46; Furthermore&#44; ectopic glands are identified with&#160;greater precision by PET than by conventional gammagraphy&#44;&#160;as it enables three-dimensional images to be obtained&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INDICATIONS</span></p><p class="elsevierStylePara">We can regard MIBI gammagraphy as our first option for&#160;identifying hyperfunctioning parathyroid glands &#40;figure 2&#41;&#46;&#160;Although SHPT patients who have not undergone surgical&#160;intervention may not need prior localization&#44; owing to the&#160;high success rate of cervical exploration&#44; the fact that the&#160;percentage of SHPT relapses &#40;10-30&#37;&#41;&#44; the main cause of&#160;which continues to be the incomplete localization of the&#160;glands&#44; is not insignificant needs to be considered&#46;&#160;This is especially evident in patients who have repeat&#160;operations&#44; in whom MIBI plays an important role in the&#160;detection of ectopic glands&#44; relapses <span class="elsevierStyleItalic">in situ </span>or the&#160;hyperfunction of an auto-transplant&#46;<span class="elsevierStyleSup">36&#160;</span>It may also be useful to decide the amount of gland which&#160;should be left or to employ for an auto-transplant when a&#160;partial parathyroidectomy or a total parathyroidectomy and&#160;an auto-transplant&#44; respectively&#44; are performed&#46; In these&#160;cases it would be advisable to remove the glands with the&#160;highest uptake and leave less active glands&#44; which would&#160;reduce the risk of relapse&#46;&#160;It may also be useful to evaluate and&#47;or predict the response&#160;to medical treatment&#46;&#160;In the most recent studies the authors coincide in regarding&#160;echography and <span class="elsevierStyleSup">99m</span>Tc-MIBI gammagraphy as complementary&#160;techniques and in recommending their combined use&#46;<span class="elsevierStyleSup">37&#160;</span>PET should be reserved for locating parathyroid&#160;hyperplasia&#47;adenoma when both echography and MIBI&#160;gammagraphy have produced negative results&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Computed Tomography and Nuclear Magnetic&#160;Resonance</span></p><p class="elsevierStylePara">Computed tomography &#40;CT&#41; can locate parathyroid glands&#160;which are less than 4mm in size&#44; as well as peri-thyroid&#44;&#160;substernal or retroclavicular soft tissue masses&#46; Some series&#160;have reported that its sensitivity is similar to that of&#160;gammagraphy and echography in the diagnosis of multiglandular&#160;parathyroid disease&#44; but the cost is greater and the&#160;detection of parathyroid tissue which is adjacent to the&#160;thyroid gland may be difficult&#46;<span class="elsevierStyleSup">38&#160;</span>With the administration of intravenous contrast agent and the&#160;0&#46;5mm slices obtained by modern equipment&#44; the sensitivity&#160;of the technique has improved&#44; achieving a success rate of up&#160;to 80&#37;&#46;&#160;CT can detect ectopic parathyroid glands&#44; although glands&#160;which are situated at the level of the shoulder or sternum are&#160;difficult to visualize because of the artefacts caused by&#160;bones&#44; as it occurs in patients who have been operated on&#160;more than once&#44; owing to the presence of metallic artefacts&#160;from previous operations&#46;&#160;Nuclear magnetic resonance &#40;NMR&#41; seems to be more&#160;sensitive and&#44; moreover&#44; it offers the possibility of improving&#160;images by the use of contrast agent and 3-D reconstruction&#46;&#160;Parathyroid adenomas have weak signals in T1-weighted&#160;images and strong signals in T2 images&#44; which can be&#160;improved if gadolinium can be employed&#46;&#160;Several studies refer to NMR as an imaging test which is&#160;more sensitive than CT&#44;<span class="elsevierStyleSup">39&#44;40 </span>although it is more difficult to&#160;differentiate parathyroid adenomas from thyroid lesions&#46;</p><p class="elsevierStylePara">Indications</p><p class="elsevierStylePara">Localization of parathyroid hyperplasia&#47;adenoma when the&#160;above tests &#40;echography and MIBI gammagraphy&#41; have&#160;proved negative and the PET technique is not available&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">HYBRID SCANNERS</span></p><p class="elsevierStylePara">The recent introduction of hybrid scanners for diagnostic&#160;purposes may have advantages compared to gammagraphy&#160;or PET alone&#46;&#160;Both SPECT&#47;CT and PET&#47;CT provide images that merge the&#160;anatomical and functional modalities of the gland&#44; which&#160;considerably improves the interpretation of the findings&#160;obtained for each of the techniques when they are used&#160;separately&#46;<span class="elsevierStyleSup">41</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Indications</span></p><p class="elsevierStylePara">Currently they are only indicated for the location of&#160;hyperfunctional glands when all the above techniques have&#160;failed&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; To sum up &#40;figure 3&#41;&#44; nowadays&#44; in all patients&#160;with SHPT who do not respond readily to&#160;medical treatment at the outset&#44; we&#160;recommend an MIBI gammagraphy which can&#160;be complemented with a colour Echo-Doppler&#160;scan&#46;</p><p class="elsevierStylePara">2&#46; If gammagraphy proves positive and&#44; after&#160;measuring the intensity of uptake&#44; any of the&#160;&#40;non-ectopic&#41; glands has an intense index &#40;3&#41;&#44;&#160;although an attempt can be made to intensify&#160;treatment&#44; we should consider the possibility&#160;of a parathyroidectomy&#46;</p><p class="elsevierStylePara">3&#46; If the findings of the gammagraphy are&#160;positive&#44; and&#44; after measuring the intensity of&#160;uptake&#44; any of the &#40;non-ectopic&#41; glands has an&#160;intense index &#40;3&#41;&#44; in other words they are grade&#160;1 or 2&#44; an attempt should be made to intensify&#160;treatment and&#44; if the response is not good&#44; a parathyroidectomy should be considered&#46;</p><p class="elsevierStylePara">4&#46; If the gammagraphy is negative&#44; we should&#160;perform a PET or hybrid scan&#44; if this is an option&#46; If&#160;them are not available&#44; an NMR scan is&#160;recommended&#46; Once the gland&#40;s&#41; have been&#160;located&#44; we would then propose a&#160;parathyroidectomy&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f1&#95;imaging&#95;techniques&#95;in&#95;secondary&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f1_imaging_techniques_in_secondary.jpg" alt="Imaging techniques in Secondary Hyperparathyroidism"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Imaging techniques in Secondary Hyperparathyroidism</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f2&#95;secondary&#95;hyperparathyroidism&#95;imaging&#95;tables&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f2_secondary_hyperparathyroidism_imaging_tables.gif" alt="Secondary Hyperparathyroidism Imaging Tables&#58; Indications"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Secondary Hyperparathyroidism Imaging Tables&#58; Indications</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f3&#95;imaging&#95;techniques&#95;in&#95;secondary&#95;hyperparathyroidism&#95;application&#95;algorithm&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f3_imaging_techniques_in_secondary_hyperparathyroidism_application_algorithm.jpg" alt="Imaging techniques in Secondary Hyperparathyroidism&#58; application algorithm&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Imaging techniques in Secondary Hyperparathyroidism&#58; application algorithm&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">For patients with chronic renal failure who develop secondary hyperparathyroidism &#40;SHPT&#41;&#44; imaging techniques can be useful&#44; especially to evaluate the location&#44; size and functional status of parathyroid glands&#46; This review analyzes all available imaging procedures in the context of SHPT&#46; We evaluate&#58; 1&#41; Cervical ultrasound &#40;B-mode&#44; Doppler&#44; colour-Doppler and power-Doppler&#41;&#44; 2&#41; Scintigraphic studies &#40;Tallium&#44; 99mTc-MIBI and 99mTc-tetrofosmin&#41;&#44; including non-standard image acquisition techniques &#40;Pinhole&#44; SPECT&#41;&#44; 3&#41; Positron emission tomography &#40;PET&#41;&#44; 4&#41; Computed tomography &#40;CT&#41; and magnetic resonance imaging &#40;MRI&#41; and 5&#41; hybrid scanners &#40;SPECT&#47;CT and PET&#47;CT&#41;&#46; Our recommendation is that SHPT patients who are initially non responders to medical therapy should be investigated using parathyroid scintigraphy and cervical ultrasound&#46; 99mTc-MIBI uptake can be graded in a semiquantitative scale&#46; Intense uptake indicates a low probability of success using medical treatment and parathyroidectomy should be considered&#46; A moderate to faint uptake indicates that a more intensive medical therapy would probably be beneficial&#46; In the case of no uptake of 99mTc-MIBI&#44; PET should be performed&#46; Where this is not available&#44; MRI could be a possible alternative&#46;</p>"
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Usefulness of imaging techniques in secondary hyperparathyroidism
Utilidad de las técnicas de imagen en el hiperparatiroidismo secundario
José Vicente Torregrosaa, I.. Félezb, D.. Fusterb
a Servicio de Nefrología. Trasplante Renal, Hospital Clínic, Barcelona, España,
b Servicio de Medicina Nuclear, Hospital Clínic, Barcelona, España,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span>In patients with chronic kidney disease&#44; who develop&#160;secondary hyperparathyroidism &#40;SHPT&#41;&#44; imaging techniques&#160;can be useful&#44; basically to evaluate the location&#44; size and&#160;function of the parathyroid glands&#46;&#160;The embryology of the parathyroid glands is&#160;complex and a knowledge of their development and&#160;their possible anatomical locations can be useful&#160;when interpreting the findings of imaging&#160;techniques&#46;&#160;Eighty five percent of the population have 4 parathyroid&#160;glands&#44; two upper glands and two lower glands&#44; which&#160;are usually situated behind the middle-upper third and&#160;the lower pole&#44; respectively&#44; of each of the two thyroid&#160;lobes&#46;<span class="elsevierStyleSup">1 </span>From 1 to 7&#37; of individuals have only 3&#160;parathyroid glands and from 3 to 13&#37; have&#160;supernumerary parathyroid glands&#46; In the latter case the&#160;glands are usually ectopic&#46;&#160;This variation in number and location is due to&#160;differences in embryological development&#46; The upper&#160;parathyroid glands originate in the fourth pharyngeal&#160;pouch of the thyroid gland and little displacement is&#160;required for them to adopt their definitive position&#44; while&#160;the lower glands develop from the third pharyngeal&#160;pouch and migrate towards the pole&#46; As a result of this&#160;greater embryological migration&#44; the lower parathyroid&#160;glands may be more likely to adopt an ectopic position&#160;than the upper parathyroid glands&#46;&#160;On average the parathyroid glands are 2-7mm long and 2-&#160;4mm wide&#44; and 0&#46;5-2mm thick&#46;&#160;The imaging techniques available for evaluating the&#160;parathyroid glands in patients with SHPT include the&#160;following &#40;figure 1&#41;&#58;</p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">CERVICAL ECHOGRAPHY</span></p><p class="elsevierStylePara">Cervical echography was the first imaging technique&#160;used to study the parathyroid glands and it continues to be a test we can recommend&#44; particularly in view of the&#160;fact that it is an economical and innocuous alternative&#44;&#160;although it has the disadvantage of being very dependent&#160;on technical expertise and&#44; consequently&#44; its sensitivity&#160;can vary considerably&#46;&#160;Colour Doppler linear multifrequency transducers &#40;7&#46;5-&#160;12MHz&#41; are used for studies of the parathyroid glands&#44;&#160;although in patients who are obese or who have a&#160;multinodular goitre transducers with lower frequencies&#160;&#40;5-7&#46;5MHz&#41; are employed&#46;</p><p class="elsevierStylePara">&#160;<span class="elsevierStyleBold">Exploration Technique</span></p><p class="elsevierStylePara">When a scan is performed&#44; the neck of the patient must&#160;be slightly stretched&#46; Images are taken of each side of&#160;the neck in longitudinal and transversal sections&#44; as well&#160;as from front to back and also with the head rotated&#160;sideways 45&#186;&#46;&#160;The thyroid gland is used as an anatomical reference&#44;&#160;given that most pathological parathyroid glands will be&#160;found behind&#44; at the sides of or below the thyroid gland&#46;&#160;Other anatomical points of reference are the long muscle&#160;of the neck&#44; the lower neurovascular bundle &#40;lower&#160;thyroid artery and recurrent laryngeal nerve&#41; and the&#160;oesophagus&#46; The scan must cover the area from the&#160;submandibular gland to the subclavian vein and laterally&#160;from the tracheal midline to the carotid artery and&#160;jugular vein&#44; as well as the area corresponding to the&#160;aortic arch&#44; in order to exclude the presence of ectopic&#160;pathological glands&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">ECHOGRAPHIC DIAGNOSIS&#160;</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Mode B Echography</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span>While the first echographic scanners only permitted onedimensional&#160;images &#40;mode A&#41;&#44; with the development of&#160;brightness modulation &#40;mode B&#41;&#44; in which variations in the&#160;amplitude of pulsations are represented at each point by&#160;different shades of grey&#44; it was possible to view an&#160;anatomical image&#46;&#160;Normal parathyroid glands are not visible in mode B&#160;echography&#46; This is due to their small size and the fact&#160;that their echogenicity is very similar to that of the&#160;thyroid gland&#46;&#160;Enlarged parathyroid glands are perceived as a nodular&#44;&#160;hypoechoic&#44; homogenous image&#44; which is rounded or&#160;oval in shape with smooth contours delimited by a fine&#160;echogenic line corresponding to the glandular capsule&#46;&#160;When they are oval&#44; their longitudinal axis is parallel to the longitudinal axis of the thyroid gland&#46; In about 15-&#160;20&#37; of cases&#44; the glandular echostructure may be&#160;heterogeneous&#44; owing to the presence of necrosis and&#47;or&#160;haemorrhage or even calcification&#44; especially in very&#160;enlarged parathyroid glands&#46;&#160;Various studies have demonstrated an excellent&#160;correlation between echographic measurements and the&#160;weight of resected glands and some of them have shown a&#160;correlation between glandular size and the severity and&#160;prognosis for secondary hyperparathyroidism and its&#160;response to treatment&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;Doppler and Colour Doppler Echography</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">&#160;</span>Pulsed Doppler</p><p class="elsevierStylePara">The combination of echography and the Doppler technique&#160;enabled vascular structures to be studied&#44; which allows&#160;velocities and flows to be estimated&#46;</p><p class="elsevierStylePara">Colour Doppler</p><p class="elsevierStylePara">When colour-Doppler is used the data on velocities and&#160;frequencies can be converted to produce a colour image&#46;&#160;Flow direction is expressed in red if it is positive and in blue&#160;if it is negative&#44; irrespective of whether the vessel in question&#160;is an artery or a vein&#46;&#160;With the colour Doppler technique pathological glands&#160;usually demonstrate a hypervascular pattern&#44;<span class="elsevierStyleSup">4 </span>the increase in&#160;vascularization showing an intraparenchymal distribution&#44;&#160;with no perinodular component&#44; although the latter is not&#160;always observed&#46;</p><p class="elsevierStylePara">Power-Doppler Echography</p><p class="elsevierStylePara">This technique is based on the analysis of the amplitude&#160;of mobile echoes inside blood vessels&#44; yielding contrasted&#160;vascular structures&#44; and enabling smaller vessels to be&#160;identified&#44; which not only facilitates their identification&#160;but also evaluates any vascularization&#46;&#160;In this case the vascular pattern is the characteristic of&#160;an arterial bed with low resistance and a continuous flow&#160;is observed during diastolic movements&#46;&#160;A recent study<span class="elsevierStyleSup">5 </span>demonstrated that 60&#37; of glands with no&#160;power Doppler result corresponded to diffuse hyperplasia&#160;or hyperplasia with initial nodularity&#44; while 83&#46;7&#37; of&#160;glands which produced power Doppler readings&#160;presented nodular hyperplasia&#44; even in parathyroid&#160;glands weighing 0&#46;5g or less&#46;&#160;An absence of vascularization has been described in&#160;approximately 10&#37; of pathological parathyroid glands&#44;&#160;owing to&#58; <span class="elsevierStyleItalic">1&#41; </span>size less than 1cm&#59; <span class="elsevierStyleItalic">2&#41; </span>deep location&#59; <span class="elsevierStyleItalic">3&#41; </span>location&#160;close to large vessels&#44; meaning there are transmission&#160;artefacts&#44; and <span class="elsevierStyleItalic">4&#41; </span>the existence of areas of necrosis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DIAGNOSTIC PROBLEMS</span></p><p class="elsevierStylePara">In general&#44; the sensitivity and specificity of echography&#160;in parathyroid pathology studies are conditioned by&#160;various factors&#46;&#160;The diagnostic sensitivity of echography is influenced&#160;by&#58; <span class="elsevierStyleItalic">a&#41; </span>the location of the pathological gland &#40;atypical&#160;location&#44; ectopic glands&#41;&#59; <span class="elsevierStyleItalic">b&#41; </span>their size &#40;&#60; 1cm&#41;&#59; <span class="elsevierStyleItalic">c&#41; </span>the&#160;coexistence of goitre and <span class="elsevierStyleItalic">d&#41; </span>a history of cervical&#160;surgery&#46;&#160;With respect to specificity&#44; as well as the diagnostic&#160;problems which may occur with adenopathies of the&#160;cervical spine and thyroid nodules&#44; there are two&#160;problems which are related to anatomical structures&#58; the&#160;thyroid vein &#40;it may cross the lower third of the thyroid&#160;lobe and be mistaken for an enlarged parathyroid gland&#41;&#160;and the long muscle of the neck&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INDICATIONS</span></p><p class="elsevierStylePara">The classic indication for mode B echography in SHPT&#160;studies is the pre-surgical location of pathological glands&#160;&#40;figure 2&#41;&#46;&#160;Although in SHPT more than one gland is affected and&#44;&#160;consequently&#44; minimally invasive surgery is not applicable&#44;&#160;the localization of the glands enables surgical exploration to&#160;be curtailed&#44; thus reducing intervention time and surgical&#160;trauma&#46;&#160;Colour Doppler imaging proves useful when&#44; in mode B&#160;studies&#44; there are diagnostic problems with thyroid nodules&#160;or cervical adenopathies&#46;&#160;With power Doppler imaging arterial flow can be assessed&#160;and&#44; consequently&#44; to some extent&#44; the degree of activity and&#160;then&#44; from this&#44; probably the response to treatment&#44; although&#160;for this purpose gammagraphy would seem more advisable&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Echography-guided Interventions</span></p><p class="elsevierStylePara">The applications of echography as a guide to intervention&#160;procedures in SHPT include&#58;&#160;1&#46; Fine-needle puncture aspiration &#40;FNPA&#41;&#160;2&#46; Percutaneous ablative treatment of adenomas or&#160;parathyroid gland hyperplasia&#160;FNPAs are of interest for characterizing nodular cervical&#160;lesions&#44; when there is reason to suspect intrathyroid&#160;parathyroid glands&#46;&#160;Percutaneous ablation with alcohol or even calcitriol<span class="elsevierStyleSup">6-8&#160;</span>consists of percutaneous injection of ethanol or calcitriol into&#160;the hyperplastic glands&#47;adenomas&#44; with the aim of reducing&#160;the PTH-producing mass&#46;&#160;It may be indicated in patients with medical problems where&#160;surgery is contraindicated&#46; In some centres it is currently&#160;used as an adjuvant to medical therapy&#46; The size of the gland&#160;amenable to percutaneous ablation varies from one centre to&#160;another &#40;generally &#62; 5-10mm&#41;&#46;&#160;The results described in recently published studies are much&#160;better than in early studies&#46; Normal long-term serum PTH&#160;levels &#40;1-3 years&#41; have been described in approximately 80&#37;&#160;of the patients who have been treated and the smaller the&#160;number of enlarged glands the better the results&#46;&#160;Greater effectiveness has been reported for the alcoholization&#160;of less vascularized parathyroid glands than for glands which&#160;demonstrate a significant initial Doppler reading&#46;&#160;The complications which may be associated with the&#160;procedure are primarily paralysis of the recurrent nerve&#44;&#160;which is usually temporary&#44; and peri-glandular fibrosis&#44;&#160;which may make subsequent surgery difficult&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">RADIONUCLIDE STUDIES</span></p><p class="elsevierStylePara">Gammagraphy</p><p class="elsevierStylePara">The first studies of parathyroid tissue functionality were&#160;conducted at the beginning of the 1980s using potassium&#160;analogues&#44; such as thallium-201&#46;<span class="elsevierStyleSup">9-11&#160;</span>Although gammagraphy using thallium-201 is still in use&#44;&#160;nowadays other radiodrugs such as technetium-99m metoxyisobutyl-&#160;isonitrile &#40;MIBI&#41; or technetium-99m tetrofosmin&#160;&#40;TTF&#41; are used&#44; chiefly because of the better physical&#160;properties of technetium-99m&#46; In fact&#44; MIBI is in the process&#160;of becoming the main radiodrug employed in the majority of&#160;nuclear medicine departments&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Radionuclides</span></p><p class="elsevierStylePara">Gammagraphy using Thallium &#40;thallium-201&#41;</p><p class="elsevierStylePara">Thallium is an analogue of potassium&#46; It reaches the tissues&#160;in a manner which is proportionate to blood flow and it&#160;enters the cell actively&#44; being transported across the cell&#160;membrane by the Na-K-ATPase pump&#46;&#160;When gammagraphy with thallium is performed&#44; the&#160;simultaneous thyroid uptake measured by technetium-99m&#160;thyroid gammagraphy needs to be subtracted from the results&#160;to avoid interferences from thyroid tissue&#46;<span class="elsevierStyleSup">10&#160;</span>Although some initial studies have reported that thallium-&#160;201 demonstrates good sensitivity in the identification of&#160;hyperplastic parathyroid glands&#44;<span class="elsevierStyleSup">9&#44;11 </span>the quality of the images&#160;is substantially poorer than images obtained using TTF and&#160;MIBI&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">Double-phase MIBI Gammagraphy</p><p class="elsevierStylePara">Parathyroid double-phase MBI gammagraphy is the most&#160;widely used nuclear medicine technique for visualizing&#160;abnormal parathyroid glands&#46; The compound used is hexakis&#160;isobutyl isonitrile &#40;sestamibi&#41; &#40;MIBI&#41;&#46;&#160;MIBI uses <span class="elsevierStyleSup">99m</span>Tc as a marker&#44; a radionuclide with a very short&#160;half-life&#44; enabling high doses to be administered without&#160;exposing patients to high levels of radioactivity&#44; which at the&#160;same time ensures better imaging quality and lower&#160;absorption by other tissues&#46;<span class="elsevierStyleSup">12&#160;</span>The procedure entails the intravenous injection of 20mCi&#160;&#40;740MBq&#41; of MIBI&#46;&#160;The images are obtained with the patient lying down&#44; if&#160;possible with their neck stretched&#46; Frontal images are&#160;obtained of an area which includes the neck and upper&#160;thorax&#46;&#160;MIBI is taken up by both hyperfunctioning parathyroid and&#160;thyroid tissue&#44; but&#44; unlike thallium&#44; there is a difference in its&#160;elimination from the hyperfunctioning thyroid and&#160;parathyroid glands&#44; the process being more rapid in the&#160;thyroid glands&#46;&#160;In a gammagraphy study an initial phase &#40;thyroid phase&#41; is&#160;obtained at 15 minutes and a late phase &#40;parathyroid phase&#41; at&#160;60 minutes&#46; Thyroid tissue has a physiological affinity during&#160;the initial phase&#44; but clearance is rapid and normally any&#160;thyroid gland activity disappears&#46; Normal parathyroid tissue&#160;shows no uptake in either of the two phases&#46; Abnormal glands&#160;have a tendency to retain the tracer&#44; which is visualized in the&#160;late phase&#46; Thus&#44; in cases of hyperplasia&#47;adenoma&#44; images are&#160;obtained of areas of hyperactive uptake activity&#44; which are&#160;marked to a greater or lesser extent and are sometimes visible&#160;even in the initial phase image&#46;&#160;Athyroid gland gammagraphy which is complementary to the&#160;MIBI gammagraphy is recommended in regions where goitre&#160;is endemic&#44; in order to avoid false positives&#46; The possibility of&#160;clearances in similar times for both tissues&#44; which could lead to&#160;false negatives&#44; has also been described&#46;<span class="elsevierStyleSup">13&#44;14&#160;</span>In MIBI gammagraphy&#44; qualitative&#44; quantitative or semiquantitative&#160;methods can be used to calculate the uptake&#160;index of pathological parathyroid glands&#58;&#160;1&#46; Qualitative methods merely confirm the presence or&#160;absence of hyperfunctioning glands&#46;&#160;2&#46; Quantitative methods include digital visualization&#44; which&#160;corresponds to the late or parathyroid phase&#46; The image&#160;is used to create a ROI &#40;<span class="elsevierStyleItalic">region of interest</span>&#41; in the&#160;parathyroid gland&#44; which exhibits high uptake&#44; and in the&#160;thyroid gland&#46; The activity&#47;pixel average in the&#160;parathyroid lesion is divided by the activity&#47;pixel average&#160;of the thyroid gland to determine the increase in the&#160;activity of the parathyroid gland&#46;&#160;3&#46; Semi-quantitative methods employ different grading&#160;options&#46; Our experience using a semi-quantitative system&#160;has shown it to be very useful&#46; The system awards a&#160;score of &#8220;0&#8221; to a lack of uptake&#44; a score of &#8220;1&#8221; &#40;mild&#41; if&#160;uptake is similar to that of bone or soft tissue&#44; a score of&#160;&#8220;2&#8221; &#40;moderate&#41; if the level of uptake is between 1 and&#160;that of the salivary glands&#44; and a score of &#8220;3&#8221; &#40;intense&#41; if&#160;it is similar or higher than the salivary glands&#46;<span class="elsevierStyleSup">15&#160;</span>This semi-quantitative system has been useful in helping us&#160;to decide which gland should be left in place or employed&#160;for an auto-transplant &#40;the one with the least uptake&#41; when a&#160;partial parathyroidectomy or a parathyroidectomy with an&#160;auto-transplant&#44; respectively&#44; is performed&#46; It has also been&#160;very useful for evaluating the efficacy of the medical&#160;treatment of SHPT&#44; both with vitamin D analogues and&#160;calcimimetic agents&#46; And&#44; finally&#44; it has served as a means of&#160;predicting the results of medical treatment and for deciding&#160;whether to perform a parathyroidectomy &#40;it is unlikely that a&#160;patient with an intense level of uptake will respond to&#160;medical treatment&#41;&#46;<span class="elsevierStyleSup">15-17</span></p><p class="elsevierStylePara">Gammagraphy with Tetrofosmin</p><p class="elsevierStylePara">Tetrofosmin &#40;TTF&#41; is a molecule which is similar to MIBI&#160;and it has been proposed as a tracer for the pre-surgical&#160;detection and screening of abnormal parathyroid glands&#44;&#160;although it is cleared more slowly in thyroid tissue than&#160;MIBI and the interpretation of double-phase images is more&#160;complex&#46;<span class="elsevierStyleSup">18&#44;19</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">SPECIAL TECHNIQUES FOR OBTAINING IMAGES&#160;GAMMAGRAPHY USING A PINHOLE COLLIMATOR</span></p><p class="elsevierStylePara">Gammagraphic images are usually visible in one plane &#40;twodimensional&#41;&#44;&#160;but there are special techniques which enable&#160;their definition and sensitivity to be improved&#46; One of them&#160;involves using a Pinhole collimator&#44; which takes the form of&#160;a cone and has the unique ability to produce a magnified&#160;inverted image&#46;&#160;The addition of Pinhole images during the late phase of&#160;<span class="elsevierStyleSup">99m</span>Tc-MIBI gammagraphy can increase the rate of detection&#160;of adenomas in indeterminate or initially negative studies&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Gammagraphy combined with the SPECT &#40;Singlephoton&#160;Emission Computed Tomography&#41; Technique</span></p><p class="elsevierStylePara">Gammagraphy with SPECT&#44; which enables 360&#186; images&#160;in three spatial planes to be obtained &#40;three-dimensional&#160;images&#41;&#44; has increased the ability of the method to locate&#160;the parathyroid glands and has permitted the detection of&#160;small lesions&#44; which has given the technique greater&#160;precision&#46;&#160;Some groups use SPECT together with the <span class="elsevierStyleItalic">pin-hole&#160;</span>technique&#44; which results in a significant increase in&#160;sensitivity&#46;<span class="elsevierStyleSup">20&#44;21 </span>However&#44; the use of this technique in clinical&#160;practice is controversial&#44; given that the <span class="elsevierStyleItalic">pin-hole </span>method is&#160;not suitable for the detection of ectopic glands located in the&#160;mediastinum&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Factors which Influence Radiotracer Uptake</span></p><p class="elsevierStylePara">Although the main factor affecting the localization of&#160;hyperfunctional parathyroid glands by nuclear medicine&#160;techniques seems to be related to their size&#44; the comparison&#160;of morphological and functional data suggests that either&#160;TTF or MIBI gammagraphy not only reveals an increase in&#160;the size of glands but also identifies the presence of&#160;hyperfunction in parathyroid tissue&#46;&#160;Small adenomas have been easy to identify but the downside&#160;is that false negatives have been described in fairly enlarged&#160;glands&#46; Consequently&#44; size is not the only factor which&#160;decides ease of detection&#46;&#160;The mechanism by means of which the radionuclide remains&#160;for a long period of time in hyperfunctional glands is&#160;unknown&#44; but it is probably the result of one or several&#160;circumstances&#44; such as the phase of the cell cycle&#44; the type of&#160;cell&#44; mitochondrial density&#44; the presence&#47;absence of&#160;expression proteins&#44; such as P-glycoprotein&#44; and specific&#160;biochemical markers like PTHi and calcaemia&#46;<span class="elsevierStyleSup">22&#160;</span>In general&#44; the uptake of both MIBI and TTF is&#160;considered to be greater in cases of nodular hyperplasia&#160;than in diffuse hyperplasia&#46; In patients with SHPT the&#160;intensity of the focal uptake of MIBI in the parathyroid&#160;glands was considered to be directly related to the&#160;phase of the cell cycle&#46; Higher uptake levels correlate&#160;with the active phase of cell growth&#44; indicating that&#160;MIBI gammagraphy reflects the functional state of the&#160;gland&#46;<span class="elsevierStyleSup">23&#160;</span>The radiotracer seems to show more intense accumulation in&#160;glands that have large areas of oxyphilic cells which are rich&#160;in mitochondria than in areas with normal cell types&#46;<span class="elsevierStyleSup">24&#160;</span>Some authors have found a correlation between serum&#160;calcium levels&#44; PTH levels and numbers of oxyphilic cells in&#160;tissues&#44; as well as between calcium levels and initial tracer&#160;uptake&#46;<span class="elsevierStyleSup">24 </span>Thus&#44; serum calcium levels could play an important&#160;role in modifying the kinetic properties of MIBI by&#160;influencing membrane potentials&#46;&#160;The level of radiotracer uptake has shown a significant&#160;correlation with the presence of greater numbers of&#160;mitochondria in the glands&#46;<span class="elsevierStyleSup">25 </span>The link which exists between&#160;MIBI uptake and retention and the number of mitochondria&#160;could also explain why uptake is greater in abnormal&#160;parathyroid tissue&#44; this constituting an indicator of metabolic&#160;activity within cells&#46;&#160;The relationship between the uptake of radiotracers and the&#160;expression of P-glycoprotein has been studied in&#160;hyperfunctional parathyroid glands&#46; It has been noted that&#160;radiotracers are rapidly eliminated from parathyroid glands&#160;which contain P-glycoprotein and&#44; therefore&#44; the uptake seen&#160;in images will be negative&#46; In parathyroid glands which do&#160;not contain P-glycoprotein the radiotracer stays in the cells&#44;&#160;which makes it easier to detect them by gammagraphy&#46;<span class="elsevierStyleSup">26-28&#160;</span>An increase in the expression of P-glycoprotein could be&#160;responsible for some false negatives in parathyroid&#160;gammagraphy&#46; Similar results have been obtained using&#160;TTF&#46;&#160;There is a significant correlation between MIBI uptake and&#160;serum PTHi values&#44; but not with serum calcium&#44; phosphorus&#44;&#160;25-OH vitamin D or 1&#46;25-OH vitamin D levels&#46;<span class="elsevierStyleSup">29&#160;</span>Calcium channel blockers&#44; which are normally prescribed to&#160;treat hypertension&#44; have been shown to reduce the secretion&#160;of PTH <span class="elsevierStyleItalic">in vitro </span>and to have an effect on the membrane&#160;potential of parathyroid cells&#44; which could reduce their&#160;sensitivity to MIBI&#46;<span class="elsevierStyleSup">30</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Surgery Radioguided by MIBI Gammagraphy</span></p><p class="elsevierStylePara">By means of a gamma radiation detection probe which&#160;permits acoustic signals to be obtained and by measuring&#160;radioactive activity&#44; a surgeon can be guided during an&#160;operation involving the excision of pathological thyroid&#160;glands&#46;&#160;The technique is recommended for single adenomas which&#160;are visible in MIBI images without the presence of active&#160;thyroid nodules that could interfere with their detection&#44;&#160;when there is no previous history of cervical irradiation or a&#160;family history of MEN&#46;<span class="elsevierStyleSup">31 </span>This technique is also indicated in&#160;patients who have been operated on more than once due to&#160;the persistence or recurrence of their hyperparathyroidism&#160;and when there is reason to suspect ectopic glands&#46;&#160;Its most obvious advantages are the reduction in surgery&#160;time and the possibility of verifying the correct excision of&#160;parathyroid tissue&#44; given that the radioactive activity of the&#160;tissue which has been surgically removed can be measured&#160;<span class="elsevierStyleItalic">ex vivo&#46;</span><span class="elsevierStyleSup">32 <br></br></span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Positron Emission Tomography &#40;PET&#41;</span></p><p class="elsevierStylePara">PET is a non-invasive technique which enables images that&#160;reflect the metabolic activity of the parathyroid glands to be&#160;obtained&#46;&#160;This technique employs isotopes which emit positrons&#160;&#40;positive electrons&#41;&#46; These isotopes generally have a very&#160;short average-life&#44; which also means a reduction in the period&#160;of exposure and exploration&#46; The agents used for PET offer&#160;better definition than those that are used for gammagraphy&#46;&#160;Carbon-11 labelled with methionine is recommended for&#160;studying the parathyroid glands&#46;&#160;Some studies have demonstrated a good correlation between&#160;<span class="elsevierStyleSup">11</span>C-methionine uptake and PTH and calcium levels&#46;<span class="elsevierStyleSup">33-35&#160;</span>PET using <span class="elsevierStyleSup">11</span>C-methionine can be a useful method in patients&#160;with secondary hyperparathyroidism when the results of&#160;echography and gammagraphy have proved negative or&#160;inconclusive&#46; Furthermore&#44; ectopic glands are identified with&#160;greater precision by PET than by conventional gammagraphy&#44;&#160;as it enables three-dimensional images to be obtained&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">INDICATIONS</span></p><p class="elsevierStylePara">We can regard MIBI gammagraphy as our first option for&#160;identifying hyperfunctioning parathyroid glands &#40;figure 2&#41;&#46;&#160;Although SHPT patients who have not undergone surgical&#160;intervention may not need prior localization&#44; owing to the&#160;high success rate of cervical exploration&#44; the fact that the&#160;percentage of SHPT relapses &#40;10-30&#37;&#41;&#44; the main cause of&#160;which continues to be the incomplete localization of the&#160;glands&#44; is not insignificant needs to be considered&#46;&#160;This is especially evident in patients who have repeat&#160;operations&#44; in whom MIBI plays an important role in the&#160;detection of ectopic glands&#44; relapses <span class="elsevierStyleItalic">in situ </span>or the&#160;hyperfunction of an auto-transplant&#46;<span class="elsevierStyleSup">36&#160;</span>It may also be useful to decide the amount of gland which&#160;should be left or to employ for an auto-transplant when a&#160;partial parathyroidectomy or a total parathyroidectomy and&#160;an auto-transplant&#44; respectively&#44; are performed&#46; In these&#160;cases it would be advisable to remove the glands with the&#160;highest uptake and leave less active glands&#44; which would&#160;reduce the risk of relapse&#46;&#160;It may also be useful to evaluate and&#47;or predict the response&#160;to medical treatment&#46;&#160;In the most recent studies the authors coincide in regarding&#160;echography and <span class="elsevierStyleSup">99m</span>Tc-MIBI gammagraphy as complementary&#160;techniques and in recommending their combined use&#46;<span class="elsevierStyleSup">37&#160;</span>PET should be reserved for locating parathyroid&#160;hyperplasia&#47;adenoma when both echography and MIBI&#160;gammagraphy have produced negative results&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Computed Tomography and Nuclear Magnetic&#160;Resonance</span></p><p class="elsevierStylePara">Computed tomography &#40;CT&#41; can locate parathyroid glands&#160;which are less than 4mm in size&#44; as well as peri-thyroid&#44;&#160;substernal or retroclavicular soft tissue masses&#46; Some series&#160;have reported that its sensitivity is similar to that of&#160;gammagraphy and echography in the diagnosis of multiglandular&#160;parathyroid disease&#44; but the cost is greater and the&#160;detection of parathyroid tissue which is adjacent to the&#160;thyroid gland may be difficult&#46;<span class="elsevierStyleSup">38&#160;</span>With the administration of intravenous contrast agent and the&#160;0&#46;5mm slices obtained by modern equipment&#44; the sensitivity&#160;of the technique has improved&#44; achieving a success rate of up&#160;to 80&#37;&#46;&#160;CT can detect ectopic parathyroid glands&#44; although glands&#160;which are situated at the level of the shoulder or sternum are&#160;difficult to visualize because of the artefacts caused by&#160;bones&#44; as it occurs in patients who have been operated on&#160;more than once&#44; owing to the presence of metallic artefacts&#160;from previous operations&#46;&#160;Nuclear magnetic resonance &#40;NMR&#41; seems to be more&#160;sensitive and&#44; moreover&#44; it offers the possibility of improving&#160;images by the use of contrast agent and 3-D reconstruction&#46;&#160;Parathyroid adenomas have weak signals in T1-weighted&#160;images and strong signals in T2 images&#44; which can be&#160;improved if gadolinium can be employed&#46;&#160;Several studies refer to NMR as an imaging test which is&#160;more sensitive than CT&#44;<span class="elsevierStyleSup">39&#44;40 </span>although it is more difficult to&#160;differentiate parathyroid adenomas from thyroid lesions&#46;</p><p class="elsevierStylePara">Indications</p><p class="elsevierStylePara">Localization of parathyroid hyperplasia&#47;adenoma when the&#160;above tests &#40;echography and MIBI gammagraphy&#41; have&#160;proved negative and the PET technique is not available&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">HYBRID SCANNERS</span></p><p class="elsevierStylePara">The recent introduction of hybrid scanners for diagnostic&#160;purposes may have advantages compared to gammagraphy&#160;or PET alone&#46;&#160;Both SPECT&#47;CT and PET&#47;CT provide images that merge the&#160;anatomical and functional modalities of the gland&#44; which&#160;considerably improves the interpretation of the findings&#160;obtained for each of the techniques when they are used&#160;separately&#46;<span class="elsevierStyleSup">41</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Indications</span></p><p class="elsevierStylePara">Currently they are only indicated for the location of&#160;hyperfunctional glands when all the above techniques have&#160;failed&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">KEY CONCEPTS</span></p><p class="elsevierStylePara">1&#46; To sum up &#40;figure 3&#41;&#44; nowadays&#44; in all patients&#160;with SHPT who do not respond readily to&#160;medical treatment at the outset&#44; we&#160;recommend an MIBI gammagraphy which can&#160;be complemented with a colour Echo-Doppler&#160;scan&#46;</p><p class="elsevierStylePara">2&#46; If gammagraphy proves positive and&#44; after&#160;measuring the intensity of uptake&#44; any of the&#160;&#40;non-ectopic&#41; glands has an intense index &#40;3&#41;&#44;&#160;although an attempt can be made to intensify&#160;treatment&#44; we should consider the possibility&#160;of a parathyroidectomy&#46;</p><p class="elsevierStylePara">3&#46; If the findings of the gammagraphy are&#160;positive&#44; and&#44; after measuring the intensity of&#160;uptake&#44; any of the &#40;non-ectopic&#41; glands has an&#160;intense index &#40;3&#41;&#44; in other words they are grade&#160;1 or 2&#44; an attempt should be made to intensify&#160;treatment and&#44; if the response is not good&#44; a parathyroidectomy should be considered&#46;</p><p class="elsevierStylePara">4&#46; If the gammagraphy is negative&#44; we should&#160;perform a PET or hybrid scan&#44; if this is an option&#46; If&#160;them are not available&#44; an NMR scan is&#160;recommended&#46; Once the gland&#40;s&#41; have been&#160;located&#44; we would then propose a&#160;parathyroidectomy&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f1&#95;imaging&#95;techniques&#95;in&#95;secondary&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f1_imaging_techniques_in_secondary.jpg" alt="Imaging techniques in Secondary Hyperparathyroidism"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Imaging techniques in Secondary Hyperparathyroidism</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f2&#95;secondary&#95;hyperparathyroidism&#95;imaging&#95;tables&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f2_secondary_hyperparathyroidism_imaging_tables.gif" alt="Secondary Hyperparathyroidism Imaging Tables&#58; Indications"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Secondary Hyperparathyroidism Imaging Tables&#58; Indications</p><p class="elsevierStylePara"><a href="grande&#47;10231108&#95;a4&#95;f3&#95;imaging&#95;techniques&#95;in&#95;secondary&#95;hyperparathyroidism&#95;application&#95;algorithm&#46;jpg" class="elsevierStyleCrossRefs"><img src="10231108_a4_f3_imaging_techniques_in_secondary_hyperparathyroidism_application_algorithm.jpg" alt="Imaging techniques in Secondary Hyperparathyroidism&#58; application algorithm&#46;"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Imaging techniques in Secondary Hyperparathyroidism&#58; application algorithm&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">For patients with chronic renal failure who develop secondary hyperparathyroidism &#40;SHPT&#41;&#44; imaging techniques can be useful&#44; especially to evaluate the location&#44; size and functional status of parathyroid glands&#46; This review analyzes all available imaging procedures in the context of SHPT&#46; We evaluate&#58; 1&#41; Cervical ultrasound &#40;B-mode&#44; Doppler&#44; colour-Doppler and power-Doppler&#41;&#44; 2&#41; Scintigraphic studies &#40;Tallium&#44; 99mTc-MIBI and 99mTc-tetrofosmin&#41;&#44; including non-standard image acquisition techniques &#40;Pinhole&#44; SPECT&#41;&#44; 3&#41; Positron emission tomography &#40;PET&#41;&#44; 4&#41; Computed tomography &#40;CT&#41; and magnetic resonance imaging &#40;MRI&#41; and 5&#41; hybrid scanners &#40;SPECT&#47;CT and PET&#47;CT&#41;&#46; Our recommendation is that SHPT patients who are initially non responders to medical therapy should be investigated using parathyroid scintigraphy and cervical ultrasound&#46; 99mTc-MIBI uptake can be graded in a semiquantitative scale&#46; Intense uptake indicates a low probability of success using medical treatment and parathyroidectomy should be considered&#46; A moderate to faint uptake indicates that a more intensive medical therapy would probably be beneficial&#46; In the case of no uptake of 99mTc-MIBI&#44; PET should be performed&#46; Where this is not available&#44; MRI could be a possible alternative&#46;</p>"
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        "resumen" => "<p class="elsevierStylePara">En los pacientes con enfermedad renal cr&#243;nica que desarrollan hiperparatiroidismo secundario &#40;HPTS&#41;&#44; las t&#233;cnicas de imagen pueden ser de utilidad&#44; fundamentalmente para valorar la localizaci&#243;n&#44; el tama&#241;o y el funcionalismo de las gl&#225;ndulas paratiroides&#46; Esta revisi&#243;n valora las t&#233;cnicas de imagen de las que se dispone actualmente para evaluar las gl&#225;ndulas paratiroides en el contexto del HPTS&#46; Se hace referencia a&#58; 1&#41; ecograf&#237;a cervical &#40;modo B&#44; Doppler&#44; Doppler-color y power-Doppler&#41;&#59; 2&#41; estudios gammagr&#225;ficos &#40;talio&#44; 99mTc-MIBI y 99mTc-tetrofosmin&#41;&#44; incluyendo t&#233;cnicas especiales de adquisici&#243;n de im&#225;genes &#40;Pinhole&#44; SPECT&#41;&#59; 3&#41; estudios PET &#40;tomograf&#237;a por emisi&#243;n de positrones&#41;&#59; 4&#41; tomograf&#237;a computarizada &#40;TC&#41; y resonancia magn&#233;tica&#44; y 5&#41; esc&#225;neres h&#237;bridos &#40;SPECT&#47;TC y PET&#47;TC&#41;&#46; Nuestra recomendaci&#243;n es practicar&#44; en todos los pacientes con HPTS que no responden inicial y f&#225;cilmente al tratamiento m&#233;dico&#44; una gammagraf&#237;a con 99mTc-MIBI que puede complementarse con un Eco-Doppler color&#46; Si la gammagraf&#237;a es positiva y&#44; tras gradaci&#243;n de la intensidad de captaci&#243;n&#44; alguna de las gl&#225;ndulas &#40;no ect&#243;picas&#41; presenta un &#237;ndice intenso&#44; aunque se puede intentar intensificar el tratamiento&#44; deber&#237;a pensarse en la realizaci&#243;n de una paratiroidectom&#237;a&#46; Si la gammagraf&#237;a es positiva y&#44; tras gradaci&#243;n de la intensidad de captaci&#243;n&#44; ninguna de las gl&#225;ndulas &#40;no ect&#243;picas&#41; presenta un &#237;ndice intenso&#44; deber&#237;a intentarse la intensificaci&#243;n del tratamiento&#44; y si no existe buena respuesta&#44; considerar la paratiroidectom&#237;a&#46; Si la gammagraf&#237;a es negativa&#44; deber&#237;a practicarse un PET si se dispone de dicha prueba&#46; En caso de no disponer de PET&#44; lo aconsejable ser&#237;a realizar una resonancia magn&#233;tica&#46;</p>"
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Article information
ISSN: 20132514
Original language: English
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2023 July 144 39 183
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2023 May 183 30 213
2023 April 137 21 158
2023 March 141 25 166
2023 February 104 28 132
2023 January 91 32 123
2022 December 133 33 166
2022 November 145 46 191
2022 October 133 62 195
2022 September 143 37 180
2022 August 91 44 135
2022 July 115 53 168
2022 June 133 55 188
2022 May 157 60 217
2022 April 162 63 225
2022 March 189 58 247
2022 February 223 55 278
2022 January 213 42 255
2021 December 187 45 232
2021 November 140 44 184
2021 October 147 62 209
2021 September 93 49 142
2021 August 100 42 142
2021 July 143 40 183
2021 June 143 29 172
2021 May 133 27 160
2021 April 409 113 522
2021 March 197 32 229
2021 February 158 30 188
2021 January 114 35 149
2020 December 98 29 127
2020 November 98 19 117
2020 October 105 20 125
2020 September 184 14 198
2020 August 88 6 94
2020 July 130 9 139
2020 June 115 30 145
2020 May 111 12 123
2020 April 111 26 137
2020 March 127 20 147
2020 February 133 25 158
2020 January 171 36 207
2019 December 114 29 143
2019 November 85 25 110
2019 October 78 20 98
2019 September 157 28 185
2019 August 138 27 165
2019 July 158 21 179
2019 June 172 22 194
2019 May 161 21 182
2019 April 246 50 296
2019 March 108 35 143
2019 February 135 30 165
2019 January 69 23 92
2018 December 285 45 330
2018 November 315 17 332
2018 October 242 17 259
2018 September 287 19 306
2018 August 121 18 139
2018 July 105 30 135
2018 June 188 10 198
2018 May 200 23 223
2018 April 200 9 209
2018 March 117 7 124
2018 February 126 6 132
2018 January 98 6 104
2017 December 109 7 116
2017 November 125 16 141
2017 October 94 12 106
2017 September 111 11 122
2017 August 115 15 130
2017 July 90 7 97
2017 June 137 16 153
2017 May 170 11 181
2017 April 74 17 91
2017 March 152 10 162
2017 February 244 15 259
2017 January 73 13 86
2016 December 132 9 141
2016 November 170 16 186
2016 October 273 5 278
2016 September 320 8 328
2016 August 502 9 511
2016 July 300 7 307
2016 June 194 0 194
2016 May 184 0 184
2016 April 137 0 137
2016 March 145 0 145
2016 February 147 0 147
2016 January 168 0 168
2015 December 146 0 146
2015 November 122 0 122
2015 October 103 0 103
2015 September 120 0 120
2015 August 123 0 123
2015 July 159 0 159
2015 June 82 0 82
2015 May 57 0 57
2015 April 5 0 5
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?