This document provides an overview of hyperparathyroidism and its imaging features. Hyperparathyroidism can be primary, secondary, or tertiary, and is caused by excessive levels of parathyroid hormone. Primary hyperparathyroidism is usually due to a parathyroid adenoma. Imaging findings include generalized osteopenia, subperiosteal bone resorption of the fingers and ribs, and brown tumors representing areas of bone destruction. Nuclear medicine scans using sestamibi can help localize parathyroid adenomas, showing rapid contrast uptake and washout. CT and ultrasound are also used to identify enlarged parathyroid glands. The document describes characteristic imaging appearances across modalities that are useful

1. IMAGING IN
HYPERPARATHYROIDISM
BY DR.ARUN BABU
JUNIOR RESIDENT
DEPT. OF
RADIODIAGNOSIS
1

2. INTRODUCTION 2
• The Parathyroid Glands are small endocrine
glands that are responsible for the production
of parathyroid hormone which acts to control
the calcium levels in body
• They are found on the posterior aspect of
Thyroid gland, typically there are four of them
but the actual number may vary

3. 3

4. HYPERPARATHYROIDISM
• Hyperparathyroidism is the effect of excess parathyroid hormone (PTH) in the body. It can be primary,
secondary or tertiary. There are many characteristic imaging features predominantly involving the
skeletal system.
• Pathology : Increased levels of the PTH lead to increased osteoclastic activity. The resultant bone
resorption produces cortical thinning (subperiosteal resorption) and osteopenia.
• Subtypes:
• Primary hyperparathyroidism:
a. Parathyroid adenoma (~80%)
b. parathyroid hyperplasia
c. parathyroid carcinoma
• Secondary Hyperparathyroidism Caused by chronic hypocalcaemia renal osteodystrophy being the most
common cause (others include malnutrition, vitamin D defeciency) results in parathyroid hyperplasia
• Tertiary hyperparathyroidism: Autonomous parathyroid adenoma caused by the chronic overstimulation
of hyperplastic glands in renal insufficiency.
4

5. ASSOCIATIONS
• Hyperparathyroidism can occur in the following conditions:
• Multiple endocrine neoplasia (MEN) type I
• MEN type IIa
• Familial hypocalciuric hypercalcaemia
• Familial isolated primary hyperparathyroidism
• Hyperparathyroid-Jaw tumor syndrome
5

6. CAUSES FOR
HYPERPARATHYROIDISM
PRIMARY SECONDARY TERTIARY
•Parathyroid Adenoma,
Hyperplasia,
Carcinoma•MEN1orMEN2a
•Familial
hypocalciurichypercalcemia
•Hyperparathyroid-jaw tumor
(HPT-JT) syndrome
•Familial isolated
hyperparathyroidism
•Renal Failure -Impaired calcitriol
production –Hyperphosphatemia
•Decreased calcium -Low oral
intake -Vit D deficiency -
Malabsoption -renal calcium loss
– lasix
•Hungry Bone Syndrome
•Autonomous hypersecretion of
parathyroid hormone -chronic
secondary hyperparathyroidism-
After renal transplantation
6

7. RADIOGRAPHIC
FEATURES
7
IN PRIMARY HYPERTHYROIDISM
• Subperiosteal bone resorption:
Classically affects the radial aspects of the proximal and
middle phalanges of the 2 and 3 rd fingers
Medial aspect of tibia, femur, humerus
Lamina dura: floating teeth
• Subchondral resorption
Lateral end of the clavicle, symphysis pubis, sacroiliac
joints
• Subligamentous resorption
Ischial tuberosity trochanters inferior surface of calcaneus
and clavicle
• Intracortical resorption:
Terminal tuft erosion
Brown tumours
Salt and pepper sign in the skull (pepper pot skull),
chondrocalcinosis

8. RADIOGRAPHIC
FEATURES
8
IN SECONDARY AND TERTIARY
HYPERPARATHYROIDSIM
• Subperiosteal bone resorption
• Osteopaenia
• Osteosclerosis
• Soft tissue calcification
• Superior and inferior rib notching.
• Superscan : Generalized increased uptake on
Tc 99M pertechnetate bone (focal uptake
with adenoma ).

9. PRIMARY SECONDARY AND TERTIARY
Chondrocalcinosis
Usually seen in the meniscus of
The knee, the triangular fibrocartilage of wrist,
and
The pubic symphysis
Nephrolithiasis, Nephrocalcinosis
Generalised osteitis fibrosa cystica
Osteosclrosis
Focal or generalised,
osteoporosis
Soft tissue and vascular calcification
Rugger Jersey spine
9
Cont..

10. • The most common radiologic finding in primary hyperparathyroidism is osteopenia,
which may be generalized or asymmetric. Fine trabeculations are initially lost, with
resultant coarse and thickened trabeculae.
• The disease may progress with further destruction that results in a ground glass
appearance in the trabeculae. About 30-50% of the bone density must be lost to show
changes on radiographs.
• Additional findings include bone resorption, which may occur at many different
anatomic sites. Bone resorption may be classified as subperiosteal, intracortical,
trabecular, endosteal, subchondral, subligamentous, or subtendinous.
• Subperiosteal bone resorption is an early and virtually Pathognomonic sign of
hyperparathyroidism. Although subperiosteal bone resorption can affect many sites, the
most common site in hyperparathyroidism is the middle phalanges of the index and
middle fingers, primarily on the radial aspect.
10

11. • Anteroposterior radiographic
view of the right hand in a
patient with multiple endocrine
neoplasia syndrome type 1
(MEN 1) and primary
hyperparathyroidism (same
patient as in the previous
image). This image shows
subperiosteal bone resorption
along the radial aspects of the
middle phalanges (arrows).
11

12. • This image demonstrates
subperiosteal resorption that has
resulted in severe tuftal resorption . Also,
note the subperiosteal and intracortical
resorption.
12

13. • In the skull, areas of decreased
radio opacity are intermingled
with sclerotic radio opaque areas,
resulting in a classic appearance
called the saltandpepper skull.
13

14. 14
• Radiograph of the shoulder in a
patient with primary
hyperparathyroidism. This image depicts
subperiosteal distal clavicular resorption
(arrows)

15. 15
• Inferior rib notching in a patient with
hyperparathyroidism
• Notching maybe superior, inferior,
unilateral or bilateral

16. • x-ray of pelvis: large osteolytic
lesion, deforming entire right
pubic bone
16

17. 17
• Radiograph of the distal femur in a
patient with primary
hyperparathyroidism. This image shows
scalloped defects along the inner
margin of the cortex, which denote
endosteal resorption.

18. 18
• A.Radiograph of the humerus in a
patient with primary
hyperparathyroidism. This image
depicts a brown tumor. Note the
osseous expansion and lucency of the
proximal humerus. Brown tumors can
have varied appearances.
• B.Radiograph of the mid
femoral diaphysis in a
patient with primary
hyperparathyroidism. This
image depicts brown
tumors. Note the eccentric
(arrowheads) and central
positions (arrow) of the
lesions.
A B

19. 19
CHONDROCALCINOSIS
There is linear calcification seen outlining
the articular surface of knee involves
both medial and lateral menisci
This is not specific for
Hyperparathyroidism

20. RUGGER JERSEY
SPINE
• Rugger jersey spine describes
the prominent endplate densities
at multiple contiguous vertebral
levels to produce an alternating
sclerotic-lucent-sclerotic
appearance.
• This mimics the horizontal
stripes of a rugby jersey.
• This term and pattern are
distinctive
for hyperparathyroidism .
20

21. RUGGER-JERSEY
SPINE MRI
21
• It shows marked loss
of T1 and T2 signal
in the end plates of
all veretbrae.

22. BROWN
TUMORS
22
• The brown tumor is a bone lesion that arises
in settings of excess osteoclasts activity, as in
hyperparathyroidism. They are a form
of osteitis fibrous. It is not a neoplasm, but
rather simply a mass.
• It most commonly affects the maxilla and
mandible, though any bone may be affected.
• Brown tumours are radiolucent on x-ray.

23. 23
X- ray of the hands showing
brown tumors in the long
bones of fingers

24. 24
• A patient with secondary
hyperparathyroidism was
detected with a brown tumor in
the body of the radius bone of
the left hand and CT also
showed a brown tumor arising
from the left maxillary region of
the face

25. 25
• A) CT image shows a 7mmdiameter
calculus in the collecting system of the
mid right kidney (black arrow). There is
diffuse mottled osteosclerosis of the
visualized bones. A healed fracture of the
posterior right 12th rib (white arrow) and
expansile lytic lesions of the anterior ribs
(arrowheads) are seen. B
• B)CT image shows subchondral
resorption on the iliac side of the
sacroiliac joints; subsequent collapse due
to weight bearing produced apparent
joint widening (black arrows). There are
lytic lesions of the right iliac crest (white
arrow) and left hemisacrum (arrowhead)
A. B

26. 26
Primary hyperparathyroidism:
A.Panoranmic radiograph
demonstrating unilocular cystic lesion
distal to the left mandibular second
premolar.
B. PeriapicaJ radiograph showing loss
of lamina dura djstal to the left
mandibular second premolar tooth.
C. Histopathologic study of the Brown
tumor showing numerous
muItinucleated giant cells .
D. The lesion healed and the lamina
dura reconstituted following removal of
the parathyroid tumor.

27. 27
A. Granular appearance of skull in
patient having renal
osteodystrophy.
B. Solitary punched-out
radiolucency in calvaritun
represents a Brown tumour in
secondary hyperparathyroidism.
C. Right humerus shows coarse
internal trabeculation in primary
hyperparathyroidism
D. metastatic calcifications in hand
and wrist of patient with primary
hyperparathyroidism.
E. Detail of calcifications adjacent
to thumb

28. 28
• MEDULLARY NEPHROCALCINOSIS:
• Conventional radiograph of
abdomen and coronal CT scan of
abdomen both show amorphous,
coarse calcifications throughout both
kidneys (white arrows) which
correspond the the shape and position
of the renal pyramids

29. 29
• Sonogram of the kidney
in a patient with primary
hyperparathyroidism. This
image shows medullary
nephrocalcinosis

30. ULTRASONOGRAPHY
• Ultrasonography is one of the
primary modalities used to localize
parathyroid tumors.
• The size of the adenoma is usually
correlated with the degree of
parathyroid hormone elevation.
• Adenomas appear as well defined
hypoechoic lesions with potential
cystic or necrotic areas.
• Ultrasonography offers the advantage
of depicting potential concomitant
thyroid disease, which is present in
approximately 40% of patients with
parathyroid disease
30

31. 31
• An axial sonogram depicts an oval,
well-defined hypoechoic solid Parathyroid
lesion (arrow).
• The lesion was found to be a
parathyroid lesion by a fine needle
aspiration-parathyroid hormone (FNA-
PTH) assay.

32. CT
32
• An oval shaped enhancing mass with
low attenuation in non contrast phase
relative to thyroid,
• It shows greatest attenuation in the
arterial phase and rapid washout of
contrast in the delayed phase.
• These findings are indicative of a
adenoma or hyperplasia of hyperthyroid

33. 33
• Axial noncontrast (A), axial early
phase post contrast (B) and axial
delayed phase post contrast C images
show a hypoattenuated hypodense
nodule contiguous with the left
posterior thyroid gland, which
demonstrates avid early contrast
enhancement and washout.
• Pathology revealed a parathyroid
adenoma

34. 34
• 4DCT scan of Left upper parathyroid
tumor, with 3D reconstruction (above)
and cross section.

35. 35
• 4D CT demonstrates the enhancement
characteristics of a hyperplastic parathyroid adenoma
(region of interest 1) and an adjacent soft tissue
structure (i.e., a normalfunctioning thyroid gland)
(region of interest 2).
• Contrast-- enhancement analysis on the
parathyroid adenoma shows an attenuation value of
36.1 HU on the virtual noncontrast scan (A), which
rapidly enhanced to 175.5 HU in the arterial phase
(B), and immediately decreased to 100.3 HU in the
dual energy venous phase (C) and 75.1 HU in the
delayed (D) image.
• The parathyroid adenoma can be easily
distinguished from the surrounding soft tissues on
the basis of its characteristic “rapid contrast uptake
and washout” feature.

36. HYPERPARATHYROIDISM-
SESTAMIBI SCAN
36
• A sestamibi parathyroid scan is a procedure
in nuclear medicine which is performed to
localize parathyroid lesion, which
causes. Adequate localization of parathyroid
adenoma allows the surgeon to use a
minimally invasive surgical approach.
• Tc99m sestamibi is absorbed faster by a
hyperfunctioning parathyroid gland than by a
normal parathyroid gland
• Newer modalities using the same sestamibi
tracer in more sophisticated scanners, such
as SPECT/CT machines, have improved
localization of parathyroid adenomas,
especially in ectopic locations.

37. 37

38. 38
• A nuclear medicine parathyroid
scan demonstrates a parathyroid
adenoma adjacent to the left
inferior pole of the thyroid gland.
The above study was performed
with Technetium-Sestamibi (1st
column) and Iodine-123 (2nd
column) simultaneous imaging
and the subtraction technique
(3rd column).

39. 39

40. 40
• Dualtracer (subtraction) scintigraphy.
Top left: Scintigram obtained after
injection of 99m sestamibi (which is taken
up by both thyroid and parathyroid
tissue) shows asymmetric increased
activity at the lateral aspect of the lower
right thyroid lobe (arrow). Bottom left:
Scintigram obtained after injection of Tc
99m Tc-- pertechnetate (which is
preferentially taken up by the thyroid)
shows a relatively photopenic focus in the
same region (arrow). Right: Subtracted
image shows differential 99m sestamibi
activity at the same location (arrowheads).
This finding was shown to represent a
parathyroid adenoma

41. • Scans performed on 64yold woman
with primary hyperparathyroidism.
• Selected coronal tomograms of
subtraction SPECT (A and D), CT (B
and E), and fused SPECT/CT (C and F)
demonstrate focus of residual activity
associated with small soft tissue nodule
located posterior to right thyroid lobe,
found at surgery to be a parathyroid
adenoma.
• Larger, more intense site of residual
activity associated with 3 Cm nodule
within left thyroid lobe (arrowhead) was
found at surgery to represent well
encapsulated thyroid adenoma
41
SUBTRACTION CT FUSED SPECT/CT
SPECT

42. 42
• A 49yearold female with
primary hyperparathyroidism and
nephrolithiasis.
• Tc99m Sestamibi SPECT/CT
demonstrates a large
parathyroid adenoma arising
from the right lower neck,
crossing the midline anterior to
the trachea and extending
towards the left side of the
neck.

43. 43
• 99m TcSestamibi scan of patient with
osteitis fibrosa cystica (group III): early
(A) and delayed (B) images of right
inferior parathyroid adenoma (arrows)

44. 44
• CT examination of the patient
shows a 6 x 3 mm nodular
parathyroid adenoma (arrows) lying
in the superomedial aspect, posterior
to the left thyroid lobe in both
sagittal (A) and axial (B) sections.
• The iodine overlay image
(acquired by using dual energy CT
in the venous phase) allows the
measurement of iodine
concentration in the tissues, to
differentiate between the
parathyroid adenoma and
surrounding thyroid tissues

45. SCINTIGRAPHIC
REPRESENTATION OF THE
"SALTPEPPER" SIGN OF THE
SKULL IN
HYPERPARATHYROIDISM
45

46. 46
• Superscan is intense symmetric
activity in the bones with diminished
renal and soft tissue activity on a
Tc99m diphosphonate bone scan
• Anterior and posterior planar images
from a Tc-99m MDP whole body bone
scan demonstrate diffusely increased
radiotracer uptake throughout the axial
and appendicular skeleton. Especially
intense activity is noted in the mandible
and maxilla. There is absent renal and
bladder activity.

47. 47
• MRI is one diagnostic modality that
can be used to evaluate ectopic
parathyroid adenomas.
• On T1 weighted images, adenomas
appear as low signal intensity masses
whereas intermediate or high signal
intensity is seen on T2 weighted images.
Gadolinium enhancement with fat
suppression results in diffuse
enhancement of the adenoma.
• MRI scan with parathyroid adenoma
identified low in the neck.

48. 48

49. • Sagittal (left image) and coronal (right
image) T1weighted magnetic
resonance images of the brain in a
patient with multiple endocrine
neoplasia syndrome type 1 (MEN 1)
(same patient as in the previous
image). These images show a
pituitary macroadenoma
49

50. • Radiographic findings of subperiosteal resorption are most specific for the disease and
should prompt consideration of the primary hyperparathyroidism.
• Ultrasonography is approximately 75% sensitive in identifying adenomas, but this
technique has low sensitivity in identifying ectopic lesions.
• The advantages of sestamibi scans are its wide availability and the ability to evaluate
for diseased glands outside of the neck at the same time.
• MRI findings of brown tumors are nonspecific. Bony expansion can be visualized, and
the extent of the lesion can be determined. The imaging characteristics depend on the
amount of fibrous tissue, hemorrhage, and cystic changes that are present in the
lesion. Lack of an associated softtissue mass is a pertinent negative finding that can be
demonstrated on MRI. MRI is one diagnostic modality that can be used to evaluate
ectopic parathyroid adenomas
CONCLUSION
50

51. THANK YOU!
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