Parathyroid imaging techniques such as Tc-99m sestamibi scintigraphy and ultrasound are useful for localizing abnormal parathyroid glands prior to surgery for primary hyperparathyroidism. While no single technique is perfect, combining modalities improves sensitivity. Intraoperative PTH monitoring helps confirm surgical success. Bilateral neck exploration is recommended for negative or equivocal imaging to avoid missed multiglandular disease. Minimally invasive approaches require clear, unilateral localization to avoid incomplete treatment.
This document discusses PET and thyroid scans. PET uses radioactive tracers to provide metabolic and functional imaging, and has better resolution than SPECT but is more expensive. Thyroid scans use radioactive iodine or technetium tracers to evaluate the thyroid gland for abnormalities, nodules, or cancer. Both scans involve injecting or ingesting radioactive tracers and using gamma cameras to detect their accumulation and distribution in the body to assess health and function.
Hyperparathyroidism exists in three different forms: primary, secondary and tertiary. Primary hyperparathyroidism (pHPT) is the most frequent pathological condition of the parathyroid glands and one of the most frequent endocrine disorders overall. The most probable location of parathyroid gland is posterior to the thyroid gland. The parathyroid glands produce parathyroid hormone (PTH), which is important for maintaining calcium, phosphate and vitamin D homeostasis, and ultimately bone health.
Primary hyperparathyroidism is characterized by increased production and secretion of parathyroid hormone. This condition causes nephrocalcinosis, urolithiasis, osteoporosis, gastrointestinal disturbances, neuromuscular manifestation and neuropsychiatric disorders. Parathyroidectomy is the only curative treatment for pHPT. pHPT is typically caused by a solitary parathyroid adenoma (80%-90%), hyperplasia (10%) and less frequently parathyroid carcinoma (5%).
Secondary hyperparathyroidism develops as a consequent to a chronic hypocalcemic condition that can be caused by renal failure, gastroinstinal malabsorption, dietary rickets and ingestion of drugs. Secondary hyperparathyroidism is a frequent and serious complication in haemodialysis patients. Tertiary hyperparathyroidism is a condition where parathyroid hyperplasia, secondary to chronic hypocalcemia, becomes autonomous with development of hypercalcemia. Tertiary hyperparathyroidism is used to designate hyperparathyroidism that persists or develops after renal transplantation.
Localization of hyperfunctioning parathyroid tissue (adenomas or hyperplasia) in primary hyperparathyroidism is useful before surgery to help the surgeon localize the lesion, thus shortening the time of the procedure. Parathyroid glands can be imaged with multiple modalities, including scintigraphy, high-resolution ultrasonograhy, thin-section CT and MRI. Parathyroid scintigraphy may also be indicated for localization of hyperfunctioning parathyroid tissue in patients with persistent or
recurrent disease. For this situation scintigraphy is superior to any other radiological modalities, including MRI, CT scan, ultrasonography combined with needle aspiration and also some invasive techniques like arteriography, selective venography and mediastinoscopy.
Organs at risk delineation is as critical as delineation of the target volumes. This atlas presentation is made from a reference material which is quoted in the second slide.
Role of radiation in carcinoma rectum and colon Bharti Devnani
1. Radiation therapy has been shown to decrease rates of local recurrence in rectal cancer when used preoperatively or postoperatively.
2. Studies have demonstrated benefits of preoperative chemoradiation over postoperative chemoradiation, including lower rates of local recurrence, reduced toxicity, and increased rates of sphincter preservation.
3. Techniques such as prone positioning, abdominal compression, and bladder filling can help displace small bowel out of the radiation field and decrease toxicity.
This document discusses modern radiotherapy techniques including conformal radiotherapy and intensity-modulated radiation therapy (IMRT). It describes the planning steps which involve CT scanning of the patient, delineating the tumor and organ-at-risk volumes, dose analysis, and treatment delivery with quality assurance and patient positioning. IMRT allows for improved target conformality and reduced radiation exposure to surrounding healthy tissues compared to traditional radiotherapy through inverse planning optimization of multiple modulated radiation beams. Image-guided radiotherapy (IGRT) further improves treatment accuracy by accounting for organ motion and setup variations using frequent imaging.
This document summarizes information about PSMA PET-CT scans for imaging prostate cancer. It explains that PSMA is overexpressed in prostate cancer cells and is a good target for imaging. A new development is using radiolabeled PSMA ligands like Ga-68 for PET imaging, which can detect prostate cancer with high sensitivity and specificity, including small lymph nodes and bone metastases. The benefits of Ga-68 include its generator production and labeling chemistry allowing automated preparation with a short half-life for reduced radiation dose. PSMA PET is useful for staging, recurrence detection, and assessing treatment response in prostate cancer.
Post-mastectomy radiotherapy (PMRT) involves delivering radiation to the chest wall and surrounding lymph node areas after a mastectomy. Studies have shown PMRT reduces the risk of local recurrence by around 20% and decreases breast cancer mortality by around 4%. While PMRT provides benefits, it also carries risks of side effects and increased non-breast cancer mortality. Current guidelines recommend PMRT for patients with large tumors, many positive lymph nodes, or an otherwise high risk of local recurrence despite optimal surgery and systemic therapy. Ongoing research continues to refine PMRT indications and techniques to maximize benefits and minimize risks.
Prostate cancer is the second most common cancer in men. Detecting recurrent prostate cancer is challenging with current imaging methods. Prostate-specific membrane antigen (PSMA) is overexpressed in prostate cancer cells and provides a promising target for imaging and therapy. A new PET tracer labeled with 18F, 18F-FACBC, shows potential superiority over choline PET/CT in detecting recurrent prostate cancer.
This document discusses PET and thyroid scans. PET uses radioactive tracers to provide metabolic and functional imaging, and has better resolution than SPECT but is more expensive. Thyroid scans use radioactive iodine or technetium tracers to evaluate the thyroid gland for abnormalities, nodules, or cancer. Both scans involve injecting or ingesting radioactive tracers and using gamma cameras to detect their accumulation and distribution in the body to assess health and function.
Hyperparathyroidism exists in three different forms: primary, secondary and tertiary. Primary hyperparathyroidism (pHPT) is the most frequent pathological condition of the parathyroid glands and one of the most frequent endocrine disorders overall. The most probable location of parathyroid gland is posterior to the thyroid gland. The parathyroid glands produce parathyroid hormone (PTH), which is important for maintaining calcium, phosphate and vitamin D homeostasis, and ultimately bone health.
Primary hyperparathyroidism is characterized by increased production and secretion of parathyroid hormone. This condition causes nephrocalcinosis, urolithiasis, osteoporosis, gastrointestinal disturbances, neuromuscular manifestation and neuropsychiatric disorders. Parathyroidectomy is the only curative treatment for pHPT. pHPT is typically caused by a solitary parathyroid adenoma (80%-90%), hyperplasia (10%) and less frequently parathyroid carcinoma (5%).
Secondary hyperparathyroidism develops as a consequent to a chronic hypocalcemic condition that can be caused by renal failure, gastroinstinal malabsorption, dietary rickets and ingestion of drugs. Secondary hyperparathyroidism is a frequent and serious complication in haemodialysis patients. Tertiary hyperparathyroidism is a condition where parathyroid hyperplasia, secondary to chronic hypocalcemia, becomes autonomous with development of hypercalcemia. Tertiary hyperparathyroidism is used to designate hyperparathyroidism that persists or develops after renal transplantation.
Localization of hyperfunctioning parathyroid tissue (adenomas or hyperplasia) in primary hyperparathyroidism is useful before surgery to help the surgeon localize the lesion, thus shortening the time of the procedure. Parathyroid glands can be imaged with multiple modalities, including scintigraphy, high-resolution ultrasonograhy, thin-section CT and MRI. Parathyroid scintigraphy may also be indicated for localization of hyperfunctioning parathyroid tissue in patients with persistent or
recurrent disease. For this situation scintigraphy is superior to any other radiological modalities, including MRI, CT scan, ultrasonography combined with needle aspiration and also some invasive techniques like arteriography, selective venography and mediastinoscopy.
Organs at risk delineation is as critical as delineation of the target volumes. This atlas presentation is made from a reference material which is quoted in the second slide.
Role of radiation in carcinoma rectum and colon Bharti Devnani
1. Radiation therapy has been shown to decrease rates of local recurrence in rectal cancer when used preoperatively or postoperatively.
2. Studies have demonstrated benefits of preoperative chemoradiation over postoperative chemoradiation, including lower rates of local recurrence, reduced toxicity, and increased rates of sphincter preservation.
3. Techniques such as prone positioning, abdominal compression, and bladder filling can help displace small bowel out of the radiation field and decrease toxicity.
This document discusses modern radiotherapy techniques including conformal radiotherapy and intensity-modulated radiation therapy (IMRT). It describes the planning steps which involve CT scanning of the patient, delineating the tumor and organ-at-risk volumes, dose analysis, and treatment delivery with quality assurance and patient positioning. IMRT allows for improved target conformality and reduced radiation exposure to surrounding healthy tissues compared to traditional radiotherapy through inverse planning optimization of multiple modulated radiation beams. Image-guided radiotherapy (IGRT) further improves treatment accuracy by accounting for organ motion and setup variations using frequent imaging.
This document summarizes information about PSMA PET-CT scans for imaging prostate cancer. It explains that PSMA is overexpressed in prostate cancer cells and is a good target for imaging. A new development is using radiolabeled PSMA ligands like Ga-68 for PET imaging, which can detect prostate cancer with high sensitivity and specificity, including small lymph nodes and bone metastases. The benefits of Ga-68 include its generator production and labeling chemistry allowing automated preparation with a short half-life for reduced radiation dose. PSMA PET is useful for staging, recurrence detection, and assessing treatment response in prostate cancer.
Post-mastectomy radiotherapy (PMRT) involves delivering radiation to the chest wall and surrounding lymph node areas after a mastectomy. Studies have shown PMRT reduces the risk of local recurrence by around 20% and decreases breast cancer mortality by around 4%. While PMRT provides benefits, it also carries risks of side effects and increased non-breast cancer mortality. Current guidelines recommend PMRT for patients with large tumors, many positive lymph nodes, or an otherwise high risk of local recurrence despite optimal surgery and systemic therapy. Ongoing research continues to refine PMRT indications and techniques to maximize benefits and minimize risks.
Prostate cancer is the second most common cancer in men. Detecting recurrent prostate cancer is challenging with current imaging methods. Prostate-specific membrane antigen (PSMA) is overexpressed in prostate cancer cells and provides a promising target for imaging and therapy. A new PET tracer labeled with 18F, 18F-FACBC, shows potential superiority over choline PET/CT in detecting recurrent prostate cancer.
Positron emission tomography (PET) uses radioactive tracers like fluorodeoxyglucose (FDG) to detect cancer cells in the body and can help stage and monitor gastrointestinal malignancies, though it has limitations for small or early lesions; PET is useful for detecting metastasis and predicting response to chemotherapy but is not adequate alone for local tumor staging; While PET provides valuable information, it works best as part of a multimodality approach using other imaging techniques.
Brachytherapy is an effective alternative to whole breast external beam radiation therapy for delivering targeted radiation in breast cancer treatment. There are two main types of brachytherapy used - interstitial brachytherapy which involves implanting catheters directly into the breast tissue, and intracavitary brachytherapy which uses balloon or strut-based applicators placed in the lumpectomy cavity. Brachytherapy provides conformal radiation delivery and spares surrounding healthy tissue. It is commonly used as accelerated partial breast irradiation for early stage disease, but can also be used as neoadjuvant treatment prior to surgery or as salvage therapy for local recurrence after breast conservation. Critical factors for successful brachytherapy
Nuclear medicine techniques such as radioactive iodine scans and therapy are important in evaluating and treating thyroid diseases. Radioactive iodine is selectively taken up and concentrated in the thyroid gland, allowing functional imaging and selective internal radiotherapy for hyperthyroidism and thyroid cancer. Radioactive iodine therapy is the primary treatment for Graves' disease and toxic multinodular goiter. It is also used to ablate residual thyroid tissue after surgery and treat thyroid cancer metastases. Precautions must be taken after radioactive iodine therapy to limit radiation exposure to others.
This document discusses various methods for managing tumor motion during radiotherapy treatment delivery, including gating, breath hold techniques, abdominal compression, and tumor tracking. It describes the basic workflow and advantages and disadvantages of each approach. Phase-based gating and breath hold methods can reduce margins and lower dose to nearby organs but require patient compliance. Tracking allows for treatment during respiration but increases imaging dose. The best solution depends on the individual clinical situation and tumor characteristics.
PET imaging is useful for cancer diagnosis and management. It provides functional information about glucose metabolism in tumors that can help establish prognosis, guide treatment decisions, and assess response. PET using 18F-FDG has high sensitivity and specificity for detecting cancer. It has applications in staging, restaging, and monitoring treatment response for many cancer types including lung cancer, lymphoma, and head and neck cancers. PET can identify tumor involvement that may be missed by anatomical imaging alone.
This document discusses various minimally invasive interventions for liver tumors. It describes procedures such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation, cryoablation, ethanol ablation, and drug-eluting bead chemoembolization. For each procedure, it covers the mechanism of action, patient selection criteria, technical details, imaging guidance and follow up. It emphasizes that these minimally invasive therapies can be used to treat primary and secondary liver malignancies when surgery is not possible or as an adjunct to other treatments, with the aim of improving patient prognosis.
Total Nroadjuvant Therapy- Carcinoma RectumRohit Kabre
This document discusses management strategies for locally advanced rectal cancer. It summarizes that trimodality treatment with neoadjuvant chemoradiation and total mesorectal excision surgery is the standard of care, but has limitations including poor adjuvant chemotherapy compliance and high distant relapse rates. Newer approaches discussed include total neoadjuvant treatment without radiation, selective radiation sparing, non-operative management for patients with a clinical complete response, and the use of pathological and radiological tools to better assess tumor response to guide treatment. The document reviews evidence from ongoing clinical trials investigating these novel strategies.
This document provides an overview of positron emission tomography (PET) scanning techniques. It discusses several non-invasive brain imaging scans conducted on patients, including normal CT and MRI scans but an abnormal PET scan where the patient was found to be dead. The document outlines topics to be covered in a seminar on PET scans, including introductions, principles, instrumentation, procedures, applications and advantages/disadvantages. It provides details on radiopharmaceutical production, PET scan instrumentation, patient preparation including tracer injection, and the imaging process.
Nuclear Medicine - Thyroid, Parathyroid - Cases & Questions@Saudi_nmc
A 55-year-old woman is referred for evaluation of a palpable thyroid nodule. Several radiographic views are shown including anterior, right anterior oblique, and left anterior oblique views. The document then provides details on two patient cases involving thyroid scintigraphy, including imaging findings, diagnoses, treatment options and cancer likelihood for each case. It also provides questions and answers on various topics relating to thyroid scintigraphy, radiotracers, anatomy, and clinical indications.
Brachytherapy improves local control rates for soft tissue sarcomas of the extremities when used as adjuvant therapy after surgery. Interstitial brachytherapy results in 5-year local control rates of 82% for high-grade lesions compared to 69% without brachytherapy. Deeper and larger tumors have worse outcomes, while doses over 60 Gy provide better local control, disease-free survival, and overall survival. Recent data shows intensity-modulated radiation therapy may provide similar local control to brachytherapy with fewer complications. Brachytherapy remains useful for sites where target volumes are extensive or critical structures preclude external beam radiation.
The thyroid gland sits in front of the trachea. It synthesizes the hormones T3 and T4 through a process involving absorption of iodine from the diet, trapping of iodide in thyroid follicular cells, organification of iodide by binding it to tyrosine residues on thyroglobulin, coupling of iodotyrosines to form the hormones, and release of T3 and T4 into circulation in response to TSH. Thyroid imaging using radiopharmaceuticals like Tc-99m pertechnetate, I-123, or I-131 allows evaluation of thyroid anatomy and function through visualization and quantification of radiotracer uptake.
This document outlines the radiotherapy planning process for pituitary adenoma. It discusses indications for radiotherapy including when medical therapy fails or tumors cause vision problems or compression symptoms. Key steps include pre-radiotherapy evaluation with endocrine and visual assessments, immobilization using customized masks, imaging with CT and MRI to delineate targets and organs at risk, target delineation of GTV, CTV and PTV, dose prescription to targets and nearby structures, and follow up to monitor treatment response and outcomes. The goal of radiotherapy is to control tumor growth and hormone production while minimizing damage to surrounding normal tissues.
Hemostatic radiotherapy uses single high doses or fractionated lower doses of external beam radiation to control tumor bleeding. Radiation works by shrinking the tumor and relaxing its aggressiveness, which stops bleeding in 80% of patients within 24-48 hours of treatment starting. Studies have found hemostatic radiotherapy effective at controlling hemorrhaging in 78-100% of advanced cancer patients, usually with doses of 4-10 Gy in a single fraction or 30 Gy over 10 fractions. While radiation achieves short-term hemostasis, most patients experience local recurrence or metastases within two years.
Nuclear medicine radiology revision notesTONY SCARIA
Nuclear medicine uses radiopharmaceuticals and imaging techniques like PET and SPECT scans to assess organ function and detect diseases. Some key applications include using F-18 FDG PET scans to identify cancer metastases based on increased glucose metabolism in malignant cells, Tc-99m sestamibi scans to detect myocardial ischemia, Tc-99m DMSA renal scans to assess kidney function, and somatostatin receptor imaging with radiolabeled octreotide to localize neuroendocrine tumors. PET provides superior detection of bone metastases compared to bone scans or whole-body MRI. Important considerations for nuclear medicine exams include selecting the appropriate radiotracer and ensuring normal blood glucose levels for oncology FDG PET scans
Accelerated partial breast irradiation (APBI) delivers radiation to only the portion of the breast at highest risk of recurrence rather than the whole breast. This allows radiation to be delivered in a significantly shortened period. Several techniques for APBI exist including brachytherapy using catheters implanted in the breast, balloon brachytherapy, and external beam radiotherapy. Ongoing clinical trials are evaluating outcomes and toxicities of APBI compared to whole breast irradiation in appropriately selected patients with early-stage breast cancer.
This document discusses high-dose-rate brachytherapy (HDR BT) and its clinical applications, with a focus on its use for prostate cancer. It defines HDR BT and compares it to low-dose-rate BT. It outlines many clinical sites where HDR BT is used and describes the procedure for prostate HDR BT in detail, including imaging, catheter placement, treatment planning, and common schedules. Complications are discussed. HDR BT is described as being commonly used as a boost with external beam radiotherapy or as monotherapy for prostate cancer.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
This slide includes physical, biological properties of proton and its advantage over the photon. It also provides information from beam production to treatment planning system of proton therapy, its potential applications, cost effectiveness and demerits.
Radioactivity is the spontaneous disintegration of unstable atomic nuclei. It was discovered in 1896 and results in the emission of radiation. The number of neutrons and protons in a nucleus determines its stability, with heavier elements above atomic number 82 generally being radioactive. Radioactive decay occurs through different types of emission and can be used for medical applications like radiation therapy or diagnostic imaging. Proper patient preparation and safety precautions are important when using radiopharmaceuticals like iodine-131 to optimize treatment and minimize radiation exposure.
Nuclear medicine application in parathyroid diordersRamin Sadeghi
A brief explanation of nuclear medicine application in parathyroid disorders including diagnosis and minimally invasive radioguided parathyroid surgery including parathyroid adenoma, carcinoma, hyperplasia, etc.
Parathyroid gland anatomy, its disorders and manangementDrAnjaliBansal1
The document discusses the parathyroid glands and hyperparathyroidism. It covers the development, anatomy, physiology, disorders like hyperparathyroidism, clinical presentation, investigations, medical and surgical management of hyperparathyroidism. Hyperparathyroidism can be primary, secondary or tertiary, and is most commonly due to a parathyroid adenoma. Surgical treatment involves identifying and removing the affected gland(s), while medical management focuses on controlling calcium levels.
Positron emission tomography (PET) uses radioactive tracers like fluorodeoxyglucose (FDG) to detect cancer cells in the body and can help stage and monitor gastrointestinal malignancies, though it has limitations for small or early lesions; PET is useful for detecting metastasis and predicting response to chemotherapy but is not adequate alone for local tumor staging; While PET provides valuable information, it works best as part of a multimodality approach using other imaging techniques.
Brachytherapy is an effective alternative to whole breast external beam radiation therapy for delivering targeted radiation in breast cancer treatment. There are two main types of brachytherapy used - interstitial brachytherapy which involves implanting catheters directly into the breast tissue, and intracavitary brachytherapy which uses balloon or strut-based applicators placed in the lumpectomy cavity. Brachytherapy provides conformal radiation delivery and spares surrounding healthy tissue. It is commonly used as accelerated partial breast irradiation for early stage disease, but can also be used as neoadjuvant treatment prior to surgery or as salvage therapy for local recurrence after breast conservation. Critical factors for successful brachytherapy
Nuclear medicine techniques such as radioactive iodine scans and therapy are important in evaluating and treating thyroid diseases. Radioactive iodine is selectively taken up and concentrated in the thyroid gland, allowing functional imaging and selective internal radiotherapy for hyperthyroidism and thyroid cancer. Radioactive iodine therapy is the primary treatment for Graves' disease and toxic multinodular goiter. It is also used to ablate residual thyroid tissue after surgery and treat thyroid cancer metastases. Precautions must be taken after radioactive iodine therapy to limit radiation exposure to others.
This document discusses various methods for managing tumor motion during radiotherapy treatment delivery, including gating, breath hold techniques, abdominal compression, and tumor tracking. It describes the basic workflow and advantages and disadvantages of each approach. Phase-based gating and breath hold methods can reduce margins and lower dose to nearby organs but require patient compliance. Tracking allows for treatment during respiration but increases imaging dose. The best solution depends on the individual clinical situation and tumor characteristics.
PET imaging is useful for cancer diagnosis and management. It provides functional information about glucose metabolism in tumors that can help establish prognosis, guide treatment decisions, and assess response. PET using 18F-FDG has high sensitivity and specificity for detecting cancer. It has applications in staging, restaging, and monitoring treatment response for many cancer types including lung cancer, lymphoma, and head and neck cancers. PET can identify tumor involvement that may be missed by anatomical imaging alone.
This document discusses various minimally invasive interventions for liver tumors. It describes procedures such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation, cryoablation, ethanol ablation, and drug-eluting bead chemoembolization. For each procedure, it covers the mechanism of action, patient selection criteria, technical details, imaging guidance and follow up. It emphasizes that these minimally invasive therapies can be used to treat primary and secondary liver malignancies when surgery is not possible or as an adjunct to other treatments, with the aim of improving patient prognosis.
Total Nroadjuvant Therapy- Carcinoma RectumRohit Kabre
This document discusses management strategies for locally advanced rectal cancer. It summarizes that trimodality treatment with neoadjuvant chemoradiation and total mesorectal excision surgery is the standard of care, but has limitations including poor adjuvant chemotherapy compliance and high distant relapse rates. Newer approaches discussed include total neoadjuvant treatment without radiation, selective radiation sparing, non-operative management for patients with a clinical complete response, and the use of pathological and radiological tools to better assess tumor response to guide treatment. The document reviews evidence from ongoing clinical trials investigating these novel strategies.
This document provides an overview of positron emission tomography (PET) scanning techniques. It discusses several non-invasive brain imaging scans conducted on patients, including normal CT and MRI scans but an abnormal PET scan where the patient was found to be dead. The document outlines topics to be covered in a seminar on PET scans, including introductions, principles, instrumentation, procedures, applications and advantages/disadvantages. It provides details on radiopharmaceutical production, PET scan instrumentation, patient preparation including tracer injection, and the imaging process.
Nuclear Medicine - Thyroid, Parathyroid - Cases & Questions@Saudi_nmc
A 55-year-old woman is referred for evaluation of a palpable thyroid nodule. Several radiographic views are shown including anterior, right anterior oblique, and left anterior oblique views. The document then provides details on two patient cases involving thyroid scintigraphy, including imaging findings, diagnoses, treatment options and cancer likelihood for each case. It also provides questions and answers on various topics relating to thyroid scintigraphy, radiotracers, anatomy, and clinical indications.
Brachytherapy improves local control rates for soft tissue sarcomas of the extremities when used as adjuvant therapy after surgery. Interstitial brachytherapy results in 5-year local control rates of 82% for high-grade lesions compared to 69% without brachytherapy. Deeper and larger tumors have worse outcomes, while doses over 60 Gy provide better local control, disease-free survival, and overall survival. Recent data shows intensity-modulated radiation therapy may provide similar local control to brachytherapy with fewer complications. Brachytherapy remains useful for sites where target volumes are extensive or critical structures preclude external beam radiation.
The thyroid gland sits in front of the trachea. It synthesizes the hormones T3 and T4 through a process involving absorption of iodine from the diet, trapping of iodide in thyroid follicular cells, organification of iodide by binding it to tyrosine residues on thyroglobulin, coupling of iodotyrosines to form the hormones, and release of T3 and T4 into circulation in response to TSH. Thyroid imaging using radiopharmaceuticals like Tc-99m pertechnetate, I-123, or I-131 allows evaluation of thyroid anatomy and function through visualization and quantification of radiotracer uptake.
This document outlines the radiotherapy planning process for pituitary adenoma. It discusses indications for radiotherapy including when medical therapy fails or tumors cause vision problems or compression symptoms. Key steps include pre-radiotherapy evaluation with endocrine and visual assessments, immobilization using customized masks, imaging with CT and MRI to delineate targets and organs at risk, target delineation of GTV, CTV and PTV, dose prescription to targets and nearby structures, and follow up to monitor treatment response and outcomes. The goal of radiotherapy is to control tumor growth and hormone production while minimizing damage to surrounding normal tissues.
Hemostatic radiotherapy uses single high doses or fractionated lower doses of external beam radiation to control tumor bleeding. Radiation works by shrinking the tumor and relaxing its aggressiveness, which stops bleeding in 80% of patients within 24-48 hours of treatment starting. Studies have found hemostatic radiotherapy effective at controlling hemorrhaging in 78-100% of advanced cancer patients, usually with doses of 4-10 Gy in a single fraction or 30 Gy over 10 fractions. While radiation achieves short-term hemostasis, most patients experience local recurrence or metastases within two years.
Nuclear medicine radiology revision notesTONY SCARIA
Nuclear medicine uses radiopharmaceuticals and imaging techniques like PET and SPECT scans to assess organ function and detect diseases. Some key applications include using F-18 FDG PET scans to identify cancer metastases based on increased glucose metabolism in malignant cells, Tc-99m sestamibi scans to detect myocardial ischemia, Tc-99m DMSA renal scans to assess kidney function, and somatostatin receptor imaging with radiolabeled octreotide to localize neuroendocrine tumors. PET provides superior detection of bone metastases compared to bone scans or whole-body MRI. Important considerations for nuclear medicine exams include selecting the appropriate radiotracer and ensuring normal blood glucose levels for oncology FDG PET scans
Accelerated partial breast irradiation (APBI) delivers radiation to only the portion of the breast at highest risk of recurrence rather than the whole breast. This allows radiation to be delivered in a significantly shortened period. Several techniques for APBI exist including brachytherapy using catheters implanted in the breast, balloon brachytherapy, and external beam radiotherapy. Ongoing clinical trials are evaluating outcomes and toxicities of APBI compared to whole breast irradiation in appropriately selected patients with early-stage breast cancer.
This document discusses high-dose-rate brachytherapy (HDR BT) and its clinical applications, with a focus on its use for prostate cancer. It defines HDR BT and compares it to low-dose-rate BT. It outlines many clinical sites where HDR BT is used and describes the procedure for prostate HDR BT in detail, including imaging, catheter placement, treatment planning, and common schedules. Complications are discussed. HDR BT is described as being commonly used as a boost with external beam radiotherapy or as monotherapy for prostate cancer.
The document discusses craniospinal irradiation (CSI), which delivers radiation to the entire cranial-spinal axis to treat intracranial tumors. It was pioneered in the 1950s and is commonly used to treat tumors that may spread through the cerebrospinal fluid such as medulloblastoma. The document outlines the techniques, challenges, indications, and evolving approaches for CSI such as reduced dose protocols and hyperfractionated regimens. It discusses topics like patient positioning, target volumes, critical structures, field arrangements, and the use of newer technologies like virtual simulation.
This slide includes physical, biological properties of proton and its advantage over the photon. It also provides information from beam production to treatment planning system of proton therapy, its potential applications, cost effectiveness and demerits.
Radioactivity is the spontaneous disintegration of unstable atomic nuclei. It was discovered in 1896 and results in the emission of radiation. The number of neutrons and protons in a nucleus determines its stability, with heavier elements above atomic number 82 generally being radioactive. Radioactive decay occurs through different types of emission and can be used for medical applications like radiation therapy or diagnostic imaging. Proper patient preparation and safety precautions are important when using radiopharmaceuticals like iodine-131 to optimize treatment and minimize radiation exposure.
Nuclear medicine application in parathyroid diordersRamin Sadeghi
A brief explanation of nuclear medicine application in parathyroid disorders including diagnosis and minimally invasive radioguided parathyroid surgery including parathyroid adenoma, carcinoma, hyperplasia, etc.
Parathyroid gland anatomy, its disorders and manangementDrAnjaliBansal1
The document discusses the parathyroid glands and hyperparathyroidism. It covers the development, anatomy, physiology, disorders like hyperparathyroidism, clinical presentation, investigations, medical and surgical management of hyperparathyroidism. Hyperparathyroidism can be primary, secondary or tertiary, and is most commonly due to a parathyroid adenoma. Surgical treatment involves identifying and removing the affected gland(s), while medical management focuses on controlling calcium levels.
Differentiated Thyroid cancer American cancer guidelines. Risk grouping and radioactive Iodine Ablation Low dose vs High dose RAI Ablation. Initial assessment of a thyroid nodule
1. Adrenal incidentalomas are adrenal lesions discovered incidentally during imaging for unrelated reasons, and their incidence has increased with more widespread use of CT and MRI imaging.
2. Evaluation of an adrenal incidentaloma involves determining if it is functioning, malignant, and if surgical intervention is needed. Malignancy is uncommon, around 2-5%, but size over 4cm increases risk.
3. Functional evaluation identifies subclinical Cushing's syndrome in around 6-10% of cases. Surgical removal is considered if the mass is over 4cm and non-functioning, or shows signs of malignancy on imaging characteristics.
This document discusses adrenal adenomas. It begins by defining adrenal adenomas and their epidemiology. It then discusses the radiological appearance of normal adrenal glands and adrenal adenomas on ultrasound, CT, and MRI. Specific imaging features that suggest adrenal adenomas include low density on non-contrast CT (<10 HU) and rapid contrast washout on CT or signal drop-out on opposed-phase MRI. The document also discusses differential diagnoses, clinical presentations of functioning adenomas, and management guidelines.
This document discusses the diagnosis and management of parathyroid disease. It begins by reviewing calcium homeostasis and the role of parathyroid hormone. It then covers parathyroid anatomy, histopathology, and embryology. The clinical features, diagnosis, and surgical or medical management of hyperparathyroidism are examined. Localization studies and the molecular basis of these studies are also reviewed. Surgical techniques including minimally invasive parathyroidectomy are discussed. The document concludes by emphasizing the importance of surgical anatomy and embryology for properly diagnosing and treating parathyroid disorders.
Thyroid nodules are common and their clinical importance relates to excluding malignancy. The document reviews advances in thyroid nodule evaluation and management according to current guidelines. Key points include: thyroid ultrasound and fine needle aspiration biopsy are recommended for initial evaluation, with FNA indicated for nodules ≥1 cm or those with suspicious ultrasound features; cytology results are categorized as diagnostic (satisfactory) or nondiagnostic (unsatisfactory); and molecular testing of thyroid nodules is mentioned but not described in detail.
Testicular tumors-Cassification, Biomarkers and Staging by Dr RajeshRajesh Sinwer
This document discusses testicular tumors, including:
- Germ cell tumors are the most common type, comprising 95% of cases. Seminomas and non-seminomatous germ cell tumors are the main subtypes.
- Important biomarkers for testicular cancer include AFP, HCG, LDH, and PLAP. Elevated levels can indicate the presence of a non-seminoma.
- Staging is important and is based on whether the cancer is confined to the testis or has spread to lymph nodes or other organs. Spread beyond the retroperitoneum is considered stage III.
- Diagnostic workup involves imaging like ultrasound, CT, MRI and PET scans
PI-RADS is a structured reporting scheme for evaluating the prostate for prostate cancer using multi-parametric MRI. Version 2 of PI-RADS (PI-RADSv2) was created by a joint committee to standardize terminology and simplify reporting. It aims to improve cancer detection, localization, characterization, and risk stratification. PI-RADSv2 uses T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced imaging to assess different areas of the prostate and assigns a score to help determine need for biopsy or treatment. It provides a standardized way to evaluate prostate MRI but has limitations such as not addressing other cancer scenarios or prescribing technical parameters.
The document discusses the embryology, anatomy, physiology and pathology of the parathyroid glands. It covers topics such as primary, secondary and tertiary hyperparathyroidism. Surgical options for treating hyperparathyroidism including traditional parathyroidectomy, minimally invasive techniques and medical management are summarized. Special conditions including parathyroid carcinoma, familial hyperparathyroidism and persistent/recurrent hyperparathyroidism are also outlined.
This document summarizes the management of pancreatic carcinoma. It discusses the anatomy, epidemiology, risk factors, hereditary syndromes, pathophysiology including pre-cancerous lesions, types of pancreatic cancer, staging, prognostic factors, diagnostic techniques, treatment including surgery, chemotherapy, targeted therapy, radiotherapy and historical prospective studies. It provides a comprehensive overview of pancreatic carcinoma covering all relevant aspects of the disease.
A 48-year-old woman underwent a thyroidectomy for papillary thyroid cancer. A PET scan found uptake in her thyroid, and an ultrasound confirmed a nodule. A post-operative iodine scan found uptake in thyroid tissue, but no metastases. She was diagnosed with the tall cell variant of papillary thyroid cancer based on pathology. Papillary thyroid cancer is characterized by mutations affecting the MAPK pathway and is usually differentiated and radioiodine avid. Imaging with iodine scans, PET, and ultrasound can help identify the primary tumor and check for metastases following treatment.
PET SCAN IN UROLOGY
Molecular imaging such as PET scans allow visualization of biochemical processes in the body. PET scans using radiotracers like 18F-FDG have various applications in urology including detecting cancers of the prostate, kidney, bladder, testes, and penis. 68Ga-PSMA PET/CT in particular has high sensitivity for detecting prostate cancer, even at low PSA levels. PET scans provide diagnostic information and can guide treatment planning and monitoring.
Urothelial carcinoma biomarkers can be detected in urine samples to aid in the diagnosis and monitoring of bladder cancer. Nuclear matrix protein 22 (NMP22) and bladder tumor antigen (BTA) tests detect proteins released by dying tumor cells with reasonable sensitivity and specificity. Urine cytology examines cells for morphological changes, having high sensitivity for high-grade tumors but low sensitivity for low-grade tumors. Newer tests like CxBladder, CertNDx, and microsatellite analysis analyze genetic markers and show promise in improving detection rates, especially for low-grade tumors. No single test is perfect and cystoscopy remains the gold standard, but urine biomarkers provide a non-invasive method to supplement standard evaluation and monitoring of patients
Management of anaplastic THYROID caNCER.pptxSatishray9
This document discusses the management of medullary thyroid cancer, anaplastic thyroid cancer, and thyroid lymphoma.
For medullary thyroid cancer, genetic testing is important to identify familial cases linked to RET proto-oncogene mutations. Treatment involves total thyroidectomy with lymph node dissection and lifelong monitoring of calcitonin and CEA levels. Targeted drug therapy may help in advanced cases.
Anaplastic thyroid cancer has the highest mortality risk and shortest survival. Treatment requires aggressive surgery if possible along with chemoradiation, though prognosis remains poor.
Thyroid lymphoma is rare but can be treated with chemotherapy, radiation, and in some cases surgery if localized. Close monitoring is needed
This document provides guidelines for screening, diagnosing, staging, and treating localized and locally advanced prostate cancer. It recommends offering PSA screening to higher risk men and using MRI to help guide biopsies. For diagnosis and staging, it recommends prostate biopsies, imaging like MRI and bone scans, and evaluating life expectancy. For treatment of localized disease, it discusses active surveillance, surgery, radiation therapy, cryotherapy, HIFU and hormonal therapy. It provides guidance on treating low, intermediate and high risk localized disease as well as locally advanced disease. It also addresses adjuvant therapy, biochemical recurrence, and second line therapies.
This document discusses the evaluation and management of adrenal incidentaloma. Some key points:
- Adrenal incidentaloma refers to an adrenal mass found incidentally on imaging not conducted for suspected adrenal abnormality.
- Biochemical, hormonal, and radiological evaluation is needed to determine if the mass is functioning or malignant. Functional masses or those over 4cm may require surgical removal.
- Surgical approaches include laparoscopic or open adrenalectomy depending on factors like mass size and invasiveness. Complete resection of malignant adrenocortical carcinoma provides the best survival outcomes.
The document discusses imaging of adrenal masses. It provides details on the anatomy and histology of the adrenal glands. Computed tomography (CT) is described as the primary imaging modality for evaluating adrenal gland morphology and masses. CT characteristics such as density measurements on non-contrast scans, enhancement patterns on contrast scans, and washout percentages are used to differentiate benign and malignant adrenal lesions. Magnetic resonance imaging (MRI) techniques such as chemical shift imaging can also help in characterization. The document outlines approaches for characterizing incidentally detected adrenal masses and differentiating functional from non-functional lesions.
Similar to Nuclear medicine application in parathyroid diorders (20)
Sentinel node biopsy in oncology a breif overviewRamin Sadeghi
In this overview, I have discussed the application and indications of sentinel lymph node biopsy in surgical oncology including gynecological cancers, Urological cancers, breast cancer, melanoma, and gastrointestinal cancers.
Several cases of our department were also included in the presentation to augment the message of the presentation.
It is an evidence based overview.
Precision and follow up scans in bone densitometryRamin Sadeghi
The current presentation is a brief overview of precision and follow up scans in BMD with especial attention to least significant change and Z-score changes in children
In this presentation imaging properties of primary bone tumors of the spinal column and sacrum are discussed in detail: Including ABC, plasmacytoma, giant cell tumor, etc.
Powerpoint presentation on techniques and artifacts of bone mineral densitometry.
Especial attention to hip, lumbar spine and forearm artifacts separately. Lots of real patient examples and the solutions to the technical errors.
Different vendors such as Norland, Hologic, and Lunar have been discussed.
Bone mineral densitometry in pediatricsRamin Sadeghi
Update of the previous presentation of the topic of bone mineral densitometry in children.
HAZ method (height for age Z-score) for height adjustment was introduced in this version.
Sentinel node in breast cancer: update of the previous presentationRamin Sadeghi
This is an update of the presentation:
Sentinel node in breast cancer: controversies
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Sentinel node mapping in breast cancer controversiesRamin Sadeghi
In this presentation the most important controversies in breast cancer lymphatic mapping and sentinel node biopsy have been discussed based on NCCN guideline.
Bone mineral density (BMD) measurements in children require adjustments for factors like body and bone size due to ongoing growth. Dual energy x-ray absorptiometry (DXA) is commonly used but provides areal BMD which is dependent on bone size. Several methods can adjust for size including calculating bone mineral apparent density (BMAD) and using the Molgaard method. Interpretation requires comparing to age-matched reference data, and the limited Iranian database may not match equipment brands. Serial scans assess changes rather than absolute BMD values due to childhood growth.
Nuclear medicine application in colorectal cancersRamin Sadeghi
In this presentation a brief evidence based application of nuclear medicine in colorectal cancer is given.
All recommendations are based on NCCN guideline.
Nuclear medicine application in neuroendocrine tumors (net)Ramin Sadeghi
This document discusses the use of nuclear medicine techniques for staging and treatment monitoring of neuroendocrine tumors. Positron emission tomography using radiolabeled somatostatin analogues like Ga-68 DOTATATE is recommended for staging most well-differentiated neuroendocrine tumors. In-111 or Tc-99m octreotide scintigraphy is also used but has lower sensitivity than PET. F-18 FDG PET is used for poorly differentiated and extrapulmonary neuroendocrine tumors. I-123 MIBG, somatostatin receptor imaging, or FDG PET are used for pheochromocytoma/paraganglioma staging if metastasis is suspected. Lu-177 DOTATATE
In this presentation nuclear medicine application in nephrology is explained in detail based on UPTODATE evidence based recommendations.
Different examples were given.
The document discusses liver segmentation from medical images. Liver segmentation is an important task for surgical planning and diagnosis but is challenging due to the liver's anatomical complexity and variations across patients. Automatic and accurate segmentation methods using techniques like atlas-based segmentation and deep learning can help physicians by providing segmented liver masks from CT and MRI volumes.
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Basavarajeeyam is a Sreshta Sangraha grantha (Compiled book ), written by Neelkanta kotturu Basavaraja Virachita. It contains 25 Prakaranas, First 24 Chapters related to Rogas& 25th to Rasadravyas.
2. HYPERCALCEMIA
Hypercalcemia is a relatively common clinical problem.
Among all causes of hypercalcemia, primary hyperparathyroidism and
malignancy are the most common, accounting for greater than 90
percent of cases
3.
4. INTERPRETATION OF SERUM
CALCIUM
In almost all patients, hypercalcemia is due to an elevation in the
physiologically important ionized (or free) calcium concentration.
However, 40 to 45 percent of the calcium in serum is bound to
protein, principally albumin; as a result, increased protein binding
can cause an elevation in the serum total calcium concentration
without any rise in the serum ionized calcium concentration.
In addition, a single elevated serum calcium concentration should be
repeated to confirm the diagnosis. If available, previous values for
serum calcium should also be reviewed.
5.
6. LABORATORY EXAMS
The initial goal of the laboratory evaluation is to differentiate
parathyroid hormone (PTH)-mediated hypercalcemia (primary
hyperparathyroidism and familial hyperparathyroid syndromes) from
non-PTH mediated hypercalcemia (primarily malignancy, vitamin D
intoxication, granulomatous disease)
It is reasonable to order an intact PTH assay as part of the routine evaluation for
hypercalcemia even in a patient with known malignant disease.
In the presence of low serum PTH concentrations (<20 pg/mL), PTH-related peptide
(PTHrp) and vitamin D metabolites should be measured to assess for hypercalcemia
of malignancy and vitamin D intoxication.
7. LABORATORY EXAMS
Ten to 20 percent of patients with primary hyperparathyroidism have
a serum PTH concentration in the upper end of the normal range
Such a "normal" level (ie, not suppressed but not frankly elevated) is also virtually
diagnostic of primary hyperparathyroidism, since it is still inappropriately high
considering the presence of hypercalcemia.
However, in this circumstance, the diagnosis of familial hypocalciuric hypercalcemia
also should be considered, and urinary calcium excretion (24 hour urinary calcium
or calcium to creatinine ratio) should be measured.
8.
9. HYPERPARATHYROIDISM
The most common clinical presentation of primary
hyperparathyroidism (PHPT) is asymptomatic hypercalcemia.
The diagnosis is usually first suspected because of the incidental finding of an
elevated serum calcium concentration on biochemical screening tests.
In addition, PHPT may be suspected in a patient with nephrolithiasis.
PHPT is diagnosed by finding a frankly elevated parathyroid hormone
(PTH) concentration in a patient with hypercalcemia.
When the PTH is only minimally elevated, or within the normal range (but
inappropriately normal given the patient's hypercalcemia), PHPT remains the most
likely diagnosis, although familial hypocalciuric hypercalcemia (FHH), a rare
disorder, is possible.
10. HYPERPARATHYROIDISM
Localization studies with ultrasonography, technetium-99m
sestamibi, computed tomography (CT), or magnetic resonance
imaging (MRI) scanning should not be used to establish the diagnosis
of PHPT or to determine management. If localization studies are
performed, they should be done after a decision for surgery has been
made.
11.
12.
13.
14.
15. ETIOLOGY
Single adenomas
80 to 85 percent of cases
Multiple gland hyperplasia
10 to 15 percent
Double adenomas
2 to 5 percent
Parathyroid carcinoma
1 percent
There is a relationship between iodine treatment as well as irradiation
and primary hyperparathyroidism
16. MANAGEMENT
Patients with symptomatic primary hyperparathyroidism (PHPT)
(nephrolithiasis, symptomatic hypercalcemia) should have parathyroid
surgery, which is the only definitive therapy.
For asymptomatic individuals who meet the Fourth International
Workshop on Asymptomatic Primary Hyperparathyroidism guidelines,
surgery is indicated.
For asymptomatic individuals who do not meet surgical criteria,
monitoring serum calcium and creatinine annually and bone density (hip, spine, and
forearm) every one to two years
22. PRE-OPERATIVE
LOCALIZATION
Preoperative parathyroid localization studies are useful for identifying
patients who are candidates for a minimally invasive surgical
approach.
Localization studies should not be used to diagnose or confirm the
diagnosis of primary hyperparathyroidism when positive, or to rule
out the diagnosis when negative.
The diagnosis of primary hyperparathyroidism should be based upon biochemical
evaluation.
Localization studies do not reliably exclude multiglandular parathyroid disease
23. PRE-OPERATIVE
LOCALIZATION
Can guide incision placement
Minimize the extent of surgical dissection
Identify concurrent thyroid pathology
Locate ectopic parathyroid tissue in patients with recurrent or
persistent hyperparathyroidism after unsuccessful parathyroid
exploration.
24. TC-99M MIBI SCINTIGRAPHY
A negative 99mTc sestamibi scan does not preclude the diagnosis of
primary hyperparathyroidism, since it occurs in 12 to 25 percent of
patients with disease
is often unrevealing in patients with parathyroid hyperplasia, multiple
parathyroid adenomas, and in those with coexisting thyroid disease
Falsely negative scans can also be caused by calcium channel
blockers that interfere with the take up of the isotope by parathyroid
cells
Other gland characteristics that can increase the likelihood of a
negative scan include small size, superior position, and a paucity of
oxyphil cells
25. SPECT
The multidimensional images illustrate the depth of the parathyroid
gland or glands in relation to the thyroid and improve detection of
ectopic glands which facilitates minimally invasive parathyroidectomy
substantially reduces the likelihood of missing multiglandular disease
compared to planar imaging
Because SPECT imaging has a high rate (7-16 percent) of missed
multiglandular disease, a validated adjunct to exclude multiglandular
disease such as intraoperative parathyroid hormone monitoring
should be routinely utilized.
SPECT-CT adds the ability to discriminate parathyroid adenomas from
other anatomic landmarks, which may facilitate the surgical
procedure
32. SUBTRACTION TECHNIQUE
Even with the addition of SPECT, distinguishing abnormal parathyroid
glands from thyroid pathology can be difficult. If necessary, a
subtraction thyroid scan can be obtained by using two radiotracers
(dual isotope scintigraphy).
The use of technetium plus a second radiotracer such as 123I or
99mTc pertechnetate (thallium) permits selective imaging of the
thyroid gland.
37. ULTRASONOGRAPHY
Sonographic characteristics of parathyroid adenomas include
homogeneous hypoechogenicity and an extrathyroidal feeding vessel
with peripheral vascularity seen on color Doppler imaging
US is highly sensitive in experienced hands and is inexpensive,
noninvasive, and reproducible in the operating room.
As with sestamibi based techniques, the sensitivity of ultrasound for
parathyroid adenoma localization is reduced in patients with thyroid
nodules
38. UTRASONOGRAPHY
Most experts in parathyroid surgery rely on both US and SPECT for
preoperative localization
Combining 99mTc-sestamibi scintigraphy with neck ultrasound
provides high sensitivity (79 to 95 percent) for predicting the location
of a single parathyroid adenoma
No imaging technique, even in combination, accurately predicts
multiglandular disease, and a bilateral neck exploration should be
strongly considered when the studies are discordant, equivocal, or
negative
Disadvantages to the use of US alone include decreased accuracy in
patients with smaller parathyroid gland size, obesity, or mediastinal
glands located behind the clavicles
39.
40.
41. FOUR DIMENSIONAL
COMPUTED TOMOGRAPHY
take advantage of the rapid contrast uptake and washout that is
characteristic of parathyroid adenomas for precise anatomic
localization
4D-CT is particularly useful in the reoperative setting when initial
imaging with sestamibi is negative
The primary disadvantage of 4D-CT is the radiation exposure, which,
compared with sestamibi imaging, results in a >50-fold higher dose
of radiation absorbed by the thyroid.
42.
43. MAGNETIC RESONANCE
IMAGING
Parathyroid adenoma characteristics on magnetic resonance imaging
(MRI) include intermediate to low signal intensity on T1 imaging and
high intensity on T2 imaging. Cervical lymph nodes can also have
similar imaging characteristics, which limit the accuracy of MRI.
The reported sensitivity of MRI for abnormal parathyroid tissue
ranges from 40 to 85 percent
44. POSITRON EMISSION
TOMOGRAPHY AND CT
The combination of 11C-methionine positron emission tomography
and computed tomography (MET-PET-CT) uses 11C-methionine as a
radiotracer to identify pathologic parathyroid glands
A prospective study that included 102 patients undergoing a
parathyroidectomy for primary hyperparathyroidism found that MET-
PET-CT scan correctly located a single gland adenoma in 83 of 97
patients (86 percent), with a positive predictive value of 93 percent
45. INVASIVE LOCALIZATION
Invasive procedures, such as selective venous sampling or selective
arteriography, are generally reserved for more definitive localization
in patients who have had prior neck surgery and in whom noninvasive
testing has been unrevealing.
They may also be used in a primary operation for the patient in whom
noninvasive techniques are equivocal or unrevealing, but enthusiasm
for their use is tempered by risks associated with the procedures
46. NEGATIVE IMAGING
should not preclude initial surgery
In such patients, a single adenoma is still the most likely intraoperative finding (62
to 77 percent); however, multiglandular disease is also common (20 to 38 percent).
These patients require bilateral exploration by an experienced parathyroid surgeon
When compared to patients with localized studies, equivalent long-term
biochemical cure rates can be achieved although more extensive surgery may be
needed
In the reoperative setting, negative sestamibi and ultrasound results
usually lead to prompt use of additional noninvasive imaging
modalities such as 4D-CT and/or MRI.
If these studies are also non-localizing, then invasive studies such as arteriography
or selective venous sampling can be performed.
Reoperation with negative imaging is associated with a high failure rate (up to 50
percent) and nonoperative medical management should be considered
47.
48.
49. PARATHYROID EXPLORATION
Parathyroidectomy provides definitive therapy for PHPT and is
performed for
all patients with symptomatic disease
patients with familial disease
patients with asymptomatic disease who have decreased glomerular filtration rates,
osteoporosis, serum calcium >1 mg/dL above normal, or age less than 50 years.
parathyroid cancer
parathyroid crisis
for selected patients with persistent or recurrent primary hyperparathyroidism.
54. MINIMALLY INVASIVE
APPROACH
Including
endoscopic and video assisted approach + intra-operative PTH monitoring
Radioguided parathyroidectomy using a gamma probe
Best reserved for
patients who have unilateral pathology as detected by imaging,
without thyroid disease
with no family history of multiple endocrine neoplasia
No evidence of parathyroid carcinoma
55. INTRA-OPERATIVE
MONITORING
Intraoperative parathyroid hormone monitoring
A reduction of at least 50 percent from the baseline following excision of the
hyperfunctioning gland is an accepted standard for intraoperative confirmation of
success
False-positive intraoperative PTH findings (defined as a >50 percent decrease)
followed by recurrent hyperparathyroidism should raise suspicion for a multiple
endocrine neoplasia (MEN) syndrome.
56. INTRA-OPERATIVE
MONITORING
Radioguided parathyroidectomy
The use of a radioguided probe has been advocated by some to serve as a useful
adjunct in parathyroid exploration. The technique involves intravenous
administration of technetium-99m labeled sestamibi approximately two hours
preoperatively
Using sestamibi uptake as an indirect measure of parathyroid gland hyperfunction,
the surgeon uses a handheld gamma probe in conjunction with preoperative
imaging results to focus the incision over the site of greatest radioactivity
Once the suspected offending gland or glands are removed, intraoperative PTH
monitoring is utilized to confirm adenoma excision of identify multiglandular
disease, and the gamma probe is also used to survey the surgical bed.
An ex vivo radioactivity count >20 percent above background is a possible
threshold for completion of the exploration
57. BILATERAL NECK
EXPLORATION
Should be considered for the following patients
patients with negative (non-localizing) preoperative imaging studies or when
bilateral foci are detected
Most forms of hereditary hyperparathyroidism
Concomitant thyroid disease requiring surgical resection
Lithium associated hyperparathyroidism
Normal parathyroid tissue should not be removed. If PTH does not
decrease, auto-transplantation should be considered.
58. PARATHYROID CARCINOMA
Rare cause of primary hyperparathyroidism.
Is difficult to distinguish from parathyroid adenoma based on preoperative
evaluation
May be suggested by
A solitary tumor greater than 3 cm in diameter.
A firm, irregular, lobulated mass.
A dense, fibrous capsule surrounding the tumor producing a white or gray-brown tint.
Invasion of, or adhesion to, surrounding structures
Lymph node metastasis (present in 3 to 19 percent of parathyroid cancer cases).
Cystic features.
The presence of these operative findings in patients with preoperative
calcium levels greater than 14 mg/dL,and parathyroid hormone levels
greater than three times the normal value, are highly suggestive of
parathyroid carcinoma
59. PARATHYROID CARCINOMA
Patients suspected of parathyroid carcinoma should undergo an en-
bloc resection of the parathyroid tumor with the ipsilateral thyroid
lobe and isthmus, and a central neck dissection (level VI).
It is important to avoid capsular violation or tumor spillage (eg, with
biopsy).
A modified lateral neck dissection is not required in the absence of
clinical nodal involvement
62. PARATHYROID CYSTS
Parathyroid cysts are uncommon, but can cause severe hypercalcemia
and other symptoms.
If noted before surgery, the cyst fluid should be aspirated for PTH
assay. The optimal treatment is surgical resection. Meticulous
dissection should be employed to avoid cyst rupture because this can
lead to elevated intraoperative PTH levels which may prolong the
surgical procedure
63. A CASE OF A PARATHYROID
CYST PROVED TO BE
PARATHYROID CARCINOMA
67. CLINICAL VALUE OF IMAGING
some noteworthy information can be obtained by performing 99mTc-
MIBI parathyroid scintigraphy in SHPT
detection of ectopic glands (pre-operative map) thus avoiding surgical failure or
reducing the extent of dissection
identification of an eventual supernumerary fifth gland (present in 10 % of
individuals and frequent cause of persistence/recurrence)
identification of the parathyroid gland with the lowest 99mTc-MIBI uptake intensity,
intended to be partially autografted or maintained.