SavedAdd your journal

Journals / İstanbul Tıp Fakültesi Dergisi / 2026 / Cilt: 89 Sayı: 1

CAN THE EXTENT OF SURGERY BE NARROWED BY USİNG 4D-CT IN PARATHYROID ADENOMAS WITH UNCLEAR LOCALIZATION?

LOKALİZASYONU BELLİ OLMAYAN PARATİROİD ADENOMLARINDA 4D-BT KULLANILARAK CERRAHİNİN KAPSAMI DARALTILABİLİR Mİ?

Sezer Akbulut(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0000-0003-4362-2240
Tuğba Matlım Özel(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0000-0001-6305-2957
Aykut Çelik(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0000-0002-0478-7723
Görkem Yıldız(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0009-0003-5453-6935
Emrecan Deniz(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0009-0000-2351-4467
Hamit Yücel Barut(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYOLOJİ ANABİLİM DALI)0000-0002-6004-9194
Serkan Sarı(SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, İSTANBUL BAŞAKŞEHİR ÇAM VE SAKURA ŞEHİR SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, GENEL CERRAHİ ANABİLİM DALI)0000-0003-2918-1776
Pages
1–6
Publication Date
2026-02-09
🏛️Bibliographic metadata and full text access for this article are provided via DergiPark.
DergiPark Record ↗
✨

AI Summary & Key Takeaways

AI Insight
⚡ TL;DR(Too Long; Didn't Read)

Results: 4D-CT accurately localised parathyroid adenomas in 13 of 22 patients (59%), with a sensitivity of 68.4%, specificity of 33.3%, positive predictive value of 86.7%, negative predictive value of 14.3%, and overall diagnostic accuracy of 63.6%.

📌 3 Key Takeaways

🎯
Objective & Hypothesis:Objective: Accurate preoperative localisation is crucial for the surgical management of primary hyperparathyroidism (pHPT).
📊
Key Findings & Data:When first-line imaging modalities such as ultrasonography (USG) and Sestamibi SPECT/CT fail to identify the hyperfunctioning gland, four-dimensional computed tomography (4D-CT) may offer additional diagnostic benefit.
💡
Conclusion & Impact:Results: 4D-CT accurately localised parathyroid adenomas in 13 of 22 patients (59%), with a sensitivity of 68.4%, specificity of 33.3%, positive predictive value of 86.7%, negative predictive value of 14.3%, and overall diagnostic accuracy of 63.6%.
🔬Design:Review & Systematic Survey
📍Scope:Comprehensive Sample
⚙️Variables:Dört Boyutlu- Bilgisayarlı Tomografi · Paratiroidektomi · Paratiroid adenom

Abstract

Objective: Accurate preoperative localisation is crucial for the surgical management of primary hyperparathyroidism (pHPT). When first-line imaging modalities such as ultrasonography (USG) and Sestamibi SPECT/CT fail to identify the hyperfunctioning gland, four-dimensional computed tomography (4D-CT) may offer additional diagnostic benefit. Materials and Methods: This retrospective study reviewed 370 parathyroidectomy cases and included adults with primary hyperparathyroidism who underwent 4D-CT after ultrasonography and technetium-99m sestamibi SPECT/CT failed to localise the parathyroid adenoma. Patients with secondary or tertiary hyperparathyroidism were excluded. Demographic and biochemical data, intraoperative findings, and histopathology results were analysed. A standardised three-phase 4D-CT protocol and intraoperative PTH monitoring were used, and the imaging results were correlated with surgical and pathological outcomes to determine diagnostic accuracy. Results: 4D-CT accurately localised parathyroid adenomas in 13 of 22 patients (59%), with a sensitivity of 68.4%, specificity of 33.3%, positive predictive value of 86.7%, negative predictive value of 14.3%, and overall diagnostic accuracy of 63.6%. Two patients had mediastinal ectopic adenomas, and the false-positive rate was 13.3%. Focused or unilateral neck exploration was feasible in 59% of patients, reducing surgical invasiveness. No major postoperative complications were observed. Conclusion: 4D-CT provides significant diagnostic and surgical value in patients with nonlocalized pHPT following inconclusive first-line imaging. Its high positive predictive value enables precise localisation and supports minimally invasive parathyroidectomy, improving operative precision and patient outcomes.

Özet

Amaç: Primer hiperparatiroidizmin (pHPT) cerrahi tedavisinde doğru preoperatif lokalizasyon büyük önem taşır. Ultrasonografi ve Sestamibi SPECT/BT gibi birinci basamak görüntüleme yöntemleriyle lokalizasyon sağlanamadığında, dört boyutlu bilgisayarlı tomografi (4D-BT) ek tanısal katkı sağlayabilir. Gereç ve Yöntemler: Bu retrospektif çalışmada, 370 paratiroidektomi hastasının tıbbi kayıtları incelendi ve primer hiperparatiroidisi olan, USG ve teknesyum-99m sestamibi SPECT/CT ile paratiroid adenomu lokalize edilemediği için 4D-CT uygulanmış erişkin hastalar analiz edildi. Sekonder ve tersiyer hiperparatiroidi nedeniyle opere edilen hastalar çalışma dışı bırakıldı. Hastaların demografik özellikleri, biyokimyasal verileri, intraoperatif bulguları ve histopatolojik sonuçları değerlendirildi. Tüm hastalarda standart üç fazlı 4D-CT protokolü ve intraoperatif PTH ölçümü kullanıldı. Görüntüleme bulguları cerrahi ve patolojik sonuçlarla karşılaştırılarak 4D-CT’nin tanısal doğruluğu belirlendi. Bulgular: 4D-BT, 22 hastanın 13’ünde (%59) paratiroid adenomunu doğru lokalize etti; duyarlılık %68,4, özgüllük %33,3, pozitif prediktif değer %86,7, negatif prediktif değer %14,3 ve genel doğruluk %63,6 olarak hesaplandı. İki hastada mediastinal ektopik adenom saptandı, yanlış pozitif oranı %13,3 idi. Hastaların %59′unda tek taraflı veya odaklanmış eksplorasyon yeterli oldu. Postoperatif major komplikasyon izlenmedi. Sonuç: Birinci basamak görüntüleme ile lokalizasyon sağlanamayan pHPT olgularında 4D-BT, yüksek pozitif prediktif değeriyle adenomu doğru saptayarak minimal invaziv cerrahiye olanak sağlar ve cerrahi başarı ile hasta sonuçlarını iyileştirir.

🔖

Cite This Article

Akbulut, S., Özel, T. M., Çelik, A., Yıldız, G., Deniz, E., Barut, H. Y., Sarı, S. (2026). CAN THE EXTENT OF SURGERY BE NARROWED BY USİNG 4D-CT IN PARATHYROID ADENOMAS WITH UNCLEAR LOCALIZATION?. İstanbul Tıp Fakültesi Dergisi, Cilt: 89 Sayı: 1, 1–6. https://doi.org/10.26650/IUITFD.1710601

📄 Full Text PDF Viewer

📄

PDF görüntüleyici hazırlanıyor...

References (30)

  1. Liddy S, Worsley D, Torreggiani W, Feeney J. Preoperative imaging in primary hyperparathyroidism: Literature review and recommendations. Can Assoc Radiol J 2017;68(1):47-55. google scholar
  2. Eller M, Dave A, Johnson C, Fingeret AL. Accuracy of 4-Dimensional computed tomography for localisation in primary hyperparathyroidism. J Surg Res 2021;257:15-21. google scholar
  3. Raeymaeckers S, De Brucker Y, Vanderhasselt T, Buls N, De Mey J. Detection of parathyroid adenomas with multiphase 4DCT: towards a true four-dimensional technique. BMC Med Imaging 2021;21(1):64. google scholar
  4. Kurian KE, Hamdi O, Roecker ZA, Barker SA, Strumpf A, Garneau JC, et al. Surgeon review of 4D CT for the identification of parathyroid adenomas. Head Neck. 2025;47(3):839-46. google scholar
  5. Noltes ME, Kruijff S, Appelman APA, Jansen L, Zandee WT, Links TP, et al. Head-to-head comparison of [11C] methionine PET, [11C] choline PET, and 4-dimensional CT as second-line scans for the detection of parathyroid adenomas in primary hyperparathyroidism. Eur J Nucl Med Mol Imaging 2024;51(4):1050-9. google scholar
  6. Bellamkonda N, Highland J, McCrary HC, Slattery L, King B, Teames C et al. Fourdimensional computed tomography for parathyroid adenoma localisation: A preoperative imaging protocol. Ann Otol Rhinol Laryngol 2024;133(4):441-8. google scholar
  7. Scerrino G, Paladino NC, Graceffa G, Melfa G, Orlando G, Di Vuolo R et al. Primary hyperparathyroidism: 18F-fluorocholine PET/CT us 4D-CT for Parathyroid Identification: Towards a Comprehensive Diagnostic Framework-An Updated Review and Recommendations. J Clin Med 2025;14(15):5468. google scholar
  8. Petranović Ovčariček P, Giovanella L, Hindie E, Huellner MW, Talbot JN, Verburg FA. An essential practice summary of the new EANM guidelines for parathyroid imaging. Q J Nucl Med Mol Imaging. 2022;66(2):93-103. google scholar
  9. Rodgers SE, Hunter GJ, Hamberg LM, Schellingerhout D, Doherty DB, Ayers GD, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 2006;140(6):932-41. google scholar
  10. Piccardo A, Bottoni G, Boccalatte LA, Camponovo C, Musumeci M, Bacigalupo L et al. Head-to-head comparison among 18F-choline PET/CT, 4D contrast-enhanced CT, and 18F-choline PET/4D contrast-enhanced CT in the detection of hyperfunctioning parathyroid glands: systematic review and meta-analysis. Endocrine 2021;74(2):404-12. google scholar
  11. Sun L, Yao J, Hao P, Yang Y, Liu Z, Peng R. Diagnostic Role of Four-Dimensional Computed Tomography for Preoperative Parathyroid Localisation in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis. Diagn Basel Switz 2021;11(4):664. google scholar
  12. Day KM, Elsayed M, Beland MD, Monchik JM. The utility of 4-dimensional computed tomography for preoperative localisation of primary hyperparathyroidism in patients not localised by sestamibi or ultrasonography. Surgery 2015;157(3):534-9. google scholar
  13. Zafereo M, Yu J, Angelos P, Brumund K, Chuang HH, Goldenberg D et al. American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism. Head Neck 2019;41(7):2398-409. google scholar
  14. Richards ML, Thompson GB, Farley DR, Grant CS. An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg Chic Ill 1960;146(3):280-5. google scholar
  15. Joshi SP, Chowdhary J, Gupta S, Mishra V. Why? What? When? Utility of 4DCT in the preoperative imaging algorithm of primary hyperparathyroidism. SA J Radiol 2025;29(1):3094. google scholar
  16. Kaseb A, Benider H, Treglia G, Cusumano C, Bessac D, Trimboli P et al. Refining the role of presurgical PET/4D-CT in a large series of patients with primary hyperparathyroidism undergoing [18F] fluorocholine PET/CT. Eur J Clin Invest 2025;55(2):e14336. google scholar
  17. Park HS, Hong N, Jeong JJ, Yun M, Rhee Y. Update on Preoperative Parathyroid Localisation in Primary Hyperparathyroidism. Endocrinol Metab. 2022 Oct 25;37(5):744-55. google scholar
  18. Hairston H, Gardner JR, Gibson AC, Wright C, Small M, King D, et al. Four-dimensional computed tomography and ultrasonography for prediction of pathological parathyroid location: A retrospective review of a single surgeon’s patients at a single institution. Gland Surg 2024;13(8):1459-68. google scholar
  19. Krol JP, Joosten FBM, de Boer H, Bernsen MLE, Slump CH, Oyen WJG. Four-dimensional computed tomography as first-line imaging in primary hyperparathyroidism, a retrospective comparison to conventional imaging in a predominantly single adenoma population. EJNMMI Rep 2024;8(1):11. google scholar
  20. Kwon HN, Kim HS, Shin SC, Cheon YI, Kim BH, Jeon YK, et al. Preoperative localisation of single-gum disease in primary hyperparathyroidism: a comparative study for preoperative localisation with four-dimensional computed tomography, ultrasonography, and technetium-99 m-sestamibi single-photon emission computed tomography. Gland Surg 2025;14(3):305-16. google scholar
  21. Said S, Das A, Turner B, Wadhwa VS, Pathak KA. Role of four-dimensional computed tomography (4D-CT) in nonlocalising and discordant first-line imaging in primary hyperparathyroidism. Ann R Coll Surg Engl 2023;105(8):739-46. google scholar
  22. Amadou C, Bera G, Ezziane M, Chami L, Delbot T, Rouxel A, et al. 18F-fluorocholine PET/ CT and parathyroid 4D computed tomography for primary hyperparathyroidism: The challenge of reoperative patients. World J Surg 2019;43(5):1. google scholar
  23. Schwartz IE, Capra GG, Mullin DP, Johnson TE, Boswell GE. Parathyroid computed tomography angiography: Early experience with a novel imaging technique in primary hyperparathyroidism. Otolaryngol Head Neck Surg 2019;161(2):251-6. google scholar
  24. Kelly HR, Bunch PM. Parathyroid computed tomography: pearls, pitfalls, and our approach. Neuroimaging Clin N Am 2022;32(2):413-31. google scholar
  25. Tlili G, Mesguich C, Gaye D, Tabarin A, Haissaguerre M, Hindié E. Dual-tracer 99mTc-sestamibi/123I imaging in primary hyperparathyroidism. J Clin Invest. Q J Nucl Med Mol Imaging 2023;67(2):114-21. google scholar
  26. Expert Panel on Neurological Imaging, Zander D, Bunch PM, Policeni B, Juliano AF, Carneiro-Pla D et al. ACR Appropriateness Criteria® Parathyroid Adenoma. J Am Coll Radiol JACR 2021;18(11S):S406-22. google scholar
  27. Zarei A, Karthik S, Chowdhury FU, Patel CN, Scarsbrook AF, Vaidyanathan S. Multimodality imaging in primary hyperparathyroidism. Clin Radiol 2022;77(6):e401-16. google scholar
  28. Vu TH, Schellingerhout D, Guha-Thakurta N, Sun J, Wei W, Kappadth SC, et al. Solitary parathyroid adenoma localisation in technetium Tc99m sestamibi SPECT and multiphase multidetector 4D CT. AJNR Am J Neuroradiol 2019;40(1):142-9. google scholar
  29. Patel DD, Bhattacharjee S, Pandey AK, Kopp CR, Ashwathanarayana AG, Patel HV, et al. Comparison of 4D computed tomography and F-18 fluorocholine PET for localisation of parathyroid lesions in primary hyperparathyroidism: A systematic review and metaanalysis. Clin Endocrinol (Oxf) 2023;99(3):262-71. google scholar
  30. Hindié E, Schwartz P, Avram AM, Imperiale A, Sebag F, Taïeb D. Primary hyperparathyroidism: Defining the appropriate preoperative imaging algorithm. J Nucl Med Off Publ Soc Nucl Med 2021;62(Suppl 2):3S-12S. google scholar