CASE 3051 Published on 14.04.2006

Imaging of a hyperfunctioning parathyroid autograft with color Doppler and power Doppler

Section

Head & neck imaging

Case Type

Clinical Cases

Authors

Reus M, Vázquez V, Morales D, Abellán D, Abellán JL

Patient

58 years, male

Categories
No Area of Interest ; Imaging Technique Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Power Doppler
Clinical History
A 58-year-old patient presented with total parathyroidectomy and right forearm graft for renal hyperparathyroidism. Color-Doppler and power-Doppler sonographies of the graft showed the presence of a hypoechoic and hypervascularized nodule of a size of 1.8 x 1.9 cm.
Imaging Findings
A 58-year-old man with end-stage renal failure of an unknown cause underwent hemodialysis 6 years earlier. Three years after starting dialysis, he underwent a total parathyroidectomy with a forearm autograft with small fragments of the parathyroid gland in the right brachioradialis muscle, due to a secondary hyperparathyroidism. Three years later, later the calcium levels in his blood were found ro be high (10 mg/dl) with a PTH of 409 pg/ml (normal PTH= 10-55 pg/ml). Suspecting a graft-dependent recurrence, a graft sonography was performed using a Philips HDI 5000 (Royal Philips Electronic Eindhoven, Netherlands) sonography unit equipped with a linear array multifrequency transducer of 7–15 MHz, with which a hypoechoic oval-shaped nodule with lobulated and ill-defined margins of a size 1.8 x 1.9 cm was detected (Fig. 1). Color-Doppler and power-Doppler sonographies showed the presence of a hypervascularized nodule (Figs. 2 and 3) which was diagnosed as graft hyperplasia. A Tc-99m sestamibi scintigraphy demonstrated that there was a focal uptake in the right forearm. After all these imaging techniques, surgical exeresis of the graft was made.
Discussion
The best treatment for reactive hyperparathyroidism, as a complication of chronic renal failure, consists in the resection of the four parathyroid glands and grafting of the parathyroid's fragments on the forearm's brachioradialis muscle. This procedure normalizes hyperparathyroidism in approximately two-thirds of the patients. The risk of recurrence, after doing a total parathyroidectomy with a graft, has decreased on using accurate surgical techniques and appropriate selection of tissue for the graft. The localization of the place where a high level of PTH is produced is difficult. Thalium-201 and Tc-99 sestamibi scintigraphies are useful to show the uptake of the tracer in the hyperplastic graft. MRI has a high sensitivity to detect a hyperfunctioning autotransplanted parathyroid. With sonography, normal grafts cannot be differentiated from muscular and adipose surrounded tissue, but hyperplastic grafts are hypoechoic and round or oval-shaped. Color-Doppler and power-Doppler sonographies clearly show the hypervascularization of the graft. Although hypervascularized lesions located in the soft tissues, can also be seen on using color Doppler and power Doppler, the clinical history of autotransplantation of parathyroid tissues in the forearm help to establish the correct diagnosis. The treatment for the graft-dependent recurrence is the surgical exeresis of the graft. Transplanted parathyroid tissue can be easily removed from the forearm by using local anesthesia.
Differential Diagnosis List
Histological analysis showed graft hyperplasia.
Final Diagnosis
Histological analysis showed graft hyperplasia.
Case information
URL: https://eurorad.org/case/3051
DOI: 10.1594/EURORAD/CASE.3051
ISSN: 1563-4086