What is the role of dual-energy radiographic absorptiometry in the workup of primary hyperparathyroidism, and what protocol may be followed to avoid the need for intraoperative parathyroid assays?

Updated: Dec 24, 2020
  • Author: Lawrence T Kim, MD, FACS, FACE; Chief Editor: Romesh Khardori, MD, PhD, FACP  more...
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Dual-energy radiographic absorptiometry is a useful tool to demonstrate the skeletal involvement in primary hyperparathyroidism. Note that hyperparathyroidism preferentially affects the cortical bone at the radius (distal third). In cases of severe primary hyperparathyroidism, skeletal radiographs show pathognomonic changes such as salt-and-pepper degranulation in the skull and subperiosteal bone resorption in the phalanges. However, plain radiographs are generally not useful for routine employment in the diagnosis and treatment of hyperparathyroidism.

A study by Thimmappa et al suggested that imaging studies can be used in place of intraoperative parathyroid assays to predict cure in surgery for primary hyperparathyroidism. The investigators described the following protocol [26] :

  • Two preoperative localization studies, including one with surgeon-performed ultrasonography, are performed
  • Preoperative vitamin D levels are assessed, with supplementation provided as indicated

The report contended that in select patients with strong corroboration between the two localization studies and intraoperative findings that are consistent with these studies, intraoperative parathyroid assays may not be required, with the study finding that cure rates in patients in whom this protocol was employed equaled those attained using parathyroid assays. [26]

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