Predictors of Multigland Disease in Primary Hyperparathyroidism: A Scoring System with 4D-CT Imaging and Biochemical Markers

Background and purposeMultigland disease represents a challenging group of patients with primary hyperparathyroidism. Additional lesions may be missed on imaging because they are not considered or are too small to be seen. The aim of this is study was to identify 4D-CT imaging and biochemical predictors of multigland disease.Materials and methodsThis was a retrospective study of 155 patients who underwent 4D-CT and successful surgery with a biochemical cure that compared patients with multigland and single-gland disease. Variables studied included the size of the largest lesion on 4D-CT, the number of lesions prospectively identified on 4D-CT, serum calcium levels, serum parathyroid hormone levels, and the Wisconsin Index (the product of serum calcium and parathyroid hormone levels). Imaging findings and the Wisconsin Index were used to calculate a composite multigland disease scoring system. We evaluated the predictive value of individual variables and the scoring system for multigland disease.ResultsThirty-six patients with multigland disease were compared with 119 patients with single-gland disease. Patients with multigland disease had significantly lower Wisconsin Index scores, smaller lesion size, and a higher likelihood of having either multiple or zero lesions identified on 4D-CT (P ≤ .01). Size cutoff of <7 mm had 85% specificity for multigland disease, but including other variables in the composite multigland disease score improved the specificity. Scores of ≥4, ≥5, and 6 had specificities of 81%, 93%, and 98%, respectively.ConclusionsThe composite multigland disease scoring system based on 4D-CT imaging findings and biochemical data can identify patients with a high likelihood of multigland disease. Communicating the suspicion for multigland disease in the radiology report could influence surgical decision-making, particularly when considering re-exploration in a previously operated neck or initial limited neck exploration

Prospective Validation of Two 4D-CT–Based Scoring Systems for Prediction of Multigland Disease in Primary Hyperparathyroidism

Background and purposePatients with multigland primary hyperparathyroidism are at higher risk for missed lesions on imaging and failed parathyroidectomy. The purpose of this study was to prospectively validate the ability of previously derived predictive score systems, the composite multigland disease score, and the multiphase multidetector contrast-enhanced CT (4D-CT) composite multigland disease score, to identify patients with a high likelihood of multigland disease.Materials and methodsThis was a prospective study of 71 patients with primary hyperparathyroidism who underwent 4D-CT and successful parathyroidectomy. The size and number of lesions identified on 4D-CT, serum calcium levels, and parathyroid hormone levels were collected. A composite multigland disease score was calculated from 4D-CT imaging findings and the Wisconsin Index (the product of the serum calcium and parathyroid hormone levels). A 4D-CT multigland disease score was obtained by using the CT data alone.ResultsTwenty-eight patients with multigland disease were compared with 43 patients with single-gland disease. Patients with multigland disease had a significantly smaller lesion size (P < .01) and a higher likelihood of having either ≥2 or 0 lesions identified on 4D-CT (P < .01). Composite multigland disease scores of ≥4, ≥5, and 6 had specificities of 72%, 86%, and 100% for multigland disease, respectively. 4D-CT multigland disease scores of ≥3 and 4 had specificities of 74% and 88%.ConclusionsPredictive scoring systems based on 4D-CT data, with or without laboratory data, were able to identify a subgroup of patients with a high likelihood of multigland disease in a prospectively accrued population of patients with primary hyperparathyroidism. These scoring systems can aid in surgical planning

Blood-Labyrinth Barrier Permeability in Menière Disease and Idiopathic Sudden Sensorineural Hearing Loss: Findings on Delayed Postcontrast 3D-FLAIR MRI

Background and purposeMenière disease and idiopathic sudden sensorineural hearing loss can have overlapping clinical presentation and may have similar pathophysiology. Prior studies using postcontrast 3D-FLAIR MR imaging suggest abnormal blood-labyrinth barrier permeability in both conditions, but the 2 diseases have not been directly compared by using the same imaging techniques. We hypothesized that delayed postcontrast 3D-FLAIR MR imaging would show differences in blood-labyrinth barrier permeability between Menière disease and idiopathic sudden sensorineural hearing loss.Materials and methodsPatients with unilateral Menière disease (n = 32) and unilateral idiopathic sudden sensorineural hearing loss (n = 11) imaged with delayed postcontrast 3D-FLAIR MR imaging were retrospectively studied. Signal intensities of the medulla and perilymph of the cochlear basal turns of both ears in each patient were measured in a blinded fashion. Cochlea/medulla ratios were calculated for each ear as a surrogate for blood-labyrinth barrier permeability. The ears were segregated by clinical diagnosis.ResultsCochlea/medulla ratio was higher in symptomatic ears of patients with Menière disease (12.6 ± 7.4) than in patients with idiopathic sudden sensorineural hearing loss (5.7 ± 2.0) and asymptomatic ears of patients with Menière disease (8.0 ± 3.1), indicating increased blood-labyrinth barrier permeability in Menière disease ears. The differences in cochlea/medulla ratio between symptomatic and asymptomatic ears were significantly higher in Menière disease than in idiopathic sudden sensorineural hearing loss. Asymptomatic ears in patients with Menière disease showed higher cochlea/medulla ratio than symptomatic and asymptomatic ears in patients with idiopathic sudden sensorineural hearing loss.ConclusionsIncreased cochlea/medulla ratio indicates increased blood-labyrinth barrier permeability in Menière disease compared with idiopathic sudden sensorineural hearing loss. Increased cochlea/medulla ratio in asymptomatic ears of patients with Menière disease also suggests an underlying systemic cause of Menière disease and may provide a pathophysiologic biomarker

Arterial spin-labeling perfusion MRI stratifies progression-free survival and correlates with epidermal growth factor receptor status in glioblastoma.

Background and purposeGlioblastoma is a common primary brain tumor with a poor but variable prognosis. Our aim was to investigate the feasibility of MR perfusion imaging by using arterial spin-labeling for determining the prognosis of patients with glioblastoma.Materials and methodsPseudocontinuous arterial spin-labeling with 3D background-suppressed gradient and spin-echo was acquired before surgery on 53 patients subsequently diagnosed with glioblastoma. The calculated CBF color maps were visually evaluated by 3 independent readers blinded to patient history. Pathologic and survival data were correlated with CBF map findings. Arterial spin-labeling values in tumor tissue were also quantified by using manual fixed-size ROIs.ResultsTwo perfusion patterns were characterized by visual evaluation of CBF maps on the basis of either the presence (pattern 1) or absence (pattern 2) of substantial hyperperfused tumor tissue. Evaluation of the perfusion patterns was highly concordant among the 3 readers (κ = 0.898, P < .001). Pattern 1 (versus pattern 2) was associated with significantly shorter progression-free survival by Kaplan-Meier analysis (median progression-free survival of 182 days versus 485 days, P < .01) and trended with shorter overall survival (P = .079). There was a significant association between pattern 1 and epidermal growth factor receptor variant III expression (P < .01).ConclusionsQualitative evaluation of arterial spin-labeling CBF maps can be used to stratify survival and predict epidermal growth factor receptor variant III expression in patients with glioblastoma

Imaging in Orbital Differential Diagnosis

Computed tomography (CT) and magnetic resonance imaging (MRI) are important modalities for refining the differential diagnosis of orbital lesions. Using these studies critically, however, requires training and experience. As with all radiographic studies, an orderly and evidence-based approach is paramount