Staining of Parathyroid Adenomas by Selective Arteriography

Abstract

LOCALIZATION of parathyroid adenomas by arteriography was originally described by Seldinger (8) in 1954. Recent reports (2, 5, 7, 8) have stressed displacement of the cranial and caudal loops of the inferior thyroid artery as the principal arteriographic sign. With this sign, successful preoperative localization has been achieved in 66 per cent (7, 8) down to 0 per cent (4) of cases studied. These “localizations” based on displacement are really “lateralizations” without specific identification of the abnormal parathyroid. Our preliminary findings with this technic indicated that such displacements were often inadequate, especially in patients with previous neck explorations and persistent hyperparathyroidism. This small but important group, for whom an accurate localizing technic would be most beneficial, included the ones most likely to show falsepositive vascular displacements. Although staining of parathyroid adenomas during arteriography has been reported previously (1, 3, 6, 7, 10, 11), this diagnostic sign has not been sufficiently stressed. The principal difficulty has been obscuration of the opacified parathyroid adenoma by the overlying and more densely staining thyroid gland. The same problem, i.e., interfering thyroid activity, has also plagued parathyroid isotopic localization methods. Using a combination of selective inferior thyroid artery injections, anteroposterior and oblique projections, prolonged filming, and routine subtraction, we have been able to identify parathyroid stains superimposed upon or adjacent to the opacified thyroid gland in 4 out of 9 cases. To routinely achieve adequate staining of a parathyroid adenoma, selective injection of the inferior thyroid artery is essential. Subclavian arteriography will demonstrate cranial and caudal loop displacement, but in our experience it has not resulted in sufficiently dense glandular opacification to permit differentiation of thyroid and parathyroid stains. Bilateral axillary artery catheterizations are performed, a subclavian injection is initially obtained for orientation, and the thyrocervical trunk is then selectively catheterized. Contrary to most anatomy texts, the thyrocervical trunk often arises from the anterior rather than the superior aspect of the subclavian artery. Ectopic origins are infrequent but do occur (Fig. 1). The following two cases are presented to illustrate the usefulness of parathyroid staining in the preoperative localization of adenomas. CASE I: This 30-year-old Caucasian male presented with a one-year history of recurrent bilateral renal calculi. Operative removal of stones from the left renal pelvis and ureter had been necessary on 3 occasions. Because of hypercalcemia (11–13 mg per 100 ml), he was referred2 to the Metabolic Disease Branch, National Institute of Arthritis and Metabolic Diseases, with the diagnosis of hyperparathyroidism.