The scintigraphic appearance of subcapsular parathyroid adenomas

Purpose: Approximately 5 to 10% of parathyroid adenomas are located within the thin, fibrous capsule of the thyroid gland. These subcapsular adenomas can complicate minimally invasive parathyroidectomy. The small incision used in this procedure limits the view of the surgical bed. Palpation is less sensitive when the adenoma is covered by the thyroid capsule. If a subcapsular parathyroid adenoma can be identified on preoperative parathyroid scintigraphy, nuclear medicine physicians can recommend exploration of the thyroid capsule early, leading to an easier, more efficient operation. The objective of this observational study was to identify the scintigraphic appearance of subcapsular parathyroid adenomas. Materials and Methods: A total of 109 patients with primary hyperparathyroidism underwent preoperative dual-phase Tc-99m sestamibi parathyroid scintigraphy at our tertiary care center from October 2002 to March 2004. Tc-99m pertechnetate was used as a supplemental technique when deemed necessary for optimal interpretation. Retrospective chart review identified 16 surgically proved subcapsular parathyroid adenomas. Parathyroid scintigraphy was reviewed. Results: Subcapsular parathyroid adenomas tend to conform to the expected shape of the thyroid gland. In this small series, subcapsular parathyroid adenomas followed 1 of 3 patterns on lateral images: (1) focal convex distortion of the posterior wall of the thyroid, (2) polar lentiform configuration, and (3) compression of the posterior thyroid parenchyma. Conclusion: Subcapsular parathyroid adenomas often have a distinct appearance on scintigraphy. Preoperative identification of this type of parathyroid adenoma can direct a subcapsular surgical approach, optimizing the efficiency of the minimally invasive parathyroidectomy.