Parathyroid Detection in Secondary Hyperparathyroidism with¹²³I/^99mTc-Sestamibi Subtraction Single Photon Emission Computed Tomography

Abstract

ABSTRACT123 I/ 99m Tc-sestamibi subtraction single photon emission computed tomography (SPECT) has been proposed to detect hyperplastic parathyroid tissue, but the clinical usefulness of this technique in secondary hyperparathyroidism is uncertain. The purpose of this study was to evaluate preoperative parathyroid localization using 123 I/ 99m Tc-sestamibi subtraction SPECT in patients with renal failure and secondary hyperparathyroidism. Nineteen patients with chronic renal failure and secondary hyperparathyroidism underwent 123 I/ 99m Tc-sestamibi subtraction SPECT imaging preoperatively. None of these patients had undergone previous neck surgery. The location, weight, and histopathological results of all identified parathyroid glands were recorded. Surgery was considered successful in all patients, with resection of a total of 74 hyperplastic parathyroid glands. 123I/ 99m Tc-sestamibi subtraction SPECT correctly identified 57 of these parathyroid glands (77% sensitivity). The mean weight among the true positive glands (n ϭ 57) was 1031 mg (range, 45-7900 mg), and that among the false negative glands (n ϭ 17) was 465 mg (range, 20 -1800 mg). This difference between the mean weights was statistically significant (P ϭ 0.018). There was a positive correlation between parathyroid weight and detectability with 123 I/ 99m Tc-sestamibi subtraction SPECT (Spearman correlation ϭ 0.28; P ϭ 0.0167).123 I/ 99mTc-sestamibi subtraction SPECT is able to correctly localize hyperplastic parathyroid glands in patients with renal failure and secondary hyperparathyroidism, but there is a fairly weak relationship between preoperative detection rate and anatomical parathyroid gland size. (J Clin Endocrinol Metab 83: [3867][3868][3869][3870][3871] 1998) T HE LOCALIZATION of abnormal parathyroid glands can be helpful in planning surgical strategy before neck exploration. For this purpose, several invasive and noninvasive procedures have been tried, mostly in patients with primary hyperparathyroidism, including high resolution ultrasonography, computed tomography, venous sampling, and magnetic resonance imaging (1). Radionuclide procedures have also been used for this purpose. Previously, the most commonly used scintigraphic approach has been a dual isotope procedure combining 201 Tl-thallous chloride with either 99m Tc-pertechnetate or 123 I-labeled sodium iodide (2). More recently, 99m Tc-sestamibi has become a popular substitute for thallium-201 in scintigraphic parathyroid localization studies. As 99m Tc-sestamibi was first described for this use by Coakley et al. (3), the so-called double phase method proposed by Taillefer et al. (4) has gained considerable attention. This method involves imaging at two points in time; initially at 15 min and later at 2-3 h after iv injection of 99m Tc-sestamibi. A positive finding is an area of increased focal uptake that persists on late planar imaging. Sestamibi accumulation in normal thyroid tissue progressively decreases over time, allowing differentiation from abnormal parathyroid tissu...

Role of Radio-Guided Surgery in Recurrent Secondary Hyperparathyroidism

“…Consequently, the localization of multiglandular hyperplasia is difficult whatever the technique adopted. In patients with secondary hyperparathyroidism, US and MRI have a sensitivity of 40–50%, while preoperative 99m Tc-radiolabelled sestamibi scan has a sensitivity of 50–70% [2]. The situation is different in case of persistent or recurrent renal hyperparathyroidism, which occurs in 4% of cases, in which radionuclide scanning shows a sensitivity rate varying between 90 and 100% [6, 7, 8, 9].…”

“…Thus we tried to determine if the intraoperative use of a hand-held gamma detection probe can help the discovery of the hyperplastic residual gland in reoperative parathyroidectomy, where distortion of normal anatomy due to previous surgery renders surgery extremely challenging [10]. The operations in a reoperative neck have lower cure rates, higher complication rates, and take longer to perform [1, 2, 3]. In the cases described the hand-held gamma probe detection guided the dissection, restricted the operative field, avoided the exploration of unnecessary areas and allowed the localization of the residual glands, thus decreasing the risk of nerve injury because of the characteristics of the technique [11].…”

“…These characteristics of the technique render it theoretically useful, in particular in case of reoperation where scarring and the distortion of normal anatomy render surgery extremely challenging. The use of RGS for the treatment of renal hyperparathyroidism remains controversial because radionuclide uptake from hyperplastic glands is limited [2, 3, 4, 5]. In the present paper the authors try to evaluate the role of intraoperative gamma detection in case of recurrent secondary hyperparathyroidism.…”

Radio-guided surgery in recurrent renal hyperparathyroidism: Report of a case

“…In renal hyperparathyroidism all glands are almost invariably hyperplastic. [2][3][4] The situation is completely different in the case of persistent or recurrent renal hyperparathyroidism, occurring in 4% to 10% of cases after surgery. 5 It has been suggested that initially in renal hyperparathyroidism glandular cells grow diffusely polyclonally, whereas the cells in the nodules become monoclonal and proliferate aggressively.…”

Role of Preoperative Diagnostic Imaging Procedures in Secondary Hyperparathyroidism

“…Some groups perform oblique views, pin-hole and SPECT as well, showing a significant increase in the overall sensitivity of this technique [55][56][57]. It consists of the intravenous injection of 740 MBq of 99mTc-Sestamibi.…”