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Efficient Parathyroidectomy Guided by SPECT-MIBI and Hormonal Measurements

Division of Nuclear Medicine, Departments of Radiology and Surgery, University of Miami School of Medicine, Jackson Memorial Hospital
Veterans Affairs Medical Center, Miami, Florida

Correspondence: For correspondence or reprints contact: George N. Sfakianakis, MD, Division of Nuclear Medicine (D-57), University of Miami School of Medicine, P.O. Box 016960, Miami, FL 33101.

ABSTRACT

Parathyroidectomy is a difficult and lengthy operation which is noncurative in 6% to 10% of cases. To improve the efficiency of this operation, a new dual diagnostic approach was prospectively applied. Methods: Preoperative tomographic ^99mTc-sestamibi (MIBI) scintigraphy and intraoperative measurements of circulating parathyroid hormone (PTH) levels by a quick assay (QPTH) were used. Scintigraphy comprised immediate and delayed planar and SPECT of the neck and chest, following 20 mCi MIBI. The presence and location of persistent foci of abnormal activity found within the neck and mediastinum on volume-rendered reprojection (RPJ) of the SPECT data were reported. The surgeon, guided by the three-dimensional MIBI-SPECT/RPJ images, identified and excised the single or most prominent scintigraphic focus and applied the QPTH. If PTH levels fell from baseline by at least 50%, the operation was concluded. Results: The operative time of primary parathyroidectomy was reduced from an average of 90 min (before the introduction of scintigraphy and intraoperative PTH measurements) to 57 min. All but two patients became normocalcemic. In 58 consecutive patients with hyperparathyroidism, MIBI-SPECT/RPJ correctly and precisely identified 51 of 53 (96%) primary parathyroid adenomas, 14 of 15 secondary hyperplasias and 2 of 3 hyperplastic glands in MEN (sensitivity 94%, specificity 92%). QPTH verified the excision of the primary parathyroid adenomas and predicted normocalcemia in 50 of 52 patients. In 6 patients with misleading scintigraphy, QPTH was especially useful and guided the surgeon to continue the operation until the abnormal parathyroid tissue was found and excised. Conclusion: MIBI-SPECT/RPJ and QPTH sequentially applied improved the efficiency of parathyroidectomy.

Key Words: parathyroidectomy • hyperparathyroidism • ^99mTc-MIBI/SPECT • parathyroid hormone measurements

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