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Limited Sensitivity of Parathyroid Imaging with ^99mTc-Sestamibi/¹²³I Subtraction in an Endemic Goiter Area

¹ Department of Nuclear Medicine, Municipal Hospital, Hanau, Germany

Double-phase single-tracer scintigraphy with ^99mTc-sestamibi is now generally used for parathyroid imaging but, at least in endemic goiter areas, complementary thyroid scintigraphy is recommended. Although ¹²³I-sodium iodide is considered to be the optimal thyroid agent, it is hardly ever used because of high costs and logistic difficulties. Our study presents the results of using the ^99mTc-sestamibi/¹²³I subtraction technique in a region with a high goiter prevalence. Special attention was paid to the changes in sensitivity and specificity and their relationship to thyroid volume as well as to autonomous and nodular thyroid disease. Methods: One hundred three scintigraphic parathyroid examinations on 96 patients were included in this study. Fifty-eight of all patients had concomitant morphologic or functional alterations of the thyroid. Initially, 10 MBq ¹²³I-sodium iodide were injected. Then, 150 MBq ^99mTc-sestamibi were administered after 3–5 h, followed by planar scintigraphic imaging of the neck and upper chest region using a double-isotope technique. Results: An area with increased tracer uptake on the subtraction image was found in 44 cases. Forty-three of them proved to be true-positive. No suspicious lesions were detected scintigraphically on the remaining 59 examinations. However, histologic examination revealed a parathyroid adenoma or hyperplasia in 11 of these cases. The mean parathyroid volume of these false-negative patients was 0.9 mL. Secondary hyperparathyroidism with multiple enlarged parathyroid glands was found in 4 of these cases. The sensitivity of the parathyroid scintigraphy was 80% (43/54) and the specificity was 98% (48/49). There was a distinct difference in the sensitivity between the subgroups with thyroid volumes of >15 mL and <15 mL (76% vs. 88%), although the resected parathyroid glands had a similar size in both subgroups. The specificity was 97% and 100%, respectively. No significant difference in the sensitivity and specificity was observed between the subgroups with and without morphologic or functional alterations of the thyroid (80% vs. 79% and 96% vs. 100%, respectively). Conclusion: The sensitivity of parathyroid imaging with ^99mTc-sestamibi/ ¹²³I subtraction depends mainly on the thyroid and parathyroid volumes rather than on the presence of nodular or autonomous thyroid disease.

Key Words: parathyroid scintigraphy • ^99mTc-sestamibi • ¹²³I • nodular goiter • autonomous thyroid adenoma