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Radioguided Surgery of Primary Hyperparathyroidism Using the Low-Dose ^99mTc-Sestamibi Protocol: Multiinstitutional Experience from the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS)

¹ Nuclear Medicine Service, "S. Maria della Misericordia" Hospital, Rovigo, Italy
² Department of Surgery, University of Padua Medical School, Padua, Italy
³ Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy
⁴ Nuclear Medicine Service, "S. Camillo-Forlanini" Hospital, Rome, Italy
⁵ Nuclear Medicine Service, "Careggi" University Hospital, Florence, Italy
⁶ Nuclear Medicine Service, "S. Martino" University Hospital, Genoa, Italy
⁷ Department of Surgery, University of Turin Medical School, Turin, Italy
⁸ Division of Surgery, "S. Camillo-Forlanini" Hospital, Rome, Italy

This study evaluated the accuracy of ^99mTc-sestamibi scintigraphy and neck ultrasonography in patients with primary hyperparathyroidism (PHPT) and the role of intraoperative hand-held -probes in minimally invasive radioguided surgery (MIRS) of patients with a high likelihood of a solitary parathyroid adenoma (PA). The study was undertaken under the aegis of the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS). Methods: Clinical records were reviewed for 384 consecutive PHPT patients undergoing radioguided surgery using a low dose of ^99mTc-sestamibi. Selection of patients for MIRS instead of traditional bilateral neck exploration was based on preoperative imaging indicating a solitary PA. ^99mTc-Sestamibi (37–110 MBq, or 1–3 mCi) was injected in the operating theater 10–30 min before the start of the intervention. Either 11-mm collimated (309 patients) or 14-mm collimated (75 patients) -probes were used. Intraoperative quick parathyroid hormone (IQPTH) assay was used on 308 patients (80.2%). Results: MIRS was successfully performed on 268 (96.8%) of 277 patients. Conversion to bilateral neck exploration was necessary in 9 patients (3.3%) because of either persistently high IQPTH levels after removal of the preoperatively visualized PA (4 patients), intraoperative frozen-section diagnosis of parathyroid carcinoma (2 patients), or hard-to-remove PA (3 patients). MIRS, which was performed under locoregional anesthesia in 72 patients, required a mean operating time of 37 min and a mean hospital stay of 1.2 d. MIRS was successfully performed also on 32 (78.0%) of 41 patients who had previously undergone thyroid or parathyroid surgery. No major surgical complications were observed in the MIRS group, and there were only 24 cases (11%) of transient postoperative hypocalcemia. The probe was of little help in patients with concomitant ^99mTc-sestamibi–avid thyroid nodules and not helpful at all in patients with negative scan findings preoperatively. IQPTH measurement helped to disclose some cases of multigland parathyroid disease. Conclusion: ^99mTc-Sestamibi scintigraphy, especially if combined with neck ultrasonography, is highly accurate in selecting PHPT candidates for MIRS. The low-dose ^99mTc-sestamibi protocol (which entails a low-to-negligible radiation exposure to the surgical team) is safe and effective for MIRS. MIRS plays a limited role in patients with concomitant ^99mTc-sestamibi–avid thyroid nodules and should be discouraged in patients with negative ^99mTc-sestamibi finding preoperatively. IQPTH can be recommended during MIRS to facilitate intraoperative identification of previously undiagnosed multigland parathyroid disease.

Key Words: primary hyperparathyroidism • solitary parathyroid adenoma • minimally invasive parathyroidectomy • radioguided surgery • ^99mTc-sestamibi scintigraphy • neck ultrasonography

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