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Preoperative Localization and Radioguided Parathyroid Surgery^*

¹ Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy
² Division of Surgery, John Wayne Cancer Institute, Santa Monica, California
³ Radiotherapy and Nuclear Medicine Department, Regional Hospital of Padua, Padua, Italy
⁴ Institute of Endocrine Surgery, University of Pisa Medical School, Pisa, Italy
⁵ Institute of General Surgery, University of Padua Medical School, Padua, Italy

View larger version (34K): [in a new window]   FIGURE 1. Diagrammatic representation of routes of descent of thymus, parathyroid glands, and "last branchial body" during fetal life. Parathyroid glands originating more cranially in third branchial pouch migrate in close association with thymus to reach final position more caudally with respect to parathyroid glands originating in fourth branchial pouch. Final location of last branchial body is intimately embedded in thyroid gland, to constitute parafollicular C-cells producing calcitonin. Thyroid gland originates at "blind foramen" along midline and migrates down to first tracheal ring (modified from (115)).

View larger version (31K): [in a new window]   FIGURE 2. Anatomic locations of abnormal parathyroid glands found at reoperation by single group. Most common ectopic sites mirror routes of descent of upper parathyroid glands (short migration path) and of lower parathyroid glands (longer migration path in association with thymus) (modified from (116)).

View larger version (71K): [in a new window]   FIGURE 3. Classical single-tracer, double-phase parathyroid scintigraphy with 99mTc-sestamibi. (Left) Image at 15 min shows physiologic early uptake in thyroid gland, with clear focus of moderately increased accumulation at lower pole of right thyroid lobe. (Right) Late scan shows almost complete washout of 99mTc-sestamibi from thyroid gland, with obvious focal retention of radioactivity at lower pole of right thyroid lobe. Minimally invasive radioguided surgery confirmed presence of parathyroid adenoma.

View larger version (93K): [in a new window]   FIGURE 4. Parathyroid scintigraphy according to dual-tracer protocol (99mTc-pertechnetate and 99mTc-sestamibi), with administration of KClO4- at start of 99mTc-pertechnetate imaging. (Top left) Virtually normal thyroid gland. (Top center) Five-minute scan recorded within 35 min of 99mTc-sestamibi injection shows summation scan suggesting presence of adenoma of upper left parathyroid gland, better outlined when subtracting 99mTc-pertechnetate scan from summation scan (top right). Minimally invasive radioguided surgery confirmed presence of parathyroid adenoma. (Bottom left) Virtually normal thyroid gland. (Bottom center) Five-minute scan recorded within 35 min of 99mTc-sestamibi injection shows summation scan suggesting presence of adenoma of lower left parathyroid gland, better outlined when subtracting 99mTc-pertechnetate scan from summation scan (bottom right). Minimally invasive radioguided surgery confirmed presence of parathyroid adenoma.

View larger version (109K): [in a new window]   FIGURE 5. Double-phase parathyroid scintigraphy with 99mTc-sestamibi in patient with multinodular goiter. (Top left) Image at 15 min shows physiologic early uptake in thyroid gland, with clear focus of increased accumulation at lower pole of left thyroid lobe. (Top right) Late 99mTc-sestamibi scan shows some residual activity in thyroid gland, with obvious focal 99mTc-sestamibi retention at lower pole of left thyroid lobe. Second tracer (99mTc-pertechnetate) was administered after recording delayed 99mTc-sestamibi scan. (Bottom left) Image obtained by subtracting delayed 99mTc-sestamibi scan from summation scan recorded after 99mTc-pertechnetate administration was used to draw profile of thyroid gland, which was then superimposed on delayed 99mTc-sestamibi scan (bottom right) for better anatomic localization of parathyroid adenoma (confirmed by minimally invasive radioguided surgery).

View larger version (54K): [in a new window]   FIGURE 6. Anatomic localization of ectopic parathyroid adenomas by 99mTc-sestamibi SPECT. (A) Patient with persistent hyperparathyroidism after total thyroidectomy and bilateral neck exploration performed because of concomitant multinodular goiter and PHPT. Tomographic slices in transverse (left), sagittal (center), and coronal (right) planes define anatomic location of single focus of intense 99mTc-sestamibi uptake in anterior planes of upper mediastinum. Minimally invasive reoperation under radioguidance enabled surgeon to remove parathyroid adenoma located within thymus. (B) Tomographic slices in transverse (1), sagittal (2), and coronal (3 and 4) planes define anatomic location of single focus of intense 99mTc-sestamibi uptake behind thyroid gland. Surgery revealed parathyroid adenoma located in retroesophageal space.

View larger version (71K): [in a new window]   FIGURE 7. Anatomic localization of ectopic parathyroid adenoma by combined 99mTc-sestamibi and 99mTc-albumin SPECT. (Top left) Tomographic coronal slice obtained after 99mTc-sestamibi administration demonstrates focal area of abnormal tracer uptake in mediastinum, whose exact anatomic location with respect to other mediastinal structures remains uncertain. (Top right) Dose of 99mTc-albumin was then injected (without moving patient) as indicator of intravascular space, and another SPECT image was acquired under same conditions as 99mTc-sestamibi SPECT. (Bottom) Image fusion of corresponding coronal slices demonstrates that lesion with focal uptake of 99mTc-sestamibi is located in aorto-pulmonary window. Subsequent radioguided surgery confirmed presence of parathyroid adenoma in anatomic location identified by fusion analysis.