Elsevier

Surgery

Volume 128, Issue 1, July 2000, Pages 29-35
Surgery

Original Communications
Technetium 99m-MIBI-SPECT: A highly sensitive diagnostic tool for localization of parathyroid adenomas*

https://doi.org/10.1067/msy.2000.107066Get rights and content

Abstract

Background: The aim of this study was to assess the value of technetium 99m-MIBI scintigraphy using the single photon emission computed tomography (SPECT) technique for preoperative localization of smaller (≤ 1 g) parathyroid adenomas. Methods: A total of 92 patients (34 men, 58 women; mean age, 60 ± 13 years) with an established diagnosis of primary hyperparathyroidism and nondiagnostic ultrasonography (inclusion criteria) were scanned preoperatively. After a thyroid examination to check for other possible radionuclide-accumulating thyroid diseases, a planar technetium 99m-pertechnetate/technetium 99m-MIBI subtraction scintigraphy (15 minutes post injection) and tomographic images (120 minutes post injection) were acquired after intravenous injection of 740 MBq of technetium 99m-MIBI and using a 3-head gamma camera (Picker Prism 3000). Sensitivity was defined by the ability to predict the correct site of a parathyroid adenoma. Results: All patients had parathyroid adenomas ≤ 1 g (53 patients, 0.5 -1.0 g; 39 patients, < 0.5 g). Correct localization of parathyroid adenomas to one side or the other was achieved in 87% of the patients using planar technetium 99m-pertechnetate/technetium 99m-MIBI subtraction scintigraphy. Sensitivity was increased to 95% by supplementary use of the SPECT technique and a 3-D display (volume-rendered reprojection for visualization). There was technetium 99m-MIBI accumulation in 11 benign thyroid nodes, but none of the healthy parathyroid glands were shown on the scan. Conclusions: This study indicates that technetium 99m-MIBI parathyroid scintigraphy is a sensitive and specific tool for topographic localization even of small parathyroid adenomas, especially with the use of SPECT. This method could help to improve the efficiency of parathyroidectomy (eg, by making unilateral exploration sufficient). (Surgery 2000;128:29-35.)

Section snippets

Patients and methods

The total patient population of 92 was made up of 34 men and 58 women, mean age 60 ± 13 years, with established diagnosis of primary hyperparathyroidism. The diagnosis was based on elevated levels of serum calcium (2.98 ± 0.24 mmol/L; normal range, 2.20-2.65 mmol/L) and parathormone (PTH, 314 ± 133 ng/L; normal range, 12-72 ng/L), a further inclusion criterion being a nondiagnostic ultrasound (7.5 MHz linear array). After the MIBI study, the patients were scheduled to undergo bilateral surgical

Results

All patients underwent a bilateral neck exploration (the average operation time alone was 50 minutes). In 4 patients, a mediastinal exploration (sternotomy) was necessary. Twelve patients were operated on additionally for a benign goiter. The mean hospital stay of the in-patients was about 4 days; the average hospital operation costs amounted to approximately $1000.

All abnormal serum parameters returned to normal values after the operation (calcium, 2.32 ± 0.14 mmol/L and parathormone 44 ± 22

Discussion

Parathyroidectomy with bilateral exploration can become a lengthy, large-scale operation and must be performed by an experienced endocrine surgeon to be successful. Bilateral exploration of the neck exposes the patient to a greater risk of recurrent laryngeal nerve injuries13 and increases the likelihood of hypoparathyroidism.14 The latter can be caused by unintentional intraoperative damage of the filamentous blood vessels supplying the normal parathyroid glands. Multiple adenomas (Fig 2, A ),

Conclusions

Although exact prior localization can render extensive bilateral exploration unnecessary in patients with a solitary adenoma,33 preoperative scintigraphic screening cannot yet be recommended for all patients with primary hyperparathyroidism, since cost-benefit analyses have still not revealed any clear advantages of this approach,13, 21, 23, 34 especially when the operation is performed by an experienced endocrine surgeon. Nevertheless, the preoperative localization of abnormal glands by using

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    *

    Reprint requests: Detlef Moka, MD, Department of Nuclear Medicine, University of Cologne, Josef Stelzmannstr 9, D-50924 Köln, Germany.

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