Elsevier

Surgery

Volume 131, Issue 2, February 2002, Pages 149-157
Surgery

Original Communications
Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism*

https://doi.org/10.1067/msy.2002.119817Get rights and content

Abstract

Background. Delayed technetium-99m sestamibi single photon emission computed tomography (SPECT) scans were prospectively analyzed in a large series of patients with primary hyperparathyroidism. Methods. Three hundred thirty-eight patients underwent sestamibi-SPECT and were explored. Prospective data included preoperative demographics, clinical, sestamibi, and operative findings, laboratory values, and pathologic and follow-up laboratory results from all patients. Results. Between 1994 and 2000, 287 unexplored patients (85%) and 51 re-explored patients (15%) participated. The abnormal parathyroid glands excised from 336 of 338 patients included 299 single adenomas (88%) and 23 double adenomas (7%), and 14 patients had multigland hyperplasia (4%). Sestamibi SPECT correctly lateralized 349 of 400 abnormal parathyroid glands, with an overall sensitivity of 87%, an accuracy of 94%, and a positive predictive value of 86%. Precise localization occurred in 82% of the abnormal parathyroid glands. Sestamibi sensitivity was similar in unexplored (87%) and reoperative (92%) cases; two hundred eighty-six of 299 (96%) solitary adenomas, 38 of 46 (83%) double adenomas, but only 25 of 55 (45%) hyperplastic glands were identified. The mean weight of the true-positive glands (1252 ± 1980 mg) was greater than that of the false-negative glands (297 ± 286 mg) (P <.005). Three patients had persistent primary hyperparathyroidism, in spite of the excision of sestamibi-identified lesions in 2 cases. Follow-up indicated curative resection in 99% of the unexplored cases and 94% of the remedial cases. Conclusions. Sestamibi SPECT is highly accurate for the localization of parathyroid adenomas in unexplored and re-explored cases, where it is often the only imaging required. Its sensitivity is limited in multiglandular disease. (Surgery 2002;131:149-57.)

Section snippets

Patient population

From 1994 to 2000, 338 consecutive patients with biochemically confirmed 10HPTH underwent preoperative Tc-99m sestamibi parathyroid SPECT scintigraphy (sestamibi-SPECT) and were explored by 1 endocrine surgeon. There were 287 patients (85%) who had not undergone cervical exploration, whereas 51 (15%) patients had undergone reoperative cervical exploration. Biochemical confirmation of 1°HPTH was obtained in every patient by demonstrating increased or inappropriate serum calcium concentrations,

Surgical results

There were 233 women and 105 men, ranging in age from 13 to 88 years, with a mean of 58.4 ± 13.5 years. In these 338 consecutive patients, there were 400 surgically excised abnormal parathyroid glands. There were 287 unexplored patients, of which 139 underwent minimally invasive parathyroidectomy and 148 underwent conventional exploration. Two hundred ninety-nine patients had solitary parathyroid adenomas, 23 had double parathyroid adenomas, and 14 patients with multiglandular hyperplasia had a

Discussion

Many investigators have documented the efficiency of Tc-99m sestamibi scans in localizing parathyroid adenomas. Reported sensitivities for the localization of parathyroid adenomas with dual phase planar Tc-99m sestamibi scintigraphy vary between 43% to 91%.20 By this method, areas of increased activity on early images that persist on delayed images (2-3 hours after injection) are interpreted to represent abnormal parathyroid glands. In contrast, activity in the normal thyroid gland washes out

References (38)

  • RM Satava et al.

    Success rate of cervical exploration for hyperparathyroidism

    Arch Surg

    (1975)
  • JA Norton

    Controversies, advances in primary hyperparathyroidism

    Ann Surg

    (1992)
  • AR Shaha et al.

    Cervical exploration for primary hyperparathyroidism

    J Surg Oncol

    (1993)
  • GL Irvin et al.

    A new approach to parathyroidectomy

    Ann Surg

    (1994)
  • NR Borley et al.

    Tc-99m sestamibi parathyroid localization is accurate enough for scan-directed unilateral neck exploration

    Br J Surg

    (1996)
  • R Taillefer et al.

    Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with Tc-99m sestamibi (Double-phase study)

    J Nucl Med

    (1992)
  • LB Johnston et al.

    The accuracy of parathyroid gland localization in primary hyperparathyroidism using sestamibi radionuclide imaging

    J Clin Endocrinol Metab

    (1996)
  • AR Shaha et al.

    Sestamibi scan for preoperative localization in primary hyperparathyroidism

    Head Neck

    (1997)
  • CC Chen et al.

    Technetium-99m-sestamibi imaging before reoperation for primary hyperparathyroidism

    J Nucl Med

    (1995)
  • Cited by (183)

    • Guide to Preoperative Parathyroid Localization Testing

      2021, Surgery of the Thyroid and Parathyroid Glands
    • Pheochromocytoma/Paraganglioma, Medullary Thyroid Carcinoma, and Hereditary Endocrine Neoplasia Syndromes

      2020, Sperling Pediatric Endocrinology: Expert Consult - Online and Print
    • Physiology and Diseases of the Parathyroid Glands in the Elderly

      2020, Endocrinology of Aging: Clinical Aspects in Diagrams and Images
    View all citing articles on Scopus
    *

    Reprint requests: Robert Udelsman, MD, MBA, Chairman, Department of Surgery, Yale University School of Medicine, 330 Cedar St, PO Box 208062, New Haven, CT 06520-8062.

    View full text