MIBI Scan Research Articles

Endoscopic parathyroidectomy: a retrospective review of 27 cases.

Primary hyperparathyroidism is a common endocrine disorder with adenomas being the most frequent cause. The condition is conventionally treated by a bilateral neck exploration through a cervical incision with removal of the affected glands. Intra-operative parathyroid hormone (IOPTH) monitoring and pre-operative Tc99m MIBI scans are facilitating focused approaches like minimally invasive video-assisted parathyroidectomy (MiVAP) and totally endoscopic parathyroidectomy (TOEP). Patients with primary hyperparathyroidism were tested for location of diseased gland and accordingly selected for endoscopic parathyroidectomy by either trans-vestibular or trans-axillary approach. Those having undergone prior neck surgery or irradiation and those with an enlarged thyroid were excluded. All patients underwent IOPTH measurement to confirm the completeness of diseased gland resection. Eleven cases meeting selection criteria underwent endoscopic trans-vestibular parathyroidectomy and 16 cases underwent endoscopic trans-axillary parathyroidectomy. The mean operative time and blood loss were 104min and 34mL in trans-vestibular approach, respectively, while they were 47min and 68mL for the trans-axillary approach. All patients had post-operative resolution of hypercalcaemia. A single conversion to cervical approach was performed due to unsatisfactory IOPTH fall. A single patient suffered transient recurrent laryngeal nerve palsy which resolved with steroids. Endoscopic parathyroidectomy is a safe and feasible surgical procedure when combined with pre-operative imaging and intra-operative parathyroid hormone monitoring. There is a steady rise in the number of patients with primary hyperparathyroidism, a majority of whom have solitary gland affliction. Focused exploration is the current standard, wherein endoscopic surgery can be an important tool to improve outcomes.

Parathyromatosis in a patient with parathyroid carcinoma and hypercalcemic crisis: Findings on MIBI scan and 4D CT

Parathyroid carcinoma is a rare tumor associated with significantly high levels of parathyroid hormone (PTH) and primary hyperparathyroidism (HPT) and is difficult to distinguish from parathyroid adenoma, which is a much more common cause of HPT. Parathyromatosis is a rare condition in which several nodules of hyperfunctioning parathyroid tissue form in the neck and mediastinum, and it presents as recurrent hyperparathyroidism. We describe the case of a 44-year-old woman with recurrent hyperparathyroidism who presented with hypercalcemic crisis and biochemical investigations showed a severely raised serum intact parathyroid hormone (iPTH) level of 2513 pg/ml and serum calcium level of 17 mg/dl. A four-dimensional computed tomography (4D CT) of the neck was done, which showed few arterially enhancing nodular lesions in the right paratracheal and retrotracheal location at the level of thoracic inlet showing washout in delayed images suggestive of recurrent/residual parathyroid lesions. A technetium-99 m methoxyisobutylisonitrile (Tc-99 m MIBI) scan was done, and the planar neck anterior early images showed an area of increased radiotracer uptake in the right lower neck region with persistent uptake in the delayed images. Single photon emission computed tomography/ computed tomography (SPECT/CT) images showed a soft-tissue lesion in the right paratracheal region at the level of C7 vertebra showing increased radiotracer uptake suggestive of a recurrent/residual parathyroid lesion. Exploration and excision of the recurrent parathyroid mass was planned, and the right paratracheal mass with nodes above the aortic arch along with the subcutaneous and intramuscular lesions were excised. Postoperative serum calcium was 7.8 mg/dl, and serum iPTH was 135 pg/ml. Histopathological examination of the excised tissue showed the features of parathyroid carcinoma. Thus, Tc-99 m MIBI scan and 4D CT were critical in evaluating this case of parathyroid carcinoma with recurrent hyperparathyroidism and planning its management.

Characteristics, Management and Outcome of Primary Hyperparathyroidism in a Predominantly Vitamin D Deficient Population: A Single-Center Experience

Primary hyperparathyroidism (PHPT) has variable clinical presentation and symptomatic PHPT is still the predominant form of the disease in Indian subcontinent. Now, there is a decreasing trend of symptomatic cases and increasing number of asymptomatic cases with time. 25-hydroxy vitamin D has no correlation with serum calcium and PTH. To study patients with hyperparathyroidism and its relation to vitamin D. We studied 78 consecutive patients with PHPT in whom vitamin D level was measured. Out of the 78 study patients, 67 (85.7%) were females and 11 (14.2%) were males. The age ranged from16 to 70 years. Nephrolithiasis was the single most common presentation (48.2%) followed by bone pain in 44%. Only 5% were asymptomatic with a decreasing trend of symptomatic cases and increasing number of asymptomatic cases with time. Mean serum calcium level was 11.5±1.0, mean serum PTH level 377±386.1 pg/ml and mean 25-hydroxy vitamin D level 37.2±58.1 ng/ml. Forty eight percent of patients were vitamin D deficient. 25-hydroxy vitamin D had no correlation with serum calcium and PTH, but had a negative correlation with tumour size. Neck ultrasonography was suggestive of parathyroid pathology (laterality) in 89.8% and exact site of parathyroid pathology in 63.3%. MIBI scan showed parathyroid pathology in 92.5% and exact site in 85.7% of patients. Single parathyroid gland was involved in 90% of cases, double glands in 8% and multiple/hyperplasia in 1.6%. Parathyroid adenoma was in 86.3%, parathyroid hyperplasia in 7.8%. Temporary post-operative hypocalcaemia was seen in 36%; cure rate was achieved in 98.37% of patients without operative mortality. Primary hyperparathyroidism is still a symptomatic disease in Kashmir Valley but now there is a decreasing trend of symptomatic cases and an increasing number of asymptomatic cases with time. 25-hydroxy vitamin D level has no correlation with serum calcium, iPTH and tumour size.

BIOKINETIC MODEL OF Tc-99m MIBI FOR EIGHT PATIENTS UNDERGONE MYOCARDIAL PERFUSION EXAMINATION via GAMMA CAMERA AND MATLAB PROGRAM: AN IN-VIVO STUDY

Biokinetic model of Tc-99m MIBI for eight patients undergone myocardial perfusion examination was studied using gamma camera and MATLAB program. A six-compartment model was adopted to interpret the metabolic mechanism of each patient. Within the model framework, the respective set of simultaneous differential equations was solved by a self-developed program run in MATLAB. The experimental results exhibited a good fit with the theoretical predictions via the model. The average biological half-lives of body fluid, heart, thyroid, liver, GI Tract and remainder were assessed as [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], [Formula: see text], and [Formula: see text][Formula: see text]h, respectively. A dimensionless AT index of disagreement between the experimental data and MATLAB optimal solution was proposed of validating the applied acquisition system and analytical method feasibility. An AT of zero implies a perfect agreement between the theoretical and empirical results, while averages of the derived AT were fluctuated from 3 [Formula: see text] 2 to [Formula: see text] for five compartments. The proposed refined equation estimated the internal dose from gamma-ray as [Formula: see text][Formula: see text]mSv for eight patients according to a fast screening method, which defined human body as a spherical ball to simplify the calculation in reality. The proposed MATLAB-based fitting of in-vivo data with the theoretical results was instrumental for assessing the radiation dose received by the Tc-99m MIBI scan participants.

Pre-operative Localisation of the Parathyroid Glands in Secondary Hyperparathyroidism: A Retrospective Cohort Study

Complete parathyroidectomy (PTx) is essential during total PTx for secondary hyperparathyroidism (SHPT) to prevent recurrent and persistent hyperparathyroidism. Pre-operative imaging evaluations, including computed tomography (CT), ultrasonography (US), and Tc-99m sestamibi (MIBI) scans, are commonly performed. Between June 2009 and January 2016, 291 patients underwent PTx for SHPT after pre-operative evaluations involving CT, US, and MIBI scans, and the diagnostic accuracies of these imaging modalities for identifying the parathyroid glands were evaluated in 177 patients whose intact parathyroid hormone (PTH) levels were <9 pg/mL after the initial PTx. Additional PTx procedures were performed on 7 of 114 patients whose intact PTH levels were >9 ng/mL after PTx, and the diagnostic validities of the imaging modalities for the remnant parathyroid glands were evaluated. A combination of CT, US, and MIBI scans achieved the highest diagnostic accuracy (75%) for locating bilateral upper and lower parathyroid glands before initial PTx. The accuracies of CT, US, and MIBI scans with respect to locating remnant parathyroid glands before additional PTx were 100%, 28.6%, and 100%, respectively. A combination of CT, US, and MIBI scans is useful for initial PTx for SHPT, and CT and MIBI scans are useful imaging modalities for additional PTx procedures.

Minimally invasive parathyroid carcinoma-A missing entity between parathyroid adenoma and carcinoma: Scintigraphic and histological features.

Minimally invasive parathyroid carcinoma (MIPC) is clinically and biochemically comparable with parathyroid adenoma (PA) though histopathologically differ from PA. MIPC is an intermediate of PA and parathyroid carcinoma (PC). In literature, there is no definite criterion to diagnose MIPC. Our aim was to evaluate and characterize the imaging and biochemical parameters with histological characteristics of MIPC. Ten patients with MIPC were recruited from (single centre) Indian PHPT registry (www.indianphptregistry.com) from January 2014 to July 2018. Clinical, biochemical, imaging and histological features of MIPC patients were reviewed. The mean age of MIPC patients (n=10; 3 males) was 39.9±11.3years (range: 17-50). All patients had an elevated preoperative parathyroid hormone (iPTH) level ranging from 427 to 2138pg/mL (median: 1328). MIBI scan showed intensely avid and enlarged parathyroid tumours in all patients; LIPT in 6, RIPT in 3 and ectopic mediastinal in 1 with mean size of the tumours was 2.8±1.1cm. The mean of maximum standardized uptake value (SUVmax) of MIPC in F-18 fluorocholine PET/CT was 6.7±1.1 (range 6.0-8.3). The mean tumour weight was 12±9.5g (range: 1.09-28). All MIPC patients had identified capsular invasion in 80% and vascular invasion in 50% only but there was no local invasion, lymph nodal or distant metastasis. The mean Ki-67 labelling index was 3.2±2.7 (range 1.1-10). The study concluded that MIPC patients are less aggressive (on the basis of imaging and histopathological findings) and should be differentiated from parathyroidadenomaandcarcinoma.

Serum Vitamin D Level Does not Affect The Sensitivity of Parathyroid Adenoma Localization Tests

The aim of the present study was to evaluate the predictive value of 25-hydroxyvitamin D, calcium and parathormone level, co-existence of thyroid nodule, thyroidectomy history and adenoma volume on the success of neck ultrasound (US) and technetium-99m sestamibi (MIBI) scan in primary hyperparathyroidism (PHP) patients. This study included 256 patients with PHP who underwent parathyroidectomy. 169 (%66) patients had vitamin D deficiency and 56 (%22) of patients had insufficiency. The sensitivity of US and MIBI studies showed no difference between vitamin D deficiency, insufficiency and replete groups (%80.5, %82 and %71 (p > 0.05) and %81, %84 and %71 respectively (p > 0.05)). Vitamin D level was not found to be an independent predictor of localization on either US or MIBI scan after adjusting for different variables (p > 0.05). Calcium level was found to be an independent predictor for US sensitivity (r2:0,033, p:0,032) and parathormone level for MIBI sensitivity (r2:0,05, p:0,025). The co-existence of nodular thyroid disease and history of thyroidectomy significantly decreased the sensitivity of US (%76 and %43). MIBI sensitivity was not impaired by nodular disease but the history of thyroidectomy also impaired the sensitivity of MIBI (%43). As a result vitamin D level does not affect the sensitivity of preoperative localization tests.

Current concepts in parathyroid carcinoma: a single Centre experience

BackgroundParathyroid carcinoma is a rare neoplasm that may present sporadically or in the context of a genetic syndrome. Diagnosis and management are challenging due to the lack of clinical and pathological features that may reliably distinguish malignant from benign disease.MethodsFrom January 2013 to December 2017, from 358 consecutive patients affected by parathyroid diseases, 3 patients with parathyroid carcinoma were treated at our academic Department of General Surgery. We present our experience as illustrative of the different features of clinical presentation of parathyroid carcinoma and review its management considering the recent relevant literature.ResultsCase 1: A 62-year-old man was hospitalized for left-sided palpable neck mass, hypercalcemia and elevated PTH. US-guided FNA was suspect for parathyroid carcinoma. A large cystic mass was excised in bloc with total thyroidectomy and central neck dissection. Genetic studies framed a pathologically confirmed parathyroid carcinoma within MEN1 syndrome. Case 2: A 48-year-old woman with hypothyroidism had total thyroidectomy performed for a suspect for right follicular thyroid lesion. Pathology revealed parathyroid carcinoma. Case 3: A 47 year-old man was admitted for hypercalcaemic crisis and renal failure in the context of PHPT. A lesion suggestive on US and MIBI scan for parathyroid adenoma in the right lower position was removed by mini-invasive approach. Pathology revealed parathyroid cancer and patient had completion hemythyroidectomy and central neck dissection.ConclusionParathyroid cancer is a particularly rare endocrine malignancy, however it should be suspected in patients with primary hyperparathyroidism when severe hypercalcemia is associated to cervical mass, renal and skeletal disease. Parathyroid surgery remains the mainstay of treatment. Radical tumour resection and expedited treatment in a dedicated endocrine Center represent crucial prognostic factors.

Could the Less-Than Subtotal Parathyroidectomy Be an Option for Treating Young Patients With Multiple Endocrine Neoplasia Type 1-Related Hyperparathyroidism?

Background: The surgical treatment of primary hyperparathyroidism (HPT) in patients with multiple endocrine neoplasia type 1 (MEN1) has evolved due the concern of permanent hypoparathyroidism. As the diagnosis has increased, the extent of operation has decreased. Most MEN1 patients requiring parathyroidectomy are younger than 50 years and they pose a difficult balance to achieve between persistent HPT and life-long hypoparathyroidism. The aim of the present study is to review our experience with a large series of patients with MEN1-related HPT (HPT/MEN1) treated at a single institution in order to find clues to a better treatment decision in these younger cases.Method: Retrospective analysis of consecutive HPT/MEN1 cases treated at a single institution with different operations: total parathyroidectomy and immediate forearm autograft (TPTX-AG), subtotal (STPTX), unintentional less than subtotal (U-LSTPTX) and intentional less than subtotal parathyroidectomy (I-LSTPTX).Results: Considering 84 initial cases operated on since 2011 (TPTX-AG, 39; STPTX, 22, U-LSTPTX, 13, and I-LSTPTX, 10), the rates of hypoparathyroidism were 30.8% (U-LSTPTX), 28.2% (TPTX-AG), 13.6% (STPTX), and 0% (I-LSTPTX). Two-thirds of them (68%; 57/84) were young (<50 years) or asdolescents. MIBI scan was more sensitive to show parathyroid glands and bilateral disease. Considering the concordance of MIBI and ultrasound for the possibility of unilateral clearance, it would be suitable to 22.6% of the cases. Intra-operative parathormone showed a significant decay even after unilateral exploration, but longer follow up is necessary. Overall, there were seven (4%) adolescents in 161 cases treated from 1987 to 2018, three underwent TPTX-AG and four had U-LSTPTX. Five are euparathyroid, one had mild recurrence, and one required a reoperation after 8 years due to the residual gland.Conclusions: Young patients are the most frequent candidates to parathyroidectomy. Less extensive procedures may be planned only if carefully reviewed preoperative imaging studies suggest a localized disease. Patients and their relatives should be fully informed of the risks and benefits during consent process. Future research with larger cohorts and long-term results are necessary to clarify if less than I-LSPTX or unilateral clearance are really adequate in selected groups of patients with HPT/MEN1 presenting lower volume of disease detected by preoperative imaging studies.

Does renal function improve after parathyroidectomy in primary hyperparathyroidism?

IntroductionPrimary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and parathormone increase. Decreased glomerular filtration rate (<60ml/min) continues to be a parathyroidectomy (PTX) criterion in asymptomatic PHPT. The influence of PTX on renal function evolution is the subject of debate. ObjectiveTo analyse the clinical, laboratory and histological characteristics of patients undergoing PHPT, as well as renal function evolution after PTX. Material and methodsRetrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016. Laboratory parameters were determined at baseline, one week and one year after PTX. ResultsThe Incidence of PTX was 38cases/million/year. Mean age was 60±14 years and 80.5% of the patients were female. Approximately 65.3% were asymptomatic. Nephrolithiasis was the most common clinical finding (33%), followed by bone involvement (29.5%). PTX indications were: clinical symptoms (34.7%), hypercalcaemia >11.2mg/dl (27%), nephrolithiasis (13%), low bone mass (12%), age <50 years (11%) and decreased glomerular filtration rate <60ml/min (2.3%).For diagnostic localisation, spect-MIBI had a sensitivity of 92% and cervical ultrasound of 70%. A total of 94.3% of PHPT cases were due to a parathyroid adenoma.After PTX, normalisation of PHPT-related parameters was observed. We found a significant increase in serum creatinine levels (0.81 vs 0.85mg/dl, p<.001) from the first week post-PTX until the end of the first year. The renal function was only found to be significant in patients with glomerular filtration rate >60ml/min (baseline serum creatinine levels 0.77mg/dl vs serum creatinine levels after one year 0.81mg/dl, p<.001). ConclusionsPHPT was asymptomatic in most patients who underwent surgery. Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients. MIBI scan was the most useful localisation method. Surgical treatment of PHPT is followed by renal function impairment, which persists after the first week post-PTX.

A Prospective Study Comparing 99mtc-Sestamibi SPECT/CT with 18f-FDG PET/CT in Multiple Myeloma Staging: A Potential Resource-Constraint Image Alternative for MM Bone Evaluation

Introduction: Multiple myeloma (MM) is a plasma cell neoplasm, characterized by plasma cell infiltration inside the bone marrow, secretion of monoclonal immunoglobulin (paraprotein), and end organ damage including lytic lesions in the bones. About 80-90% of myeloma patients suffer from osteolytic lesions during the course of the disease. 18F-FDG PET/CT is an imaging technique capable to detect active disease in patients in multiple myeloma (MM) and can be helpful in staging and prognosis. However, its routine use is still hampered by several factors, including high cost, reimbursement issues, lack of cost-effectiveness studies and limited availability. 99mTc-sestamibi (MIBI) has also been proposed as a potential tracer in MM evaluation and is more accessible with lower costs. The aim of this study was to compare these two imaging modalities at staging disease and their relation with clinical data.Materials and Methods: Sixty-four patients with newly diagnostic MM (30 male; 34 female) were submitted to 18F-FDG PET/CT and 99mTc-Sestamibi SPECT/CT before treatment. Whole body PET/CT images were acquired 60 minutes after FDG administration and anterior and posterior whole-body scans (WBS) plus SPECT/CT of chest and abdomen were obtained 10 minutes after MIBI injection. Number of focal lesions, bone marrow involvement, contiguous soft tissue impairment and extra osseous lesions were recorded. Number of focal lesions was classified in 3 groups: 0 (no lesions); 1 (1-3 lesions); 2 (4-10); 3 (more than 10). A visual degree of uptake was defined for bone marrow involvement: comparison to liver on PET/CT and to myocardium on MIBI. Standardized uptake value (SUVmax) of the hottest lesion of each patient was registered. Potentials factors contributing to progression-free survival (PFS) were assessed with Cox regression model combining baseline clinical data (including renal function, anemia, hypercalcemia, LDH, bone marrow plasma cell percentage and ISS (I, II or III)) along with PET/CT and MIBI scan status.Results: PET/CT was positive in 61 patients (95%) and MIBI in 59 subjects (92%; P = 0.15). WBS was positive in 56 patients while WBS plus SPECT/CT was positive in 59 (p= 0.08). PET/CT detected extra osseous lesions in 4 patients and sestamibi in 1 subject. Contiguous soft tissue involvement was found in 29 and 24 patients on PET/CT and MIBI, respectively (p=0.05). PET/CT detected much more focal lesions than MIBI: 13, 11, 16 and 24 patients were in group 0, 1, 2 and 3 on PET/CT and 30, 18, 6 and 10 were on the same groups respectively on MIBI (p: 0.0001). In the figure below, a comparison between 99mTc-Sestamibi WBS (A) and 18F-FDG PET/CT (B) at staging in a 67 years-old male.SUVmax were statistically different in subjects who presented elevated LDH (p= 0.02). Seventy-five percent and 100% of patients with elevated LDH had contiguous soft tissue involvement on MIBI and PET/CT respectively. More focal lesions on PET/CT were found in patients with hypercalcemia (p=0.02), however this correlation was not observed on MIBI (p=0.45). Renal insufficiency was a negative prognostic factor for PFS (HR: 2.25). The same was observed with advanced ISS staging (HR: 4.29). However, only advanced ISS staging (III) and extramedullary disease detected by MIBI were independent predictors of worse PFS.Conclusion: There was no difference in the detection of active disease when comparing FDG PET/CT and MIBI SPECT/CT in MM staging, although the first one detected more number of lesions. Including SPECT/CT to planar images on MIBI did also not improve the number of positive scans. Elevated LDH and hypercalcemia were the only clinical parameters related to higher number of bone lesions while ISS staging (III) and extramedullary disease detected by MIBI were independent predictors of worse PFS. Our study demonstrated that sestamibi WBI detects less volume of disease compared to PET/CT, however it may substitute PET/CT in centers where it is not available or there is no reimbursement for MM staging. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

¿Mejora la función renal tras la paratiroidectomía en el hiperparatirodismo primario?

IntroductionPrimary hyperparathyroidism (PHPT) is a common endocrine disorder characterised by hypercalcaemia and parathormone increase. Decreased glomerular filtration rate (<60ml/min) continues to be a parathyroidectomy (PTX) criterion in asymptomatic PHPT. The influence of PTX on renal function evolution is the subject of debate. ObjectiveTo analyse the clinical, laboratory and histological characteristics of patients undergoing PHPT, as well as renal function evolution after PTX. Material and methodsRetrospective study of 297 patients diagnosed with PHPT and referred to surgery in a single centre between 1998 and 2016. Laboratory parameters were determined at baseline, one week and one year after PTX. ResultsThe Incidence of PTX was 38 cases/million/year. Mean age was 60±14 years and 80.5% of the patients were female. Approximately 65.3% were asymptomatic. Nephrolithiasis was the most common clinical finding (33%), followed by bone involvement (29.5%). PTX indications were: clinical symptoms (34.7%), hypercalcaemia>11.2mg/dl (27%), nephrolithiasis (13%), low bone mass (12%), age<50 years (11%) and decreased glomerular filtration rate<60ml/min (2.3%).For diagnostic localisation, spect-MIBI had a sensitivity of 92% and cervical ultrasound of 70%. A total of 94.3% of PHPT cases were due to a parathyroid adenoma.After PTX, normalisation of PHPT-related parameters was observed. We found a significant increase in serum creatinine levels (0.81 vs 0.85mg/dl, P<.001) from the first week post-PTX until the end of the first year. The renal function was only found to be significant in patients with glomerular filtration rate>60ml/min (baseline serum creatinine levels 0.77mg/dl vs serum creatinine levels after one year 0.81mg/dl, P<.001). ConclusionsPHPT was asymptomatic in most patients who underwent surgery. Hypercalcaemia and nephrolithiasis were the most common indications of parathyroidectomy in asymptomatic patients. MIBI scan was the most useful localisation method. Surgical treatment of PHPT is followed by renal function impairment, which persists after the first week post-PTX.

Negative Sestamibi Scans Predict Lower Likelihood of Surgical Referral in Patients with Primary Hyperparathyroidism

99mTechnetium sestamibi scans (MIBI) can provide negative or inaccurate results in patients with biochemical primary hyperparathyroidism. Reliance on MIBI as a diagnostic modality rather than as a localization tool leads to misdiagnosis and inappropriate care. The aim of this study was to determine the impact of negative MIBI scans on referral patterns and surgical intervention. Adults with MIBI scans at our institution from January 1, 2011, to May 31, 2017, were retrospectively reviewed. Data collected include demographics, study date and results, ordering physician specialty, pre/postoperative laboratories, and operative and final pathology. Statistical analysis was performed with SPSS v24 (IBM Corp., Armonk, NY). Three hundred fifty-seven patients had a MIBI scan; 10 were excluded for incomplete data or incorrect diagnosis. One hundred eighty-six were interpreted as positive (53.6%) and 161 were interpreted as negative (46.4%). Of the 186 positive MIBI scans, 135 (72.6%) were seen by an endocrine surgeon (ES). Of these 135 patients, 111 (82.2%) underwent parathyroidectomy. Of the 161 negative MIBI scans, 69 (42.9%) were seen by an ES. Of these, 53 (76.8%) underwent parathyroidectomy. In all, 90/92 (97.8%) with a negative MIBI scan who were not seen by an ES did not have surgery. Nonendocrine surgeon physicians are more likely to use MIBI scans as diagnostic tools to assist with clinical decision-making. Patients with a negative MIBI scan not seen by an ES were significantly less likely to undergo parathyroidectomy. Patients with primary hyperparathyroidism should be referred to an experienced parathyroid surgeon for evaluation, regardless of the MIBI result.

Clinical presentation and management of patients with primary hyperparathyroidism in Italy.

Evaluation of the phenotype of primary hyperparathyroidism (PHPT), adherence to International Guidelines for parathyroidectomy (PTx), and rate of surgical cure. From January 2014-January 2016, we performed a prospective, multicenter study in patients with newly diagnosed PHPT. Biochemical and instrumental data were collected at baseline and during 1-year follow-up. Over the first year we enrolled 604 patients (age 61 ± 14years), mostly women (83%), referred for further evaluation and treatment advice. Five hundred sixty-six patients had sporadic PHPT (93.7%, age 63 ± 13 years), the remaining 38 (6.3%, age 41 ± 17 years) had familial PHPT. The majority of patients (59%) were asymptomatic. Surgery was advised in 281 (46.5%). Follow-up data were available in 345 patients. Eighty-seven of 158 (55.1%) symptomatic patients underwent PTx. Sixty-five (53.7%) of 121 asymptomatic patients with at least one criterion for surgery underwent PTx and 56 (46.3%) were followed without surgery. Negative parathyroid imaging studies predicted a conservative approach [symptomatic PHPT: OR 18.0 (95% CI 4.2-81.0) P < 0.001; asymptomatic PHPT: OR 10.8, (95% CI 3.1-37.15) P < 0.001). PTx was also performed in 16 of 66 (25.7%) asymptomatic patients without surgical criteria. Young age, serum calcium concentration, 24h urinary calcium, positive parathyroid imaging (either ultrasound or MIBI scan positive in 75% vs. 16.7%, P = 0.001) were predictors of parathyroid surgery. Almost all (94%) of patients were cured by PTx. Italian endocrinologists do not follow guidelines for the management of PHPT. Negative parathyroid imaging studies are strong predictors of a non-surgical approach. PTx is successful in almost all patients.

Biochemical and pathologic factors affecting technetium-99m-methoxyisobutylisonitrile imaging results in patients with primary hyperparathyroidism.

Technetium 99m methoxyisobutylisonitrile (Tc-99m MIBI) scintigraphy represents the most commonly utilized imaging modality for the detection of the diseased gland in patients with primary hyperparathyroidism (PHPT). In this study, we aimed to identify potential biological factors with an impact on MIBI sensitivity. A total of 147 patients with surgically confirmed parathyroid adenomas were assessed retrospectively. Data including medical history, biochemical and hormonal measurements, cervical US, Tc-99m MIBI scans as well as pathology reports were retrieved and recorded. Of the 147 patients, there were a total of 77, 39, and 31 cases with a positive, negative, and suspicious parathyroid adenoma on Tc-99m MIBI scan, respectively. Serum calcium (Ca), parathyroid hormone (PTH) and 25 (OH) D levels were comparable among MIBI positive and negative patients [Ca: 11.5 ± 0.9 vs 11.3 ± 0.9mg/dL (P = 0.42); PTH: 216 (146-347) vs 194 (140-317) pg/mL (P = 0.45); 25(OH)D: 8.4 (5.7-18.2) vs 10.0 (4.7-23.3) ng/mL (P = 0.64), respectively]. P-glycoprotein (P-gp) staining was negative in both groups. Also, pathological examination of tissue preparations revealed no difference in terms of the volume of the adenomas, incidence of cystic adenomas, cell-type dominance (oxyphilic cell), percent fat, and Ki-67 ratio in MIBI positive and negative groups. The rate of hyalinization was 13% in MIBI positive and 28% in MIBI negative subjects, the difference being statistically significant (P = 0.04). Presence of hyalinization in parathyroid adenomas was found to be negatively correlated with MIBI scan results.

Association of Histological Findings with Tc-99m Sestamibi Parathyroid Imaging in Hyperfunctional Parathyroid Gland

Background: Hyperthyroidism is a relatively common disorder that results from increased production of parathormone. Tc-99m sestamibi (MIBI) scanning is used for localization of abnormal parathyroid gland, with high reported sensitivities. However, there exists a group of patients in whom MIBI scan is either equivocal or negative. Objectives: The aim of this study was to see association of the histological features of pathologic parathyroid gland with MIBI scan in hyperfunctional parathyroid gland. Methodology: This retrospective study was conducted with primary hyperthyroidism who underwent MIBI scan. The data were collected from the record from January 2012 to December 2014 for a period of two years. All patients underwent parathyroid surgery followed by histopathological examination. According to oxyphil cell distribution patients are divided in three groups. Group I comprised of &gt;25.0% oxyphil cell; group II included the 25 to 75% oxyphil cell and group III included &gt;75% of oxyphil cell. Result: A total 56 patients with hypercalcaemia and high serum parathyroid hormone (PTH) level were studied. Mean age was 41.3(±19.8) years with a range of 21 to 63 years. MIBI scan was true positive in 34(60.7%) cases and false negative in 22(39.3%) cases. In group I MIBI scan was true positive in 4(36.3%) cases and false negative in 7(63.7%) cases. In group II MIBI scan showed positive in 17(62.9%) cases and negative in 10(37.1%) cases. In group III out of 18 patients 13(72.2%) showed MIBI scan positive whereas, 5(27.8%) showed negative scan. The sensitivity was 36.3% in group I whereas, 62.9% and 72.2% in group II and group III respectively. Conclusion: Based on these findings, it could be say that Tc–99m setamibi uptake correlate with parathyroid oxyphil cell content, and false negative scan can occur with parathyroid glands containing predominantly clear cell.Journal of National Institute of Neurosciences Bangladesh, 2016;2(1):14-18

The diagnostic accuracy of neck ultrasound, 4D-Computed tomographyand sestamibi imaging in parathyroid carcinoma

IntroductionOur aim was to investigate the accuracy of available imaging modalities for parathyroid carcinoma (PC) in our institution and to identify which imaging modality, or combination thereof, is optimal in preoperative determination of precise tumor location. MethodsAll operated PC patients in our institution between 2000 and 2015 that had at least one of the following in-house preoperative scans: neck ultrasonography (US), neck 4D-Computed Tomography (4DCT) and 99mTc Sestamibi SPECT/CT (MIBI). Sensitivity, specificity and accuracy of PC tumor localization were assessed individually and in combination. Results20 patients fulfilled the inclusion criteria and were analysed. There were 18 US, 18 CT and 9 MIBI scans. The sensitivity and accuracy for tumor localisation of US was 80% (CI 56–94%) and 73% respectively, of 4DCT was 79% (CI 58–93%) and 82%, and of MIBI was 81% (CI 54–96%) and 78%. The sensitivity and accuracy of the combination of CT and MIBI was 94% (CI 73–100%) and 95% and for the combination of US, CT and MIBI was 100% (CI 72–100%) and 100% respectively. The wash-out of the PC lesions, expressed as a percentage change in Hounsfield Units from the arterial phase to early delayed phase was −9.29% and to the late delayed phase was −16.88% (n=11). ConclusionsThe sensitivity of solitary preoperative imaging of PC patients, whether by US, CT or MIBI, is approximately 80%. Combinations of CT with MIBI and US increase the sensitivity to 95% or better. Combined preoperative imaging of patients with clinical possibility of PC is therefore recommended.

Prospective comparison of high resolution ultrasonography with technetium sestamibi scintigraphy and operative findings in detection of abnormally hyper functioning parathyroid gland/glands in primary hyperparathyroidism

Background:Ultrasonography is cheap, easily available and convenient modality of diagnosis.Methods: We prospectively studied 61 patients with PHPT. Patients preoperatively underwent USG neck and MIBI scan, results were interpreted independently and compaired with intra operative findings.Results:61 patients who underwent parathyroidectomy for PHPT were studied. Ultrasonography neck showed correct side in 46/51 (90%) and correct site in 32/51 (63%) patients with single parathyroid adenomas. MIBI scan showed correct side and site of parathyroid adenoma in 46/50 (92%) and 43/50 (86%) patients respectively. Patients with double adenomas USG neck showed positive results in all 5 patient with 100% sensitivity where as MIBI scan showed positive results in four out of five patients (80%). 1 patient with four gland hyperplasia USG picked three out of four enlarged glands while as MIBI scan not picked any of the enlarged glands. Operative findings revealed that right lower parathyroid gland was the most common gland involved (54%) followed by left lower (29%), right upper (6.6%), left upper (0%) and multiple / bilateral (9.6%).Conclusions:USG is an affordable, conventional and useful tool in detecting enlarged parathyroid glands in most of the patients with PHPT, but operator dependant. However, when USG can’t detect enlarged parathyroid gland 99mTc-MIBI Scan is complimentary to it.

The prognostic value of conventional imaging tools to determine how patients with hodgkin lymphoma will respond to treatment

Introduction: This systematic review studies the prognostic value of two conventional imaging tools, sestamibi and gallium scans, for predicting how patients with Hodgkin lymphoma will respond to treatment.Methods: The PubMed database was searched for English-language articles that contained the following search terms: (Hodgkin AND [mibi OR sestamibi OR gallium OR spect] AND response). All articles that were identified during this search were included in the study, regardless of date published. The inclusion criteria were as follows: articles that described studies that were limited to Hodgkin patients and that reported the predictive value of conventional imaging tools. Articles about other types of lymphoma and/or those that focused on the diagnostic and staging accuracy of mibi and gallium scans were excluded.Result: In total, 14 articles were retrieved. Of these, the majority met the inclusion criteria of the systematic review with the exception of two, which were limited to an examination of the reliability of performing sestamibi scans to predict the response to treatment. All remaining 12 articles considered both the sestamibi scans and the gallium scintigraphy.The results of the systematic review indicate that positive gallium scan results can be proposed as a poor prognostic factor that is associated with partial or full recurrence of Hodgkin disease, a reduction in overall survival rate, and progression-free survival compared with patients with a negative scan.Discussion: Both sestamibi and gallium scans revealed high sensitivity and specificity in predicting the response to treatment including complete remission, partial remission, and recurrence of the disease.Conclusion:These imaging tools can appropriately assess how Hodgkin patients will respond to chemotherapy. As such, clinicians can use these tools to devise appropriate treatment strategies.

Shear wave elastography and parathyroid adenoma: A new tool for diagnosing parathyroid adenomas

ObjectivesThis study prospectively determines the shear wave elastography characteristics of parathyroid adenomas using virtual touch imaging quantification, a non-invasive ultrasound based shear wave elastography method. MethodsThis prospective study examined 57 consecutive patients with biochemically proven primary hyperparathyroidism and solitary parathyroid adenoma identified by ultrasound and confirmed by at least one of the following: surgical resection, positive Technetium–99m Sestamibi Scintigraphy (MIBI) scan, or fine needle aspiration biopsy with positive PTH washout (performed only in MIBI negative patients). Vascularity and shear wave elastography were performed for all patients. Parathyroid adenoma stiffness was measured as shear wave velocity in meters per second. ResultsThe median (range) pre-surgical value for PTH and calcium were 58pg/mL (19, 427) and 10.8mg/dL (9.5, 12.1), respectively. 37 patients had positive MIBI scan. 20 patients had negative MIBI scan but diagnosis was confirmed with positive PTH washout. 42 patients underwent parathyroidectomy, and an adenoma was confirmed in all. The median (range) shear wave velocity for all parathyroid adenomas enrolled in this study was 2.02m/s (1.53, 2.50). The median (range) shear wave velocity for thyroid tissue was 2.77m/s (1.89, 3.70). The shear wave velocity of the adenomas was independent of adenoma size, serum parathyroid hormone concentration, or plasma parathyroid hormone concentration. ConclusionsTissue elasticity of parathyroid adenoma is significantly lower than thyroid tissue. B-mode features and distinct vascularity pattern are helpful tools in diagnosing parathyroid adenoma with ultrasound. Shear wave elastography may provide valuable information in diagnosing parathyroid adenoma.