99mTc-sestamibi Scintigraphy Research Articles

Does the sonography-scintigraphy correlation affect the success of minimally invasive parathyroid Surgery? Results from a single center

In patients with primary hyperparathyroidism, complete surgical resection of all hyperfunctioning parathyroid tissue is essential. The aim of this study was to evaluate the success rates of minimally invasive parathyroidectomies for primary hyperparathyroidism performed after localization studies with 99mTc-sestamibi (MIBI) scintigraphy and neck ultrasonography (USG). And also, we aimed to determine the factors affecting the success rate in surgery. Retrospective analysis of 58 consecutive patients with a diagnosis of primary hyperparathyroidism who underwent parathyroidectomy between January 2018 and December 2021 in our institution. The patients were evaluated according to Miami criteria and divided into two groups as successful or unsuccessful surgery. Demographic and clinical characteristics of the patients were obtained from hospital records. Surgical success was achieved in 50 (86.2%) of the 58 patients included in the study. In both groups, neck USG and MIBI scintigraphy showed the same localization for the lesion in a correlated manner. The clinical complaints of the patients, preoperative PTH, Ca and 24-hour urinary Ca levels were similar in both groups. In 10 (17.2%) patients, inconsistency in localization was found between USG and MIBI scintigraphy, and surgical failure was found in 4 (40%) of these patients. Surgical failure was statistically significant in patients with inconsistency in localization between USG and MIBI scintigraphy. The sono-scintigraphic scan concordance increases surgical success rates in cases where minimally invasive parathyroid surgery is planned. If there is an inconsistency between USG and MIBI, preoperative four dimentional computed tomography, intraoperative rapid PTH, gamma probe or frozen method can be used. It should be kept in mind that multiple gland pathologies may be more common in addition to solitary adenoma in lesions smaller than 1 cm in USG. In addition, in these cases, as the diagnostic value of scintigraphy is low, surgical success will also decrease.

PSAT205 A Case of Persistent Primary Hyperparathyroidism Secondary to an Occult Supernumerary Parathyroid Adenoma

Abstract Background Persistent primary hyperparathyroidism accounts for the vast majority of patients who require reexploration. With the advancements in preoperative localization, surgical outcomes have improved over time. However, in patients with failed reoperative parathyroid exploration, an occult supernumerary parathyroid adenoma should be considered. Clinical Case A 60 year-old female diagnosed with primary hyperparathyroidism presented with recurrent nephrolithiasis, osteoporosis and declining eGFR. Initial laboratory evaluation showed elevated serum calcium (1.54 mmol/L, normal 1.09-1.30) and intact PTH (146 pg/mL, normal 18.50-88.0). 99mTc-sestamibi scintigraphy showed a sestamibi-avid focus in the inferior aspect of the right lobe hence, she underwent radionuclide-guided focused right parathyroidectomy. Post-operatively, her intact PTH level was still elevated (171.2 pg/mL). Histopathologic examination showed a normocellular parathyroid gland and a multifocal papillary thyroid carcinoma. The failed 1st surgery was attributed to the false positive scintigraphy from the papillary thyroid carcinoma. She then underwent total thyroidectomy with central neck dissection and 3½ parathyroidectomy with intraoperative parathyroid hormone assay. However, serial PTH monitoring after exploration and parathyroidectomy failed to decrease the PTH level by 50%. Histopathologic examination showed normocellular parathyroid glands. The bilateral carotid sheath, retropharyngeal region and superior mediastinum were explored but no ectopic parathyroid tissues were seen. Post-operatively, calcium and PTH were still elevated (1.48 mmol/L and 200.5 pg/mL, respectively). FDG PET CT imaging failed to show any ectopic parathyroid gland or adenoma. No further surgical intervention was done and she was medically managed with Cinacalcet 30 mg twice daily. 15 months after her parathyroid gland exploration, calcium and PTH were still elevated (1.46 mmol/L and 156.80 pg/mL, respectively). F18 Choline PET CT imaging was done showing a small hypoenhancing persistently FCH-positive focus in the left thyroid bed and sliver of enhancing tissue relating to a parathyroid adenoma. Conclusion This case highlights the diagnostic and therapeutic challenges in a patient with persistent primary hyperparathyroidism after a failed 2nd surgery. Occult parathyroid adenomas can cause significant symptoms regardless of its size and its imperceptible nature on imaging. The role of medical management is emphasized in this case when surgical management was not possible. Furthermore, re-evaluation for growth of the possible occult parathyroid adenoma should be done, which in this case took 15 months until its detection. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Positive predictive values of ultrasound-guided fine-needle aspiration with parathyroid hormone assay and Tc-99m sestamibi scintigraphy in sporadic primary hyperparathyroidism

ObjectivesUltrasonography (US) and Tc-99m sestamibi scintigraphy (SS) are usually performed as preoperative imaging modalities for patients with sporadic primary hyperparathyroidism (SPHP). Fine-needle aspiration (FNA) under US guidance for parathyroid hormone (PH) assay can enhance the diagnostic accuracy of US. The main aim of the present study was to compare positive predictive values between US-FNA and SS. The secondary aim was to draw up a decision-tree for FNA and SS. MethodsThe single-center retrospective study included patients with previously non-operated SPHP. They underwent US-guided FNA, PET-CT SS, and 18 F-choline scintigraphy if the first two methods were inconclusive. PH washout level was considered pathological when greater than the serum PH level. Postoperative histology data were correlated to imaging data. ResultsIn total, 117 patients were included, with a mean age of 64 years (range, 26–89 years). A single adenoma was identified on pathology in 101 patients (89%). FNA findings were pathologic for 64 patients (55%), with a mean PH level of 2,604ng/L [range, 585–9,074ng/L], higher than the serum level of 179ng/L [range, 60–1,000ng/L]. US-guided FNA showed sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of respectively 72%, 92%, 99% and 28%, compared to 89%, 42%, 93% and 32% for SS. The rate of error in locating the parathyroid gland was 8% for US-guided FNA versus 12% for SS. Comparison of the two methods showed better sensitivity for SS (P=0.0052) and better specificity for FNA (P=0.0143), with no significant difference in PPV or NPV. 18 F-choline scintigraphy detected the hyperfunctioning parathyroid in 11 out of the 15 patients. ConclusionPPV did not significantly differ between FNA and SS. US-guided FNA performed by an experienced operator could be a simple first-line method for more than 50% of patients with non-operated SPHP, with 99% PPV. In case of negative or doubtful FNA findings, SS can be performed in second line.

Pathological uptake with 18-Fluorocholine versus 99mTc-MIBI in the location of the parathyroid glands in hyperparathyroidism. Systematic review and meta-analysis

Introduction: The location of the pathological parathyroid glands in hyperparathyroidism is usually carried out by means of 99mTc-sestamibi scintigraphy, which increases its precision by adding the ultrasound examination. The non-localization of the parathyroid glands increases the difficulties for surgical removal. To increase the detection of pathological glands, other radioactive tracers are used, such as methionine, fluorocholine or 18F-flurpiridaz. Objective: To establish if PET / CT with 18-Fluorocholine in patients with hyperparathyroidism increases the number of uptakes compared to the 99mTc-sestamibi scan. Method: Systematic review and meta-analysis. Two subgroups were analyzed. Subgroup 1: trials comparing both techniques as an initial exploration. Thirteen studies including 1131 examinations were selected (596 PET / CT with 18-Fluorocholine vs. 535 scintigraphy with 99mTc-sestamibi). Meta-analysis was performed following the random effects model and the odds ratio was calculated. Subgroup 2: studies that include 18-Fluorocholine as a rescue examination in patients with a previous negative study with a 99mTc-sestamibi scan. 17 articles including 412 examinations with 359 patients in which there was at least one uptake were selected. Meta-analysis of the prevalence of the number of patients in whom there was at least one uptake was performed using the random effects model. Results: Subgroup 1: The number of patients in which at least one uptake occurs is significantly higher with the 18-Fluorocholine examinations (OR 4.264, 95% CI 2.400-7.577). The prevalence of uptake with 18-Fluorocholine is 0.91 [0.86, 0.95] and with sestamibi 0.68 [0.56, 0.80]. Subgroup 2: the prevalence of uptake among patients with previous negative MIBI studies was 0.90 [0.87, 0.94]. The probability of detection of both techniques in this group reaches 0.98. Publication bias in the meta-analyzes is low. Discussion: 18-Fluorocholine protocols provide higher precision, clearer images, with faster acquisition as well as being readily available for most PET / CT centers. Conclusion: The PET / CT study with 18-Fluorocholine can be recommended as a study for the location of pathological parathyroid glands after studies with negative MIBI.

The Role of Surgeon-Performed Office and Preincision Ultrasounds in Localization of Parathyroid Adenomas in Primary Hyperparathyroidism

ObjectiveWe studied the use of surgeon-performed office ultrasound (OU) and preincision ultrasound (PIU) in preoperatively localizing parathyroid adenomas in primary hyperparathyroidism (PHPT). MethodsA retrospective chart review was performed for patients with PHPT who underwent parathyroidectomy between 2013 and 2015. The results of OU and PIU were recorded and compared with the final surgical pathology. ResultsOf 348 patients with PHPT, 285 (81.9%) had single-lesion disease, 49 (14.1%) had double-lesion disease, and 14 (4.0%) had multigland disease with 3 or more lesions. For single-lesion disease, the overall sensitivity and specificity of OU to correctly lateralize the lesion were 64.2% and 91.2%, while those of PIU were 89.4% and 93.6%, respectively. The sensitivity and specificity of PIU were comparable to those of 4-dimensional computed tomography (87.1% and 90.7%, respectively) and 99mTc-sestamibi scintigraphy (70.4% and 95.9%, respectively). While the majority of PIU cases were preceded by other imaging studies, the accuracy in localizing lesions was not largely affected by the presence of prior computed tomography and/or 99mTc-sestamibi scintigraphy, as opposed to ultrasounds only. For detecting the presence of multigland disease, the sensitivity and specificity of OU were 26% and 92.2%, while those of PIU were 64.3% and 94.7%, respectively. ConclusionSurgeon-performed OU and PIU are valuable tools in preoperatively localizing the parathyroid adenoma in single-lesion disease, while their utility may be limited for double-lesion or multigland disease. PIU in particular yields high accuracy in detecting parathyroid lesions in combination with other imaging modalities.

A Retrospective Cohort Study of the Utility of Ultrasound, 99mTc-Sestamibi Scintigraphy, and Four-Dimensional Computed Tomography for Pre-Operative Localization of Parathyroid Disease To Facilitate Minimally Invasive Parathyroidectomy.

BackgroundThis study investigated the utility of ultrasound (US), 99mTc-Sestamibi scintigraphy (Sestamibi), and four-dimensional computed tomography (4DCT) for pre-operative localization of a single abnormal parathyroid gland prior to minimally invasive parathyroidectomy (MIP) to determine the optimum pre-operative scans to facilitate a MIP.MethodsPatients with primary hyperparathyroidism who underwent curative parathyroidectomy at Broomfield Hospital, Mid and South Essex NHS Foundation Trust between 2009 and 2018 were included. Diagnostic performance parameters and the agreement between US, Sestamibi, and 4DCT were evaluated. Cohen’s κ was used to assess the strength of agreement between imaging modalities.ResultsAt localizing pathology to the correct side of the neck, Sestamibi had the highest sensitivity (87%), followed by US (76%) and 4DCT (64%). 4DCT had a positive predictive value (PPV) of 95%, similar to Sestamibi (96%), but higher than US (92%). Amongst patients who underwent both US and Sestamibi, the abnormal parathyroid gland was localized to the same area by both imaging modalities in 77% of patients (Cohen’s κ: 0.383). Following an inconclusive US or Sestamibi scan, or discordance between the two modalities, 4DCT was correct at localization in 63% of patients.ConclusionSestamibi has the highest sensitivity and PPV for accurately localizing parathyroid pathology. The addition of US to a positive Sestamibi scan adds little additional value. 4DCT is the preferred imaging modality following an inconclusive Sestamibi or US.

Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy

IntroductionThe primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. MethodsObservational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an endocrine surgery unit for 18 years. The cure rate, the intraoperatory PTH, the etiology and the pathological glands location were analyzed. ResultsIn the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. 14.1% presented a multigland disease. 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. ConclusionsThe absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Diagnostic Performance of Cervical Ultrasound, 99mTc-Sestamibi Scintigraphy, and Contrast-Enhanced 18F-Fluorocholine PET in Primary Hyperparathyroidism.

Preoperative localization of pathologic parathyroids is crucial for minimally invasive treatment of primary hyperparathyroidism (PHPT). This study compared contrast-enhanced 18F-fluorocholine PET/CT, cervical ultrasonography (CU), and conventional scintigraphic imaging modalities (MIBI scintigraphy, consisting of 99mTc-sestamibi/123I-sodium iodide SPECT/CT, 99mTc-sestamibi/123I-sodium iodide planar subtraction imaging, and 99mTc-sestamibi planar dual-phase imaging), combined and individually, for preoperative localization of hyperfunctional parathyroids in PHPT. The gold standard was histologic examination. Methods: Data from consecutive patients with clinically suspected PHPT were retrospectively collected. All 3 imaging modalities were systematically performed. The ability of 18F-fluorocholine PET/CT, CU, and MIBI scintigraphy to identify a hyperfunctional parathyroid and specify the side or identify an ectopic location was noted. Patients underwent surgical exploration if at least 1 examination was positive. The findings of CU + MIBI scintigraphy combined were considered positive if CU and MIBI scintigraphy separately showed a hyperfunctional parathyroid gland on the same side or in the same ectopic location; any findings other than these were considered negative. The composite judgment criterion for pathologic parathyroid was a combination of histologic analysis and normalization of parathyroid hormone and calcium levels. Results: In total, 149 pathologic parathyroids were found in 143 of the 144 included patients. 18F-fluorocholine PET/CT diagnosed 148 of 149 pathologic parathyroids. Only 4 false-positives and 1 false-negative were found. The 18F-fluorocholine PET/CT sensitivity of 99.3% was superior to that of CU, at 75.2% (P < 0.0001); MIBI scintigraphy, at 65.1% (P < 0.0001); and CU + MIBI scintigraphy, at 89.9%, (P = 0.0009). Five of the 5 ectopic locations were diagnosed by 18F-fluorocholine PET/CT, 2 of the 5 by MIBI scintigraphy, and none by CU. Accuracy was better for 18F-fluorocholine PET/CT, at 98%, than for CU, at 84% (P < 0.0001); MIBI scintigraphy, at 81% (P < 0.0001); or CU + MIBI scintigraphy, at 91% (P < 0.0001). Among the 72 (50%) patients who had a negative CU + MIBI scintigraphy result, 18F-fluorocholine PET/CT correctly identified hyperfunctional thyroids in 70 (97.2%). Average uptake in the 18F-fluorocholine PET/CT hyperfunctional parathyroid was higher than that in the adjacent thyroid (SUVmax adjusted for lean body mass, 6.45 vs. 2.15) (P < 0.0001). Conclusion: The accuracy of 18F-fluorocholine PET/CT is higher than that of CU and MIBI scintigraphy for localization of hyperfunctional parathyroids, justifying the systematic use of 18F-fluorocholine PET/CT as the first-line method for PHPT diagnosis.

Usefulness of 99mTc-SESTAMIBI Scintigraphy in Persistent Hyperparathyroidism after Kidney Transplant.

99mTc-labeled sestamibi scintigraphy combined with single-photon emission computed tomography (SPECT) has a high positive predictive value for localizing hyperfunctioning parathyroid lesions in primary hyperparathyroidism (pHPT) but relatively low sensitivity and specificity in secondary hyperparathyroidism (sHPT) and tertiary hyperparathyroidism (tHPT). The purpose of this study is to investigate the usefulness of 99mTc-sestamibi scintigraphy in persistent hyperparathyroidism after kidney transplant (KT). Retrospectively evaluated 50 patients who received parathyroidectomy after KT at a single medical center. The parathyroid lesion with the highest sestamibi uptake intensity of a patient was graded from 0 to 3. Uptake intensity was analyzed in correlation with parathyroid hormone (PTH), calcium, ionized calcium, phosphorus, and vitamin D. Per-patient analysis, 43 patients had hyperplasia, 6 patients had adenomas, and 1 patient had a carcinoma. Only 3 patients with hyperplasia did not demonstrate any sestamibi uptake in the parathyroid scans. Out of the 148 pathologically confirmed parathyroid lesions, SPECT/CT images were able to identify 89 lesions (60%) and planar images of 71 lesions (48%). The average of sestamibi uptake intensity was mild at grade 1.6. Uptake intensity showed a positive correlation with parathyroid hormone (PTH) level but not with phosphorus, calcium, ionized calcium, or vitamin D levels. The largest lesion showed a high positive predictive value, especially in lesions with a diameter over 1.0cm. Regardless of relatively low and less discrete uptake in KT patients, it well depicts the largest and the most hyperfunctioning lesion.

Primary Hyperparathyroidism: Defining the Appropriate Preoperative Imaging Algorithm.

Primary hyperparathyroidism is a common and potentially debilitating endocrine disorder for which surgery is the only curative treatment. Preoperative imaging is always recommended, even in cases of conventional bilateral neck exploration, with a recognized role for 99mTc-sestamibi scintigraphy in depicting ectopic parathyroid lesions. Scintigraphy can also play a major role in guiding a targeted, minimally invasive parathyroidectomy. However, the ability to recognize multiple-gland disease (MGD) varies greatly depending on the imaging protocol used. Preoperative diagnosis of MGD is important to reduce the risks of conversion to bilateral surgery or failure. In this article we discuss imaging strategies before first surgery as well as in the case of repeat surgery for persistent or recurrent primary hyperparathyroidism. We describe a preferred algorithm and alternative options. Dual-tracer 99mTc-sestamibi/123I subtraction scanning plus neck ultrasound is the preferred first-line option. This approach should improve MGD detection and patient selection for minimally invasive parathyroidectomy. Second-line imaging procedures in case of negative or discordant first-line imaging results are presented. High detection rates can be obtained with 18F-fluorocholine PET/CT or with 4-dimensional CT. The risk of false-positive results should be kept in mind, however. Adding a contrast-enhanced arterial-phase CT acquisition to conventional 18F-fluorocholine PET/CT can be a way to improve accuracy. We also briefly discuss other localization procedures, including 11C-methionine PET/CT, MRI, ultrasound-guided fine-needle aspiration, and selective venous sampling for parathyroid hormone measurement.

A Case of an Ectopic Parathyroid Adenoma With a Concomitant 99mTc-sestamibi-avid Papillary Thyroid Carcinoma

Background: The evaluation and management of parathyroid adenomas have improved over the years. Localization of parathyroid adenomas in patients with primary hyperparathyroidism was simplified with the use of 99mTc-sestamibi scintigraphy. In the advent of minimally invasive parathyroid surgery, use of radionuclide probes reduced the need for neck exploration and intraoperative frozen section leading to fewer complications, shorter operative time and hospitalization and rapid postoperative recovery. However, limitations of these techniques should be taken into consideration in certain cases. Clinical Case: A 60 year-old female diagnosed with primary hyperparathyroidism presented with recurrent nephrolithiasis and osteoporosis. Initial laboratory evaluation showed elevated serum calcium and intact PTH (1.54 mmol/L and 146 pg/mL, respectively). 99mTc-sestamibi scintigraphy showed a sestamibi-avid focus in the inferior aspect of the right lobe suggestive of a parathyroid adenoma or hyperplasia. Pre-operative neck ultrasound showed non-specific thyroid parenchymal changes and nodules on both lobes with benign sonographic features. She underwent radionuclide-guided focused right parathyroidectomy. The identified enlarged right inferior parathyroid gland registered a highest reading of 70 cps on radionuclide probe. Post-operatively, repeat intact PTH level was still elevated (171.2 pg/mL). There was an interval non-demonstration of the sestamibi-avid focus in the inferior aspect of the right thyroid lobe with an increased sestamibi uptake in the left thyroid lobe compared to the previous parathyroid scan. Histopathologic examination showed a normocellular parathyroid gland and a multifocal papillary thyroid carcinoma. She underwent total thyroidectomy with central neck dissection and 4 parathyroid gland exploration with intraoperative parathyroid hormone assay. However, serial PTH monitoring after left inferior parathyroidectomy and after bilateral partial superior parathyroidectomy still showed elevated levels. Histopathologic examination showed mildly enlarged, normocellular parathyroid gland. The bilateral carotid sheath, retropharyngeal region and superior mediastinum were explored but no ectopic parathyroid tissues were seen. Post-operatively, calcium and PTH were still elevated (1.48 mmol/L and 200.5 pg/mL, respectively). Conclusion: This case highlights the predicaments in the management of parathyroid adenomas, recognizing the possibility of false-positive sestamibi scans due to malignant thyroid nodules and the possibility of the two diseases occurring concurrently, albeit rare.

Primary Hyperparathyroidism From Ectopic Parathyroid Adenoma in a Patient With Bilateral Slipped Capital Femoral Epiphysis

Background: Primary hyperparathyroidism has been reported in 13 pediatric patients presenting with slipped capital femoral epiphysis (SCFE), but never in patients with ectopic parathyroid adenoma [1]. Case report: A 12-year-old boy with obesity (BMI 99th percentile) and autism spectrum disorder presented with a limp and was found to have bilateral SCFE. Calcium was elevated to 12.3 mg/dL (reference range 8.0–10.5) with phosphorus of 3.2 mg/dL (3.0–5.7), alkaline phosphatase 775 units/L (40–360), tubular reabsorption of phosphorus 89% (> 95%), 25OH-vitamin D 12.1 ng/mL (30–80), 1,25OH-vitamin D 246.6 pg/mL (19.9–79.3), and PTH 1191 pg/mL (10–65). He had significant neuropsychiatric agitation but denied constipation, polyuria, and other symptoms of hypercalcemia. He had in situ pinning of the SCFE bilaterally and was hyperhydrated with minimal improvement in his calcium level. Neck ultrasound revealed no parathyroid adenoma. He was discharged on cholecalciferol 1000 IU daily with plans for outpatient Tc-99m Sestamibi scintigraphy. Following discharge, he developed significant nausea, did not tolerate the cholecalciferol, and was non-weight bearing. Repeat labs and imaging 5 days later demonstrated calcium had risen to 16.7 mg/dL with phosphorus of 2.2 mg/dL. He was admitted and calcium improved transiently to less than 12 mg/dL with intranasal calcitonin therapy. Sestamibi and subsequent CT scan revealed a 2.7x1.6x1.9 cm ectopic parathyroid adenoma in the upper anterior mediastinum. He had thoracoscopic resection of the mass, which was revealed to be intrathymic, and PTH levels fell from 1613 pg/mL pre-operatively to 76 pg/mL 30 minutes post-resection. Post-operatively, he developed hungry bone syndrome with a calcium nadir of 7.6 mg/dL and phosphorus nadir of 1.6 mg/dL, which required oral calcium and calcitriol for 10 days. With normalization of his calcium, his neuropsychiatric symptoms improved. Pathology revealed a parathyroid adenoma. Conclusion: Primary hyperparathyroidism can be associated with SCFE and should be considered even in patients with traditional risk factors for SCFE, especially with bilateral disease. Pediatric patients with primary hyperparathyroidism and negative neck imaging should be further evaluated for ectopic parathyroid adenomas.

Preoperative Imaging in Renal Transplant Patients with Tertiary Hyperparathyroidism.

Tertiary hyperparathyroidism following kidney transplantation is most commonly characterized by 4-gland hyperplasia, but single and double adenomatous disease has been demonstrated in this population as well. It is unknown whether preoperative imaging can assist in identifying patients who may qualify for focused surgery for adenomatous disease. We performed a retrospective review of our patient database from 1998-2018 for patients with tertiary hyperparathyroidism following renal transplant. Patient charts were reviewed for patient demographics, laboratory values, preoperative imaging, operative findings, pathology, and complications. We identified 113 patients with tertiary hyperparathyroidism following renal transplant who underwent parathyroidectomy. There were 51 females and 62 males with a mean age of 53.4 ± 13.4years. Median preoperative calcium and PTH were 10.9mg/dl (IQR 10.3-11.2) and 228pg/ml (IQR 118-305). Preoperative ultrasound was performed in 60 patients. Of these, 11 (18%) were negative, 38 (63%) showed 1-2 adenomas, and 11 (18%) showed ≥ 3 adenomas. 99mTc-sestamibi parathyroid scintigraphy was performed in 101/113 patients. Of these, 11 (11%) were negative, 62 (61%) showed 1-2 areas of discordant sestamibi uptake, and 28 (28%) showed ≥ 3 areas of discordant uptake. Ultimately, 19 (17%) patients had a single adenoma removed, 16 (14%) had 2 adenomas removed, and (69%) had multi-gland disease. There were 26 ectopic glands found in 21 patients, 42.3% of which were identified on preoperative imaging. 94.1% of patients were eucalcemic at last follow-up, mean (± SD) 5.8 ± 3.6years. Adenomas that were visualized on ultrasound were larger on pathology than those non-visualized (997 ± 120mg (mean ± SE) vs. 388 ± 109mg, p = 0.0003). This was also true for parathyroid scintigraphy (647 ± 41mg vs. 355 ± 51mg, p = 0.0001). In patients with tertiary hyperparathyroidism, preoperative imaging can aid in predicting which patients will have 1-2 gland disease. In patients with 1-2 gland disease on congruent ultrasound and nuclear medicine imaging studies, the accuracy increases to 59%. Preoperative imaging can help identify ectopic glands. Larger adenomas are more likely to be identified on both imaging modalities.

The feasibility of anterior 180° 99m Tc-sestamibi parathyroid SPECT/CT.

For 99mTc-sestamibi parathyroid single photon emission computed tomography/computed tomography (SPECT/CT), the traditional full-arc 360° acquisition technique has been suggested but not the theoretically low tissue-attenuated anterior 180° method. We aimed to compare the diagnostic performances and target-to-background ratios of anterior 180° and 360° SPECT/CT imaging. Ninety-nine patients who underwent 99mTc-sestamibi scintigraphy and received a surgical-pathological diagnosis of parathyroid adenoma or hyperplasia were enrolled. The SPECT/CT reconstructed images with anterior 180° and full-arc 360° data were interpreted by two physicians using a scoring scale, and the lesions were semi-quantified using target-to-background ratios for both image sets. In total, 113 abnormal parathyroid lesions were identified on the SPECT/CT images. The agreements of interpretation between the two image sets and readers were very good (κ value: 0.83-1.00). The accuracies of summative interpretation for the anterior 180° and full-arc 360° SPECT/CT were 83.04% and 82.46%, respectively. The target-to-background ratios were significantly higher for the anterior 180° than the full-arc 360° images (P < 0.01). The anterior 180° SPECT/CT technique, a time-saving method, can provide satisfactory diagnostic performance and superior lesion contrast compared with the full-arc 360° SPECT/CT technique in 99mTc-sestamibi parathyroid imaging.

Video-assisted thoracoscopic surgery for primary hyperparathyroidism with ectopic parathyroid adenoma in thymus

Introduction. Primary hyperparathyroidism is rare pathology in children (2?5:100,000). In more than 85% of patients, a single adenoma is present, and its extirpation is usually the only treatment a patient requires. In approximately 15?80% of cases, ectopic mediastinal parathyroid tissue can be found inside the thymus. Case outline. Our patient was a 13-year-old boy, who presented with multiple bone fractures in the previous period of time, and fatigue. Parathyroid hormone levels preoperatively were extremely high (1320 pg/ml ? more than 19 times higher than normal). Serum calcium was also elevated (total 3.55 mmol/l; ionized 1.41 mmol/l). He was examined and diagnosed as primary hyperparathyroidism by a pediatric endocrinologist. Imaging procedures for the preoperative localization of parathyroid adenomas were done (99mTc sestamibi scintigraphy and magnetic resonance imaging suggested ectopic mediastinal parathyroid adenoma). The patient underwent video-assisted thoracoscopic surgery procedure. After exploration of the mediastinum and chest, no ectopic parathyroid tissue was found, so total thoracoscopic thymectomy was performed. Final pathological section confirmed parathyroid adenoma inside the thymus. Conclusion. We believe that if no parathyroid tissue is found during surgical exploration of mediastinum, in a child with preoperatively detected parathyroid adenoma in anterior mediastinum, recommendation is to think about possible intrathymic localization and consider removing the thymus. Greater sample size is necessary for higher reliability of this statement.

Selective venous sampling in primary hyperparathyroidism: Is it worth doing?

Accurate preoperative localization of the culprit gland is the key point for the surgical treatment of primary hyperparathyroidism. Conventional imaging techniques (ultrasound and Tc99m sestamibi scintigraphy) are usually adequate for preoperative localization. However, in some patient groups, additional imaging modalities may be required since noninvasive techniques may fail. In this study, we aimed to evaluate the diagnostic value of selective parathyroid venous sampling in patients with unclear noninvasive localization tests. Among 513 cases who underwent parathyroidectomy due to primary hyperparathyroidism, twelve cases (2.3%) were undergone selective parathyroid venous sampling and were included in the study. Age, sex, presenting symptom, presence of a genetic disease, medical and surgical history, serum calcium (Ca)-parathormone (PTH) levels (preoperative, intraoperative, and postoperative), imaging reports (US, SM, and SVS), surgery reports, pathology reports, and complications were retrospectively reviewed. Seven cases (58.3%) had persistent primary hyperparathyroidism and one patient (8.3%) had past surgical history of total thyroidectomy. The remaining four patients (33.3%) had no previous neck surgery. T he sensitivity of selective venous sampling was 75%. According to the medical history, accurate localization was achieved in 85.7% of persistent cases and 60% of primary cases. Eight cases (66.6%) underwent unilateral neck exploration and four cases (33.3%) underwent four gland exploration. A single adenoma was detected in ten cases (90.9%) while one patient (9.1%) had double adenoma.

A case report of a patient with parathyroid carcinoma and a CDC73 germline mutation

Background: Parathyroid carcinoma (PC) is an uncommon cause of primary hyperparathyroidism (pHPT). Mutations of the cell division cycle protein 73 homolog (CDC73) gene are associated with both sporadic and familial pHPT and PC, including hyperparathyroidism-jaw tumor (HPT-JT) syndrome. Case Presentation: A 38-year-old man presented with severe hypercalcemia and acute renal injury due to pHPT. He had a palpable left cervical mass of 50 mm, characterized by both ultrasound and 99mTc-sestamibi scintigraphy as an enlarged hyperfunctioning parathyroid gland. Histological diagnosis after parathyroidectomy was of PC. During follow-up, patient developed metastasis of the skin, mediastinal lymph-nodes, and lungs. Even after surgical excision of all detectable metastasis parathyroid hormone (PTH) remained elevated. Genetic analysis found a germline mutation (c.766_767delGT) of the CDC73 gene, which was not previously reported in PC. Conclusion: Germline CDC73 analysis may be considered in HPT-JT syndrome, familial isolated pHPT, PC, and young individuals with pHPT.

Primary Hyperparathyroidism due to Ectopic Intrathymic Parathyroid Adenoma in A Child: A Case Report

Primary hyperparathyroidism (PHPT) is a rare endocrine disorder in children and adolescents. Surgery is curative in most pediatric patients with PHPT. PHPT due to ectopic parathyroid adenoma (EPA) presents the difficulty of their exact topographic diagnosis and there is no consensus for the optimal imaging modality. The 99mTc-sestamibi (99mTechnetium -labeled methoxy-isobutyl-isonitrile) scintigraphy appears to be the best exam to establish a topographic diagnosis of parathyroid adenoma. Herein, we present the case of a 14-year-old girl with the diagnosis of PHPT with bone involvement. Parathyroid scintigraphy (dual-phase and dual tracer subtraction imaging), has shown an abnormal tracer uptake in the anterior mediastinum. Computed tomography (CT), has confirmed the mediastinal seat of the adenoma, measured 40 x 24.6 mm, repressing the thymus. An adenectomy was performed using video-assisted mini-thoracoscopic surgery. Histological findings have shown intrathymic ectopic parathyroid adenoma. After surgery, the patient had profound and persistent hypocalcemia as a result of extensive remineralization in a relation to Hungry Bone Syndrome (HBS). Through this clinical report, we insist on the importance of preoperative localization of parathyroid adenoma to select the surgical approach and to avoid failed cervicotomy especially in cases of ectopic adenomas.

Resultados quirúrgicos y localización de las glándulas patológicas en el tratamiento del hiperparatiroidismo primario esporádico con gammagrafía 99mTc-sestamibi negativa

IntroductionThe primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy. MethodsObservational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an Endocrine Surgery Unit for 18 years. The cure rate, the intraoperatory parathyroid hormone (PTH), the etiology and the pathological glands location were analyzed. ResultsIn the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. The 14.1% presented a multigland disease; 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum. ConclusionsThe absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Effect of ursodeoxycholic acid in facilitating early hepatic clearance of radiotracer among patients undergoing 99mTc-sestamibi myocardial perfusion scintigraphy: A randomized double blind placebo controlled parallel trial

BackgroundInfra-cardiac tracer activity due to persistent hepatic activity interferes in inferior and infero-septal wall assessment during 99mTc-MIBI SPECT/CT myocardial perfusion scintigraphy (MPS) in evaluation of patients with coronary artery disease. It affects image interpretation with increased study duration. Ursodeoxycholic acid (UDCA) is known to enhance hepatic excretion of bilirubin and bile salts, though its role in enhancing the hepatic tracer clearance in facilitating cardiac imaging is not known. MethodsThis prospective, randomized double-blind, placebo controlled clinical trial of 120 patients, referred for adenosine stress or viability MPS studies were randomized 1:1 to receive either UDCA or placebo. Outcome was quantitative & qualitative improvement in imaging for better interpretation and to reduce the waiting time for scan. Results118 participants (59 ± 11.9 years; 84 men) underwent adenosine stress MPS or viability MPS. Sixty participants had UDCA while 58 had placebo intervention. The study showed significant decrease in liver counts with improved myocardial to liver ratio at 30 and 60 minutes in adenosine stress MPS group, and marginally significant alteration in liver counts at 60 minutes in viability MPS group receiving UDCA, resulting in better images. ConclusionUDCA intervention in MPS provides early and better image due to faster hepatic tracer clearance.