Advertisement

Annals of Nuclear Medicine

, Volume 22, Issue 2, pp 123–131 | Cite as

Preoperative evaluation of hyperparathyroidism: the role of dual-phase parathyroid scintigraphy and ultrasound imaging

  • Aysun SukanEmail author
  • Mehmet Reyhan
  • Mehmet Aydin
  • Ali F. Yapar
  • Yasar Sert
  • Tuba Canpolat
  • Ayse Aktas
Original Article

Abstract

Objective

The aim of this study was to evaluate the efficacy of dual-phase 99mTc-methoxyisobutylnitrile (MIBI) parathyroid scintigraphy (PS) and ultrasound (US) in primary (pHPT) and secondary (sHPT) hyperparathyroidism.

Methods

A total of 69 patients (mean age 47 ± 16; age range 14–79 years), including 19 patients with sHPT were enrolled in this study. Preoperative serum intact parathyroid hormone (iPTH) levels, calcium (Ca), phosphate (P), alkaline phosphatase, and 24-h urinary-free Ca measurements were obtained. Concomitant thyroid pathology was also recorded.

Results

Histopathology revealed 30 solitary adenomas and 71 hyperplastic glands in 55 patients. The remaining patients’ histopathology revealed normal parathyroid, thyroid, or lymph nodes. The sensitivities of MIBI and US in pHPT were 70% and 60%, respectively. It was 60% for both procedures in sHPT. The overall sensitivity of combined US + MIBI in pHPT and sHPT was 81% and 71%, respectively. The overall specificity of MIBI and US was 87% and 91%; positive predictive value (PPV) was 94% and 92%, respectively. MIBI and US identified the parathyroid pathology in 92% and 85% of patients in the non-concomitant thyroid disease group, and in 53% and 47% of patients in the concomitant thyroid disease group, respectively. The weight of the gland between primary and secondary hyperparathyroidism did not reveal a significant difference (P = 0.4). Significant differences were found with respect to age, PTH, Ca, and P levels between the pHPT and sHPT (P < 0.001). Intact PTH levels showed significant differences between MIBI positive and negative patients (P = 0.013), and also US positive and negative patients (P = 0.012). A significant negative correlation was found between iPTH and Ca at sHPT (P < 0.001).

Conclusions

The concomitancy of thyroid disease greatly influences scintigraphic and ultrasonographic detection of parathyroid pathology in pHPT and sHPT. The combination of MIBI and US appears promising for localizing parathyroid pathology in patients with both primary and secondary hyperparathyroidism. The concordance rate is high together with a lower chance of missing concomitant thyroid pathology, which might alter the surgical approach.

Keywords

Hyperparathyroidism 99mTc-MIBI Ultrasound Thyroid nodules 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. 1.
    Marx SJ. Hyperparathyroid and hypoparathyroid disorders. N Engl J Med 2000;343:1863–1875.PubMedCrossRefGoogle Scholar
  2. 2.
    John T. Potts. Disease of the parathyroid gland and other hyper and hypocalcemic disorders. In: Harrison’s Principles of Internal Medicine, Braunwald E, Fauci AS, Kasper DL (eds), 15th ed. New York: McGrawhill; 2001. p. 2205–2226.Google Scholar
  3. 3.
    Coakley AJ, Kettle AG, Wells CP, O’Doherty MJ, Collins RE. 99Tcm sestamibi-a new agent for parathyroid imaging. Nucl Med Commun 1989;10:791–794.PubMedCrossRefGoogle Scholar
  4. 4.
    Wei JP, Burke GJ, Mansberger AR Jr. Prospective evaluation of the efficacy of technetium 99m sestamibi and iodine 123 radionuclide imaging of abnormal parathyroid glands. Surgery 1992;112:1111–1116; discussion 1116-7.PubMedGoogle Scholar
  5. 5.
    Pattou F, Oudar C, Huglo D, Racadot A, Carnaille B, Proye C, et al. Localization of abnormal parathyroid glands with jugular sampling for parathyroid hormone, and subtraction scanning with sestamibi or tetrofosmine. J Surg 1998;68:108–111.Google Scholar
  6. 6.
    Wakamatsu H, Noguchi S, Yamashita H, Yamashita H, Tamura S, Jinnouchi S, et al. Technetium-99m tetrofosmin for parathyroid scintigraphy: a direct comparison with 99m Tc-MIBI, (201) Tl, MRI and US. Eur J Nucl Med 2001;28:1817–1827.PubMedCrossRefGoogle Scholar
  7. 7.
    Crane P, Laliberte R, Heminway S, Thoolen M, Orlandi C. Effect of mitochondrial viability and metabolism on technetium-99m-sestamibi myocardial retention. Eur J Nucl Med 1993;20:20–25.PubMedCrossRefGoogle Scholar
  8. 8.
    Mitchell BK, Cornelius EA, Zoghbi S, Murren JR, Ghoussoub R, Flynn SD. Mechanism of technetium 99m sestamibi parathyroid imaging and the possible role of p-glycoprotein. Surgery 1996;120:1039–1045.PubMedCrossRefGoogle Scholar
  9. 9.
    Neumann DR, Esselstyn CB Jr, Madera AM. Comparison of double-phase 99mTc-sestamibi with 123I-99mTc-sestamibi subtraction SPECT in hyperparathyroidism. Am J Roentgenol 1997;169:1671–1674.Google Scholar
  10. 10.
    Lee VS, Spritzer CE, Coleman RE, Wilkinson RH Jr, Coogan AC, Leight GS Jr. The complementary roles of fast spin-echo MR imaging and double-phase 99m Tc-sestamibi scintigraphy for localization of hyperfunctioning parathyroid glands. Am J Roentgenol 1996;67:1555–1562.Google Scholar
  11. 11.
    Taillefer R, Boucher Y, Potvin C, Lambert R. Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med 1992;33:1801–1807.PubMedGoogle Scholar
  12. 12.
    Moka D, Voth E, Dietlein M, Larena-Avellaneda A, Schicha H. Preoperative localization of parathyroid adenomas using 99mTc-MIBI scintigraphy. Am J Med 2000;108:733–736.PubMedCrossRefGoogle Scholar
  13. 13.
    Kaczirek K, Prager G, Kienast O, Dobrozemsky G, Dudczak R, Niederle B, et al. Combined transmission and (99m) Tcsestamibi emission tomography for localization of mediastinal parathyroid glands. Nuklearmedizin 2003;42:220–223.PubMedGoogle Scholar
  14. 14.
    Ishibashi M, Uchida M, Nishida H, Hiromatsu Y, Kohno K, Okuda S, et al. Presurgical localization of ectopic parathyroid glands using three-dimensional CT imaging, 99Tcm sestamibi, and 99Tcm tetrofosmin imaging. Br J Radiol 1999;72:296–300.PubMedGoogle Scholar
  15. 15.
    Ishibashi M, Nishida H, Hiromatsu Y, Kojima K, Tabuchi E, Hayabuchi N. Comparison of technetium-99m MIBI, technetium-99m tetrofosmin, ultrasound and MRI for localization of abnormal parathyroid glands. J Nucl Med 1998;39:320–324.PubMedGoogle Scholar
  16. 16.
    Palestro CJ, Tomas MB, Tronco GG. Radionuclide imaging of the parathyroid glands. Semin Nucl Med 2005;35:266–276.PubMedCrossRefGoogle Scholar
  17. 17.
    Lopez Hanninen E, Vogl TJ, Steinmuller T, Ricke J, Neuhaus P, Felix R. Preoperative contrast-enhanced MRI of the parathyroid glands in hyperparathyroidism. Invest Radiol 2000;35:426–430.PubMedCrossRefGoogle Scholar
  18. 18.
    Mazzeo S, Caramella D, Lencioni R, Molea N, De Liperi A, Marcocci C, et al. Comparison among sonography, double-tracer subtraction scintigraphy, and double-phase scintigraphy in the detection of parathyroid lesions. Am J Roentgenol 1996;166:1465–1470.Google Scholar
  19. 19.
    Mazzeo S, Caramella D, Marcocci C, Lonzi S, Cambi L, Miccoli P, et al. Contrast-enhanced color Doppler ultrasonography in suspected parathyroid lesions. Acta Radiol 2000;41:412–416.PubMedCrossRefGoogle Scholar
  20. 20.
    Norman J, Cheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery 1997;122:998–1003.PubMedCrossRefGoogle Scholar
  21. 21.
    Wells SA Jr, Ellis GJ, Gunnells JC, Schneider AB, Sherwood LM. Parathyroid autotransplantation in primary parathyroid hyperplasia. N Engl J Med 1976;295:57–62.PubMedCrossRefGoogle Scholar
  22. 22.
    Rosai and Ackerman’s; Ackerman’s Surgical Pathology, Juan Rosai, Lauren V. Ackerman. 9th ed. Parathyroid glands. 9th ed. Philadelphia: Mosby; 2004. p. 597–601.Google Scholar
  23. 23.
    Melloul M, Paz A, Koren R, Cytron S, Feinmesser R, Gal R. 99mTc-MIBI scintigraphy of parathyroid adenomas and its relation to tumour size and oxyphil cell abundance. Eur J Nucl Med 2001;28:209–213.PubMedCrossRefGoogle Scholar
  24. 24.
    Carpentier A, Jeannotte S, Verreault J, Lefebvre B, Bisson G, Mongeau CJ, et al. Preoperative localization of parathyroid lesions in hyperparathyroidism: relationship between technetium-99m-MIBI uptake and oxyphil cell content. J Nucl Med 1998;39:1441–1444.PubMedGoogle Scholar
  25. 25.
    Hajioff D, Iyngkaran T, Panagamuwa C, Hill D, Stearns MP. Preoperative localization of parathyroid adenoma: ultrasonography, sestamibi scintigraphy, or both? Clin Otolaryngology 2004:29:549–552.CrossRefGoogle Scholar
  26. 26.
    Gotthardt M, Lohmann B, Behr TM, Bauhofer A, Franzius C, Schipper ML, et al. Clinical value of parathyroid scintigraphy with technetium-99m methoxyisobutylisonitrile: discrepancies in clinical data and a systematic metaanalysis of the literature. World J Surg 2004;28:100–107.PubMedCrossRefGoogle Scholar
  27. 27.
    Haber RS, Kim CK, Inabnet WB. Ultrasonography for preoperative localization of enlarged parathyroid glands. Clin Endocrinol (Oxf) 2002;57:241–249.CrossRefGoogle Scholar
  28. 28.
    Barczynski M, Golkowski F, Konturek A, Buziak-Bereza M, Cichon, Hubalewska A, et al. Technetium-99m-sestamibi subtraction scintigraphy vs. ultrasonography combined with a rapid parathyroid hormone assay in parathyroid aspirates in preoperative localization of parathyroid adenomas in directing surgical approach. Clin Endocrinol (Oxf) 2006;65:106–113.CrossRefGoogle Scholar
  29. 29.
    Mortier P-E, Mozzon MM, Fouquet OP, Soudan BC, Huglo DG, Cussac JF. Unilateral Surgery for Hyperparathyroidism: Indications, Limits, and Late Results-New Philosophy or Expensive Selection without Improvement of Surgical Results? World J Surg 2004;28:1298–1304.PubMedCrossRefGoogle Scholar
  30. 30.
    Ambrosoni P, Heuguerot C, Olaizola I, Acuna G, Fajardo L, Petraglia A, et al. Can we use 99mTc-MIBI in functional studies of the parathyroid gland? Nephrol Dial Transplant 1998;13Suppl 3:33–36.PubMedCrossRefGoogle Scholar
  31. 31.
    Hung GU, Wang SJ, Lin WY. Tc-99m MIBI parathyroid scintigraphy and intact parathyroid hormone levels in hyperparathyroidism. Clin Nucl Med 2003;28:180–185.PubMedCrossRefGoogle Scholar
  32. 32.
    Biertho LP, Kim C, Wu HS, Ungar P, Inabnet WB. Relationship between sestamibi uptake, parathyroid hormone assay, and nuclear morphology in primary hyperparathyroidism. J Am Coll Surg 2004;199:229–233.PubMedCrossRefGoogle Scholar
  33. 33.
    Feinfeld DA, Sherwood LM. Parathyroid hormone and 1,25(OH) 2D3 in chronic renal failure. Kidney Int 1988;33:1049–1058.PubMedCrossRefGoogle Scholar
  34. 34.
    Sekiyama K, Akakura K, Mikami K, Mizoguchi K, Tobe T, Nakano K, et al. Usefulness of diagnostic imaging in primary hyperparathyroidism. Int J Urol 2003;10:7–11; discussion 12.PubMedCrossRefGoogle Scholar
  35. 35.
    Moka D, Eschner W, Voth E, Dietlein M, Larena-Avellaneda A, Schicha H. Iterative reconstruction: an improvement of technetium-99m MIBI SPET for the detection of parathyroid adenomas? Eur J Nucl Med 2000;27:485–489.PubMedCrossRefGoogle Scholar
  36. 36.
    De Feo ML, Colagrande S, Biagini C, Tonarelli A, Bisi G, Vaggelli L, et al. Parathyroid glands: Combination of (99m) Tc MIBI scintigraphy and US for demonstration of parathyroid glands and nodules. Radiology 2000;214:393–402.PubMedGoogle Scholar
  37. 37.
    Torregrosa JV, Fernandez-Cruz L, Canalejo A, Vidal S, Astudillo E, Almaden Y, et al. (99m)Tc-sestamibi scintigraphy and cell cycle in parathyroid glands of secondary hyperparathyroidism. World J Surg 2000;24:1386–1390.PubMedCrossRefGoogle Scholar
  38. 38.
    Purcell GP, Dirbas FM, Jeffrey RB, Lane MJ, Desser T, McDougall IR, et al. Parathyroid localization with high-resolution ultrasound and technetium Tc 99m sestamibi. Arch Surg 1999;134:824–828; discussion 828-30.PubMedCrossRefGoogle Scholar
  39. 39.
    Lumachi F, Zucchetta P, Marzola MC, Boccagni P, Angelini F, Bui F, et al. Advantages of combined technetium-99m-sestamibi scintigraphy and high resolution ultrasonography in parathyroid localization: comparative study in 91 patients with primary hyperparathyroidism. Eur J Endocrinol 2000;143:755–760.PubMedCrossRefGoogle Scholar
  40. 40.
    Prager G, Czerny C, Ofluoglu S, Kurtaran A, Passler C, Karzirek K, et al. Impact of localisation studies on feasibility of minimally invasive parathyroidectomy in an endemic goiter region. J Am Coll Surg 2003;196:541–548.PubMedCrossRefGoogle Scholar
  41. 41.
    Rutledge R, Stiegel M, Thomas CG Jr, Wild RE. The relation of serum calcium and intact parathormone levels to parathyroid size and weight in primary hyperparathyroidism. Surgery 1985;98:1107–1112.PubMedGoogle Scholar
  42. 42.
    Saxe AW, Lincenberg S, Hamburger SW. Can the volume of abnormal parathyroid tissue is predicted by preoperative biochemical measurement? Surgery 1987;102:840–845.PubMedGoogle Scholar
  43. 43.
    Adalet I, Hawkins T, Clark F, Wilkonson R. 1994 Thallium-technetium-subtraction scintigraphy in secondary hyperparathyroidism. Eur J Nucl Med 1994;21:509–513.PubMedGoogle Scholar
  44. 44.
    Piga M, Bolasco P, Satta L, Altieri P, Loi G, Nicolosi A, et al. Double phase parathyroid technetium-99m-MIBI scintigraphy to identify functional autonomy in secondary hyperparao thyroidism. J Nucl Med 1996;37:565–569.PubMedGoogle Scholar
  45. 45.
    Ryan JA, Eisemberg B, Pado KM and Lee. Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests. Arch Surg 1997;132:886–890.PubMedGoogle Scholar
  46. 46.
    Taira N, Doihara H, Hara F, Shien T, Takabatake D, Takahashi H, et al. Less invasive surgery for primary hyperparathyroidism based on preoperative 99mTc-hexakis-2-methoxyisobutylisonitrile imaging fi ndings. Surg Today 2004;34:197–203.PubMedCrossRefGoogle Scholar
  47. 47.
    Regal M, Paramo C, Luna Cano R, Perez Mendez LF, Sierra JM, Rodriguez I, et al. Coexistence of primary hyperparathyroidism and thyroid disease. J Endocrinol Invest 1999;22:191–197.PubMedGoogle Scholar
  48. 48.
    dell’Erba L, Baldari S, Borsato N, Bruno G, Calo-Gabrieli G, Carletto M, et al. Retrospective analysis of the association of nodular goiter with primary and secondary hyperparathyroidism. Eur J Endocrinol 2001;145:429–434.PubMedCrossRefGoogle Scholar
  49. 49.
    Gofrit ON, Lebensart PD, Pikarsky A, Lackstein D, Gross DJ, Shiloni E. High-resolution ultrasonography: highly sensitive, specific technique for preoperative localization of parathyroid adenoma in the absence of multinodular thyroid disease. World J Surg 1997;21:287–290; discussion 290-1.PubMedCrossRefGoogle Scholar
  50. 50.
    Staudenherz A, Abela C, Niederle B, Steiner E, Helbich T, Puig S, et al. Comparison and histopathological correlation of three parathyroid imaging methods in a population with a high prevalence of concomitant thyroid diseases. Eur J Nucl Med 1997;24:143–149.PubMedCrossRefGoogle Scholar
  51. 51.
    Masatsugu T, Yamashita H, Noguchi S, Nishii R, Watanabe S, Uchino S, et al. Significant clinical differences in primary hyperparathyroidism between patients with and those without concomitant thyroid disease. Surg Today 2005;35:351–356.PubMedCrossRefGoogle Scholar
  52. 52.
    Lorberboym M, Minski I, Macadziob S, Nikolov G, Schachter P. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma. J Nucl Med 2003;44:904–908.PubMedGoogle Scholar
  53. 53.
    Nishiyama RH, Farhi D, Thompson NW. Radiation exposure and the simultaneous occurrence of primary hyperparathyroidism and thyroid nodules. Surg Clin North Am 1979;59:65–75.PubMedGoogle Scholar

Copyright information

© The Japanese Society of Nuclear Medicine 2008

Authors and Affiliations

  • Aysun Sukan
    • 1
    Email author
  • Mehmet Reyhan
    • 1
  • Mehmet Aydin
    • 1
  • Ali F. Yapar
    • 1
  • Yasar Sert
    • 2
  • Tuba Canpolat
    • 3
  • Ayse Aktas
    • 1
  1. 1.Department of Nuclear Medicine, Adana Teaching and Medical Research CenterBaskent University Faculty of MedicineAdanaTurkey
  2. 2.Department of BiostatisticsCukurova UniversityAdanaTurkey
  3. 3.Department of PathologyBaskent University Faculty of MedicineAnkaraTurkey

Personalised recommendations