Skip to main content
SpringerLink
Log in

Can a Lightbulb Sestamibi SPECT Accurately Predict Single-Gland Disease in Sporadic Primary Hyperparathyroidism?

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

Technetium-99m sestamibi scintigraphy with single photon emission computed tomography (SPECT) is widely used to guide minimally invasive exploration in patients with sporadic primary hyperparathyroidism (SPH), although its sensitivity in multiglandular disease is limited. We examined the incidence of missed multiglandular disease and associated anatomic findings when sestamibi SPECT was positive for a single intense focus of delayed tracer uptake, termed a lightbulb scan (LBS).

Methods

Prospectively entered data from 764 patients with SPH treated with initial parathyroid exploration from March 5, 2000, to December 31, 2006, were reviewed. A single radiologist performed blinded interpretation of 585 available sestamibi SPECT images, classifying 167 (28.5%) patients with a LBS. Clinical findings were compared among LBS patients with a single adenoma (true positive) and LBS patients with multiglandular disease (false negative).

Results

One hundred fifty of 167 (89.8%) LBS patients had a single adenoma and 3 (1.8%) had carcinoma. Multiglandular disease was anatomically present in 14 of 167 (8.4%) LBS patients compared with 60 of 418 (15.6%) non-LBS patients (p = 0.05). Parathyroid hyperplasia occurred less frequently in LBS patients [5/167 (3%)] compared with non-LBS patients [36/418 (8.6%)], (p = 0.02), while double adenomas occurred equally often in LBS patients [9/167 (5.4%)] compared with non-LBS patients [24/418 (5.7%)], (p = 0.87). Double adenomas in LBS patients were more likely ipsilateral (7/9, p = 0.005) and left-sided (7/7, p = 0.008). LBS patients with multiglandular disease were more likely to have a history of neck irradiation, prior neck exploration, and concomitant thyroid pathology.

Conclusions

In patients with SPH, sestamibi SPECT studies show a single bright focus of uptake in only 29% of patients. LBS findings do not exclude multiglandular disease. To avoid unacceptable rates of failure at initial parathyroid exploration, the expert surgeon should use validated adjuncts such as intraoperative PTH monitoring or four-gland exploration.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235:665–670

    Article  PubMed  Google Scholar 

  2. van Heerden JA, Grant CS (1991) Surgical treatment of primary hyperparathyroidism: an institutional perspective. World J Surg 15:688–692

    Article  PubMed  Google Scholar 

  3. Siperstein A, Berber E, Mackey R et al (2004) Prospective evaluation of sestamibi scan, ultrasonography, and rapid PTH to predict the success of limited exploration for sporadic primary hyperparathyroidism. Surgery 136:872–880

    Article  PubMed  Google Scholar 

  4. Kebebew E, Clark OH (1998) Parathyroid adenoma, hyperplasia, and carcinoma: localization, technical details of primary neck exploration, and treatment of hypercalcemic crisis. Surg Oncol Clin N Am 7:721–748

    PubMed  CAS  Google Scholar 

  5. Kaplan EL, Yashiro T, Salti G (1992) Primary hyperparathyroidism in the 1990s. Ann Surg 215:300–315

    Article  PubMed  CAS  Google Scholar 

  6. Billotey C, Sarfati E, Aurengo A et al (1993) Advantages of SPECT in Tc99m sestamibi parathyroid scintigraphy. J Nucl Med 37:1773–1778

    Google Scholar 

  7. Perez-Monte JE, Brown ML, Shah AN et al (1996) Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT. Radiology 201:85–91

    PubMed  CAS  Google Scholar 

  8. Civelek AC, Ozalp E, Donovan P et al (2002) Prospective evaluation of delayed technetium-99m sestamibi SPECT scintigraphy for preoperative localization of primary hyperparathyroidism. Surgery 131:149–157

    Article  PubMed  Google Scholar 

  9. Lavely WC, Goetze S, Friedman KP et al (2007) Comparison of sestamibi SPECT/CT, sestamibi SPECT, and planar imaging with single- and dual-phase 99mTc-sestamibi parathyroid scintigraphy. J Nucl Med 48:1084–1089

    Article  PubMed  Google Scholar 

  10. Sharma J, Mazzaglia P, Milas M et al (2006) Radionuclide imaging for hyperparathyroidism (HPT): which is the best technetium-99m sestamibi modality? Surgery 140:856–865

    Article  PubMed  Google Scholar 

  11. Solarzano CC, Carneiro-Pla DM, Irvin GL (2006) Surgeon-performed ultrasonography as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll Surg 202:18–24

    Article  Google Scholar 

  12. Quiros RM, Alioto J, Wilhelm SM et al (2004) An algorithm to maximize use of minimally invasive parathyroidectomy. Arch Surg 139:501–507

    Article  PubMed  Google Scholar 

  13. Arici C, Cheah WK, Ituarte PHG et al (2001) Can localization studies be used to direct focused parathyroid operations? Surgery 129:720–729

    Article  PubMed  CAS  Google Scholar 

  14. Kebebew E, Hwang J, Reiff E et al (2006) Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism. Arch Surg 141:777–782

    Article  PubMed  Google Scholar 

  15. Gil-Cardenas A, Gamino R, Reza A et al (2007) Is intraoperative parathyroid hormone assay mandatory for the success of targeted parathyroidectomy? J Am Coll Surg 204:386–290

    Google Scholar 

  16. Jacobson SR, van Heerden JA, Farley DR et al (2004) Focused cervical exploration for primary hyperparathyroidism without intraoperative parathyroid hormone monitoring or use of the gamma probe. World J Surg 28:1127–1131

    Article  PubMed  Google Scholar 

  17. Carty SE, Roberts MM, Virji MA et al (2002) Elevated serum parathormone level after “concise parathyroidectomy” for primary sporadic hyperparathyroidism. Surgery 132:1086–1093

    Article  PubMed  Google Scholar 

  18. Carty SE, Worsey J, Virji MA et al (1997) Concise parathyroidectomy: The impact of preoperative SPECT 99m-Tc sestamibi scanning and intraoperative quick parathormone assay. Surgery 122:1107–1116

    Article  PubMed  CAS  Google Scholar 

  19. Sfakianakis GN, Irvin GL, Foss J et al (1996) Efficient parathyroidectomy guided by sestamibi SPECT-MIBI and hormonal measurements. J Nucl Med 37:798–804

    PubMed  CAS  Google Scholar 

  20. Westerdahl J, Bergenfelz A (2004) Sestamibi scan-directed parathyroid surgery: potentially high failure rate without measurement of intraoperative parathyroid hormone. World J Surg 28:1132–1138

    Article  PubMed  Google Scholar 

  21. Palestro CJ, Tomas MB, Tronco GG (2005) Radionuclide imaging of the parathyroid glands. Semin Nucl Med 35:266–276

    Article  PubMed  Google Scholar 

  22. Carneiro-Pla DM, Solarzano CC, Irvin GL (2006) Consequences of targeted parathyroidectomy guided by localization studies without intraoperative parathyroid hormone monitoring. J Am Coll Surg 202:715–722

    Article  PubMed  Google Scholar 

  23. Weber KJ, Misra S, Lee JK et al (2004) Intraoperative PTH monitoring in parathyroid hyperplasia requires stricter criteria for success. Surgery 136:1154–1159

    Article  PubMed  Google Scholar 

  24. Chen H, Mack E, Starling JR (2005) A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg 242:375–383

    PubMed  Google Scholar 

  25. Inabnet WB III, Kim CK, Haber RS et al (2002) Radioguidance is not necessary during parathyroidectomy. Arch Surg 137:967–970

    Article  PubMed  Google Scholar 

  26. Haciyanli M, Lal G, Morita E et al (2003) Accuracy of preoperative localization studies and intraoperative parathyroid hormone assay in patients with primary hyperparathyroidism and double adenoma. J Am Coll Surg 197:739–746

    Article  PubMed  Google Scholar 

  27. Milas M, Wagner K, Easley KA et al (2003) Double adenomas revisited: Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). Surgery 134:995–1004

    Article  PubMed  Google Scholar 

  28. Stephen AE, Roth SI, Fardo DW et al (2007) Predictors of an accurate preoperative sestamibi scan for single-gland parathyroid adenomas. Arch Surg 142:381–386

    Article  PubMed  Google Scholar 

  29. Mehta NY, Ruda JM, Kapadia S et al (2005) Relationship of technetium Tc 99m sestamibi scans to histopathological features of hyperfunctioning parathyroid tissue. Arch Otolaryngol Head Neck Surg 131:493–498

    Article  PubMed  Google Scholar 

  30. Mihai R, Gleeson F, Buley ID et al (2006) Negative imaging studies for primary hyperparathyroidism are unavoidable: correlation of sestamibi and high-resolution ultrasound scanning with histological analysis in 150 patients. World J Surg 30:697–704

    Article  PubMed  Google Scholar 

  31. Chiu B, Sturgeon C, Angelos P (2006) What is the link between nonlocalizing sestamibi scans, multigland disease, and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy. Surgery 140:418–422

    Article  PubMed  Google Scholar 

  32. Chan TYK, Serpell JW, Chan O et al (1991) Misinterpretation of the upper parathyroid adenoma on thallium-201/technetium-99m subtraction scintigraphy. Br J Radiol 64:1–4

    Article  PubMed  CAS  Google Scholar 

  33. Krausz Y, Betman L, Guralnik L et al (2006) Technetium-99m-MIBI sestamibi SPECT/CT in primary hyperparathyroidism. World J Surg 30:76–83

    Article  PubMed  Google Scholar 

  34. Doherty GM, Weber B, Norton JA (1994) Cost of unsuccessful surgery for primary hyperparathyroidism. Surgery 116:954–957

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Surgery, University of Pittsburgh School of Medicine, 497 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261, USA

    Linwah Yip, John H. Yim, Sally E. Carty & Jennifer B. Ogilvie

  2. Department of Radiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA

    Daniel A. Pryma

  3. Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA

    Mohamed A. Virji

Authors
  1. Linwah Yip
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel A. Pryma
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. John H. Yim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mohamed A. Virji
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sally E. Carty
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Jennifer B. Ogilvie
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jennifer B. Ogilvie.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Yip, L., Pryma, D.A., Yim, J.H. et al. Can a Lightbulb Sestamibi SPECT Accurately Predict Single-Gland Disease in Sporadic Primary Hyperparathyroidism?. World J Surg 32, 784–792 (2008). https://doi.org/10.1007/s00268-008-9532-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-008-9532-x

Keywords

Search

Navigation