Localization of abnormal parathyroid glands with jugular sampling for parathyroid hormone, and subtraction scanning with sestamibi or tetrofosmine

Efficacy of Scintigraphy, Ultrasound and Both Scintigraphy and Ultrasonography in Preoperative Detection and Localization of Primary Hyperparathyroidism

Objective: The aim of our study was to evaluate the efficacy of preoperative dual-phase 99mTc-methoxyisobutylnitrile (MIBI) parathyroid scintigraphy (PS), and ultrasound (US) in primary hyperparathyroidism (pHPT) diagnosis and compare the results with the surgical findings.

Methods: Forty-five patients were enrolled in this study. Preoperative serum parathyroid hormone (PTH) levels, calcium (Ca), phosphate (P), and alkaline phosphatase (AP) levels were measured. All parathyroid patients were evaluated by ultrasonography, dual phase 99mTc-MIBI. Surgical findings were used as a reference standard.

Results: Of the 45 patients included in this study, 30 were females (66.7%) with an age range between 30 years and 70 years (mean age 41± 13). The sensitivity and specificity of 99mTc-MIBI scintigraphy was 97.4% and 71.4%, respectively, while the sensitivity of ultrasound was 94.4% and specificity 44.4%. The sensitivity, specificity, and accuracy of combined scintigraphy and ultrasound was higher-97.4%, 83.3%, and 95.6%, respectively.

Conclusions: The combination of MIBI and US appears promising for localizing parathyroid pathology in patients with primary hyperparathyroidism. The concordance rate is high together with a lower chance of missing concomitant thyroid pathology, which might alter the surgical approach.

American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism

Health care consumer organizations and insurance companies increasingly are scrutinizing value when considering reimbursement policies for medical interventions. Recently, members of several American Academy of Otolaryngology-Head & Neck Surgery (AAO-HNS) committees worked closely with one insurance company to refine reimbursement policies for preoperative localization imaging in patients undergoing surgery for primary hyperparathyroidism. This endeavor led to an AAO-HNS parathyroid imaging consensus statement (https://www.entnet.org/content/parathyroid-imaging). The American Head and Neck Society Endocrine Surgery Section gathered an expert panel of authors to delineate imaging options for preoperative evaluation of surgical candidates with primary hyperparathyroidism. We review herein the current literature for preoperative parathyroid localization imaging, with discussion of efficacy, cost, and overall value. We recommend that planar sestamibi imaging, single photon emission computed tomography (SPECT), SPECT/CT, CT neck/mediastinum with contrast, MRI, and four dimensional CT (4D-CT) may be used in conjunction with high-resolution neck ultrasound to preoperatively localize pathologic parathyroid glands. PubMed literature on parathyroid imaging was reviewed through February 1, 2019.

Selective parathyroid venous sampling in primary hyperparathyroidism: A systematic review and meta-analysis

OBJECTIVE

Minimally invasive parathyroidectomy requires accurate preoperative localization techniques. There is considerable controversy about the effectiveness of selective parathyroid venous sampling (sPVS) in primary hyperparathyroidism (PHPT) patients. The aim of this meta-analysis is to examine the diagnostic accuracy of sPVS as a preoperative localization modality in PHPT.

METHODS

Studies evaluating the diagnostic accuracy of sPVS for PHPT were electronically searched in the PubMed, EMBASE, Web of Science, and Cochrane Controlled Trials Register databases. Two independent authors reviewed the studies, and revised quality assessment of diagnostic accuracy study tool was used for the quality assessment. Study heterogeneity and pooled estimates were calculated.

RESULTS

Two hundred and two unique studies were identified. Of those, 12 studies were included in the meta-analysis. Pooled sensitivity, specificity, and positive likelihood ratio (PLR) of sPVS were 74%, 41%, and 1.55, respectively. The area-under-the-receiver operating characteristic curve was 0.684, indicating an average discriminatory ability of sPVS. On comparison between sPVS and noninvasive imaging modalities, sensitivity, PLR, and positive posttest probability were significantly higher in sPVS compared to noninvasive imaging modalities. Interestingly, super-selective venous sampling had the highest sensitivity, accuracy, and positive posttest probability compared to other parathyroid venous sampling techniques.

CONCLUSION

This is the first meta-analysis to examine the accuracy of sPVS in PHPT. sPVS had higher pooled sensitivity when compared to noninvasive modalities in revision parathyroid surgery. However, the invasiveness of this technique does not favor its routine use for preoperative localization. Super-selective venous sampling was the most accurate among all other parathyroid venous sampling techniques. Laryngoscope, 2662-2667, 2018.

Selective parathyroid venous sampling in patients with complicated hyperparathyroidism

OBJECTIVE

The role of preoperative localisation of abnormal parathyroid glands remains controversial but is particularly relevant to the management of patients with recurrent or persistent hyperparathyroidism and familial syndromes. We report our experience of the use of selective parathyroid venous sampling (PVS) in the localisation of parathyroid disease in such patients.

DESIGN

We report a retrospective 10-year experience (n = 27) of the use of PVS in complicated primary hyperparathyroidism and contrast the use of PVS with neck ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and sestamibi imaging modalities.

RESULTS

In 14 out of 25 patients who underwent surgery PVS results were completely concordant with surgical and histological findings and 88% of patients achieved post-operative cure. Out of 13 patients referred after previous failed surgery, 12 underwent further surgery which was curative in 9. In total PVS yielded useful positive (n = 13) and/or negative information (n = 6) in 19 out of 25 patients undergoing surgery. Using histology as the gold standard, 59% of PVS studies were entirely consistent with histology, as compared with 39% of ultrasound scans, 36% of sestamibi scans and 17% of MRI/CT scans.

CONCLUSIONS

PVS is a valuable adjunct to MRI/CT and sestamibi scanning in selected patients with complicated hyperparathyroidism when performed in an experienced unit.

Nonequivalent Results of Tetrofosmin and Sestamibi Imaging of Parathyroid Tumors

OBJECTIVE

To report the case of a patient with a large parathyroid carcinoma missed by dual-phase technetium Tc 99m tetrofosmin (TETRO) parathyroid scanning.

METHODS

We present the clinical findings, laboratory results, imaging studies, and surgical pathology report in a man with parathyroid carcinoma and review the literature regarding the use of TETRO scintigraphy in patients with hyperparathyroidism.

RESULTS

In an 83-year-old man with hyperparathyroidism, severe hypercalcemia developed in the context of nephrolithiasis. An in-office ultrasonographic evaluation of the neck revealed a partially calcified mass (2.3 by 1.3 by 1.6 cm) at the inferoposterior border of the left thyroid lobe. Technetium Tc 99m sestamibi (MIBI) scanning was requested and reported as "negative." In fact, TETRO scanning had been substituted for MIBI scanning by the management of the nuclear medicine facility. Before neck exploration, performance of dual-phase MIBI parathyroid scintigraphy revealed radionuclide retention in the left lower neck area at 120 minutes, in the same site as the ultrasonographically visualized mass. A limited left inferior parathyroidectomy was performed, and intraoperative parathyroid hormone levels declined from 254 pg/mL to 28 pg/mL 10 minutes after near-complete resection of the mass. Pathology evaluation of the surgical specimen revealed a 2,000-mg parathyroid carcinoma.

CONCLUSION

Although both agents incorporate the same technetium Tc 99m radionuclide, TETRO and MIBI parathyroid scanning are not equivalent in the detection of parathyroid tumors with use of the dual-phase technique. We do not recommend substitution of TETRO for MIBI as a cost-control measure in the evaluation of hyperparathyroidism.

A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003

OBJECTIVE

To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism.

STUDY DESIGN

A systematic literature review.

RESULTS

Of the 20,225 cases of primary hyperparathyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc 99m -sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries.

CONCLUSION

The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normocalcemia than is typically quoted. IOPTH was a helpful but not "fool-proof" adjunct in parathyroid exploration surgery.

SIGNIFICANCE

These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.

Intraoperative testing for parathyroid hormone: a comprehensive review of the use of the assay and the relevant literature

OBJECTIVE

The rapid intraoperative parathyroid hormone assay is transforming the parathyroidectomy procedure. We present a review of the literature on the use of the assay as an adjunct to surgery. To our knowledge, this is the first review of the literature to encompass and compare all known primary studies of this assay in parathyroidectomy patients.

DATA SOURCES

Articles were collected by searching MEDLINE databases using relevant terminology. The references of these articles were reviewed for additional studies. Supplementary articles pertinent to the parathyroidectomy procedure, preoperative parathyroid localization studies, and intraoperative parathyroid hormone assay development also were examined.

STUDY SELECTION AND DATA EXTRACTION

One hundred sixty-five references were analyzed and categorized separately into groups.

DATA SYNTHESIS

The primary studies of intraoperative data on patients undergoing parathyroidectomy were compared when possible. Studies were analyzed by type of assay used, where performed, turnaround time, and efficiency of use. Reviews of the types of parathyroid surgery and preoperative localization were included for educational purposes.Conclusions.-The intraoperative parathyroid hormone assay is a useful adjunct to preoperative imaging and parathyroid surgery because of its unique ability to detect an occult residuum of hyperfunctioning parathyroid tissue. Use of this assay will obviate the need for frozen section in most routine cases. The test facilitates minimally invasive parathyroidectomy for single parathyroid adenomas, which, in turn, improves cost-effectiveness and cosmetic outcome. Its use in patients with known preoperative multiglandular disease is promising but requires further study.

Parathyroid scintigraphy with 99mTc-MIBI and 123I subtraction: a comparison with magnetic resonance imaging and ultrasonography

The aim of this study was to evaluate the efficacy of 99mTc-MIBI and 123I subtraction scintigraphy for the detection of abnormal parathyroid glands to be referred for surgical treatment. Thirty-nine consecutive patients, including 35 primary and four secondary cases of hyperparathyroidism, were evaluated. 99mTc-MIBI/123I subtraction scintigraphy (MIBI/I) was performed on all patients, and the results were compared with delayed images of 99mTc-MIBI (D-MIBI), magnetic resonance imaging (MRI) and ultrasonography (US). The overall sensitivity of MIBI/I, MRI, US and D-MIBI was 55.9%, 43.4%, 50.8% and 39.0%, respectively. In cases of single-gland disease, the sensitivity of MIBI/I, MRI, US and D-MIBI was 62.1%, 48.3%, 55.2% and 44.8%, respectively. In cases of multi-gland disease, the sensitivity of MIBI/I, MRI, US and D-MIBI was 50.0%, 37.5%, 46.7% and 36.7%, respectively. In cases of parathyroid adenoma, the sensitivity of MIBI/I, MRI, US and D-MIBI was 71.4%, 50.0%, 71.4% and 50.0%, respectively. In cases of parathyroid hyperplasia, the sensitivity of MIBI/I, MRI, US and D-MIBI was 55.2%, 42.3%, 50.0% and 39.7%, respectively. It is concluded that 99mTc-MIBI/123I subtraction is more useful than the delayed imaging of 99mTc-MIBI, MRI and US.

Double-phase parathyroid 99mTc-Sestamibi scintigraphy in chronic haemodialysis patients: correlation with biochemical markers of parathyroid function

99mTc-Sestamibi identifies the presence of hyperfunctioning autonomous parathyroid glands in patients with secondary hyperparathyroidism (SHP). The objectives of this study were: (i) to evaluate the interdependence between biochemical markers of SHP and 99mTc-Sestamibi uptake; and (ii) to determine whether 99mTc-Sestamibi uptake could be efficiently predicted by any combination of the former variables. Double-phase parathyroid 99mTc-Sestamibi uptake and total serum calcium, phosphorus, intact parathormone, 25-OH vitamin D and 1,25(OH) vitamin D determinations were performed simultaneously in 74 patients (36 female, 38 male) with SHP. Planar images of the neck and upper thorax were obtained in anterior view, 15 min (early phase) and 120 min (delayed phase) after the injection of 740 MBq of 99mTc-Sestamibi. In each patient, a final parathyroid/thyroid (P/T) activity index was obtained by adding the results of the P/T index of all parathyroid lesions. There was a significant correlation between intact parathormone levels and delayed 99mTc-Sestamibi uptake ( r=0.656; P<0.01). Of all the variables, intact parathormone was the only significant predictor of delayed 99Tc-Sestamibi uptake ( r=0.487; P<0.001). Calcium, phosphorus, vitamin D metabolites, age, gender, time spent on haemodialysis and cause of chronic renal failure displayed no significant correlation with 99mTc-Sestamibi uptake. It can be concluded that 99mTc-Sestamibi uptake is a potential predictor of parathyroid function in SHP patients. Hence, 99mTc-Sestamibi scintigraphy could be useful to assess parathyroid function and in the clinical follow-up of these patients.

Does anorectal manometry predict clinical outcome after laparoscopic ACE procedures in children with spina bifida?

PURPOSE

The laparoscopic antegrade continence enema (LACE) procedure is used for the treatment of faecal incontinence in children with spina bifida. The purpose of this study was to relate the outcome of the LACE procedure to anorectal function, as determined by anorectal manometry.

METHOD

Eleven children with spina bifida who had the LACE procedure underwent anorectal manometry (ARM) to document their anorectal function, and its relationship to the level of continence obtained following surgery.

RESULTS

There was a consistently high level of functional continence achieved following surgery despite wide variability in the parameters of anorectal manometry. There was no demonstrable correlation between the outcome of the LACE procedure and anorectal function as assessed by manometry.

CONCLUSION

Anorectal function as determined by manometry failed to predict outcome after the laparoscopic ACE procedure in children with spina bifida.

Correlation of parathyroid scanning and anatomy in 261 unselected patients with sporadic primary hyperparathyroidism

BACKGROUND

Despite abundant literature on parathyroid scanning with technetium 99m-labeled cationic complexes, comprehensive clinical reports that unequivocally correlate scanning findings with the anatomy of parathyroid glands in extensive and homogeneous cohorts of patients are lacking.

METHODS

We analyzed the records of patients with sporadic primary hyperparathyroidism who had had a preoperative scan with either 99mTc-labeled sestamibi or 99mTc-labeled tetrofosmin at our institution and who were cured after a bilateral surgical neck exploration procedure.

RESULTS

In 261 patients, 710 normal and 347 abnormal glands (1494 +/- 2626 mg), including 15 glands within the mediastinum, were identified. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of scanning were 82%, 98%, 91%, 94%, and 94%, respectively, in 197 patients with uniglandular disease and 53%, 98%, 98%, 60%, and 72%, respectively, in 64 patients with multiglandular disease. False-positive uptakes were encountered in 17 patients (7%), 3 false-positive uptakes being within the mediastinum. If the unilateral approach had been followed, guidance with preoperative scanning would have significantly increased the number of effective unilateral neck exploration procedures (164 patients (63%) vs 78 patients (30%); P < .001). One abnormal gland would also have been neglected in 28 patients (11%).

CONCLUSIONS

Preoperative scanning would limit neck exploration procedures in two thirds of patients with sporadic primary hyperparathyroidism but may also increase the risk of failure in the most challenging cases.

Radionuclide scanning in parathyroid diseases

BACKGROUND

New radionuclide agents and scanning procedures have markedly improved preoperative parathyroid gland localization. The aim of this review was to evaluate the results of parathyroid scanning and to clarify its current place in the clinical management of parathyroid diseases.

METHODS

The literature describing the different radioisotopes and available scanning techniques was analysed and their clinical outcome in various parathyroid diseases was evaluated.

RESULTS

Using 99mTc-radiolabelled sestamibi or other 9mTc-labelled cationic complexes, parathyroid scintigraphy detects 87 per cent of solitary adenomas (n=894), 55 per cent of abnormal glands in patients with multiglandular disease (n=303) and 75 per cent of persistent or recurrent lesions in patients with previous neck surgery (n=240). If necessary, three-dimensional imaging techniques can clarify the spatial localization of an ectopic uptake focus. The positive predictive value of the available scanning procedures is over 95 per cent, but false-positive uptake may be encountered.

CONCLUSION

Radionuclide parathyroid gland scanning with 99mTc-labelled cationic complexes is the initial non-invasive method of choice for preoperative parathyroid gland localization in patients at special risk and/or with previous neck exploration. While scanning has also been proposed to facilitate parathyroidectomy, there is no objective evidence to support its routine use before a first-time surgical procedure.