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World Journal of Surgery

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01-03-2016 | Original Scientific Report

A Multimodal Imaging Protocol, ¹²³I/⁹⁹Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization

Authors: Grace S. Lee, Travis J. McKenzie, Brian P. Mullan, David R. Farley, Geoffrey B. Thompson, Melanie L. Richards

Published in: World Journal of Surgery | Issue 3/2016

Abstract

Introduction

Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown.

Method

Patients with 1°HPT, who underwent parathyroidectomy in 2012–2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of ¹²³I/⁹⁹Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed.

Results

Of 360 patients who were identified, a curative operation was performed in 96 %, using pre-operative imaging and IOPTH. Imaging analysis showed that ¹²³I/⁹⁹Tc-sestamibi had a sensitivity of 86 % (95 % CI 82–90 %), positive predictive value (PPV) 93 %, and accuracy 81 %, based on correct lateralization. SPECT had a sensitivity of 77 % (95 % CI 72–82 %), PPV 92 % and accuracy 72 %. SPECT/CT had a sensitivity of 75 % (95 % CI 70–80 %), PPV of 94 %, and accuracy 71 %. There were 3 of 45 (7 %) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 %) with positive uptake on sestamibi (93 % true positive, 7 % false positive), concordant findings were present in 86 % SPECT and 84 % SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, ¹²³I/⁹⁹Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p < 0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold.

Conclusion

¹²³I/⁹⁹Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with ¹²³I/⁹⁹Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.

Mandl F (1926) Therapeutisher versuch bein falls von ostitis fibrosa generalisata mittles. Extirpation eines epithelkörperchen tumors. Wien Klin Wochenshr Zentral 143:245–284

van Heerden JA, Beahrs OH, Woolner LB (1977) The pathology and surgical management of primary hyperparathyroidism. Surg Clin N Am 57(3):557–563PubMed

Felger EA, Kandil E (2010) Primary hyperparathyroidism. Oto Clinic North Am 43(2):417–432CrossRef

Shaha AR, Sarkar S, Strashun A et al (1997) Sestamibi scan for preoperative localization for primary hyperparathyroidism. Head Neck 19:87–91CrossRefPubMed

Coakley AJ, Kettle AG, Wells CP et al (1989) 99Tm sestamibi—a new agent for parathyroid imaging. Nucl Med Commun 10(11):791–794CrossRefPubMed

Grant CS, Thompson GB, Farley DR et al (2005) Primary hyperparathyroidism surgical management since the introduction of minimally invasive parathyroidectomy. Arch Surg 140:472–479CrossRefPubMed

Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235(5):665–672PubMedCentralCrossRefPubMed

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

Richards ML, Thompson GB, Farley DR et al (2011) An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg 146(3):280–285CrossRefPubMed

10.

Sager S, Shafipour H, Asa S et al (2014) Comparison of Tc-99 m pertechnetate images with dual-phase Tc 99 m MIBI and SPECT images in primary hyperparathyroidism. IJEM 18(4):531–536PubMedCentralPubMed

11.

Neumann DR, Obuchowski NA, DiFilippo FP (2008) Preoperative 123I/99 m Tc-Sestamibi subtraction SPECT and SPECT/CT in primary hyperparathyroidism. J Nucl Med 49:2012–2017CrossRefPubMed

12.

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

13.

Gayed IW, Kim EE, Broussard WF (2005) The value of 99mTc-Sestamibi SPECT/CT over conventional SPECT in the evaluation of parathyroid adenomas or hyperplasia. J Nucl Med 46:248–252PubMed

14.

Tokmak H, Demirkol MO, Alagol F et al (2014) Clinical impact of SPECT-CT in the diagnosis and surgical management of hyperparathyroidism. Int J Clin Exp Med 7(4):1028–1034PubMedCentralPubMed

15.

Rubello D, Gross MD, Mariani G et al (2007) Scintigraphic techniques in primary hyperparathyroidism: from pre-operative localization to intra-operative imaging. Eur J Nucl Med Mol Imaging 34:926–933CrossRefPubMed

16.

Pham TH, Sylvester Sterioff S, Mullan BP et al (2006) Sensitivity and utility of parathyroid scintigraphy in patients with primary versus secondary and tertiary hyperparathyroidism. World J Surg 30:327–332CrossRefPubMed

17.

Shin JJ, Milas M, Mitchell J et al (2011) Impact of localization studies and clinical scenario in patients with hyperparathyroidism being evaluated for reoperative neck surgery. Arch Surg 146(12):1397–1403CrossRefPubMed

18.

Yen TW, Wang TS, Doffek KM et al (2008) Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in successful focused approach. Surgery 144:611–621CrossRefPubMed

19.

Richards ML, Thompson GB, Farley DR et al (2008) Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 196:937–943CrossRefPubMed

20.

Dy BM, Richards ML, Vazquez BJ et al (2012) Primary hyperparathyroidism and negative Tc99 Sestamibi Imaging: to operate or not? Ann Surg Oncol 19:2272–2278CrossRefPubMed

Title: A Multimodal Imaging Protocol, 123I/99Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization
Authors: Grace S. Lee
Travis J. McKenzie
Brian P. Mullan
David R. Farley
Geoffrey B. Thompson
Melanie L. Richards
Publication date: 01-03-2016
Publisher: Springer International Publishing
Published in: World Journal of Surgery / Issue 3/2016
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI: https://doi.org/10.1007/s00268-015-3389-6

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A Multimodal Imaging Protocol, ¹²³I/⁹⁹Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization

Abstract

Introduction

Method

Results

Conclusion

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Springer Medicine

Abstract

Introduction

Method

Results

Conclusion

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