sodium-pertechnetate-tc-99m and Parathyroid-Neoplasms

Primary hyperparathyroidism, most commonly due to a solitary parathyroid adenoma, has become an increasingly diagnosed condition and is one with great potential for cure following appropriate surgical intervention. Functional imaging with Tc-99m-based radiopharmaceuticals has contributed significantly to increased success in preoperative adenoma localization but the advent of fusion of this functional information with anatomical details obtained with computed tomographic imaging has yielded a potentially more powerful clinical tool and one that is particularly well suited to ectopic adenomas and cases of prior failed surgery. Aspects of this modality are discussed with reference to software- and hardware-based fusion techniques and evidence for efficacy. The allied technique of PET/computed tomography is also discussed.

Topics: Adenoma; Humans; Hyperparathyroidism; Image Processing, Computer-Assisted; Parathyroid Neoplasms; Positron-Emission Tomography; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed

Calciphylaxis is a condition with a generally poor prognosis about which relatively little is known. Possible improvement in prognosis is noted if the diagnosis can be made early to avoid progression of soft tissue lesions and resulting complications. The mainstays of therapy are wound care and therapy aimed at controlling infection and the progression of disease. Parathyroidectomy seems to benefit some patients, but controversy remains as to the extent of overall patient benefit and scenarios for its appropriate use.

Topics: Adenoma; Calciphylaxis; Gamma Cameras; Humans; Hyperparathyroidism, Secondary; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Sodium Pertechnetate Tc 99m

Primary hyperparathyroidism and concomitant thyroid cancer is a rare and complicated setting for diagnostic imaging.. The authors report the accidental finding of primary hyperparathyroidism in a patient with rapid enlargement of a thyroid nodule and the results of a literature review.. Tl-201-Tc-99m subtraction scintigraphy correctly revealed the malignant nature of a large cold thyroid nodule and mediastinal parathyroid hyperplasia. In contrast, high-resolution ultrasound indicated a retrothyroidal hyperplastic parathyroid gland. Surgery followed the findings of the preoperative ultrasound and intraoperative biopsy, yet hyperparathyroid disease persisted. Repeated scintigraphy confirmed an ectopic parathyroid gland, which was resected from a paraesophageal location. Subsequently, hormone and calcium levels returned to normal and remained normal during a follow-up period of 3 years. A literature review revealed a prevalence of approximately 3% of nonmedullary thyroid cancer, which was found in patients operated on for primary hyperparathyroidism. Previous neck irradiation, especially in childhood, appears to be a risk factor for the development of both nonmedullary thyroid carcinoma and for primary hyperparathyroid disease.. This case illustrates the need for clinical awareness of concomitant hyperparathyroidism and nonmedullary thyroid cancer and is substantiated with published case reviews. The preoperative scintigraphic localization of hyperfunctioning parathyroid tissue, although not advised as a routine procedure, may provide diagnostic information in addition to high-resolution ultrasound and intraoperative biopsy. In addition, scintigraphy can be useful even in the technically difficult setting of concomitant thyroid cancer.

Topics: Adenoma; Adult; Carcinoma; Humans; Hyperparathyroidism; Male; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Thyroid Neoplasms

Patients with recurrent or persistent primary hyperparathyroidism have increased operative risk because of scarring in the operative field and the frequent presence of an ectopic gland. Preoperative imaging studies will identify the hyperfunctioning parathyroid gland in the majority of circumstances. The best types or combination of imaging tests has not been definitely established. However, because of their wide availability and demonstrated sensitivity, US and sestamibi scans are most commonly obtained. Based on the clinical setting, additional tests including CT or MRI may be useful. In circumstances when the noninvasive imaging modalities are inconclusive, invasive imaging tests including selective angiography venous sampling and/or direct fine needle aspiration should be used. IOUS, MIRP, and intraoperative PTH determination are useful adjuncts to the safe and successful conduct of reoperative parathyroid surgery: however, the benefit of the routine use of these modalities in reoperative parathyroid surgery has yet to be critically determined.

Topics: Adenoma; Biopsy; Diagnostic Imaging; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Intraoperative Period; Monitoring, Intraoperative; Parathyroid Hormone; Parathyroid Neoplasms; Preoperative Care; Recurrence; Sodium Pertechnetate Tc 99m; Surgery, Computer-Assisted; Technetium Tc 99m Sestamibi

We herewith report an unusual case of primary hyperparathyroidism whose parathyroid adenoma strongly accumulated technetium (Tc)-99m pertechnetate. A 41-year-old woman was referred to our department under the tentative diagnosis of primary hyperparathyroidism. Scintigraphy by thallium-201 chloride showed homogeneous uptake in the whole thyroid, whereas Tc-99m image revealed a strong local accumulation in the middle portion of the right thyroidal lobe. Neck exploration revealed a 12x8x5 mm tumor in the posterolateral region of the right thyroidal lobe, the pathology of which was parathyroid adenoma. In addition, a small nodule (8 mm in diameter) with pathological findings revealing follicular adenoma of the thyroid, was found within the medial portion of the right thyroidal lobe. Both lesions were removed by surgery, and a postoperative Tc-99m scintigraphy no longer demonstrated a significant uptake in the right thyroidal lobe. Since the thyroid adenoma was too small to be detected by any scintigraphic study and located much closer to the median line than the site of the marked accumulation of Tc-99m pertechnetate, it was considered very likely that the parathyroid adenoma concentrated Tc-99m. Search of literature revealed that there have been only thirteen cases of parathyroid tumor reported to date which significantly accumulated Tc-99m pertechnetate. The present patient represents another rare case of parathyroid adenoma showing sueh an unusual scintigraphic image.

Topics: Adenoma; Adult; Female; Humans; Parathyroid Neoplasms; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m

Scintigraphy of the parathyroid glands continues to be controversial from several standpoints, including radiopharmaceutical choice, imaging protocol, results, and utility in clinical situations. This article reviews: the anatomy, physiology and pathology of the parathyroid glands; mechanisms of radiopharmaceutical localization; commonly accepted imaging protocols; image results; and the appropriate use of parathyroid scintigraphy.

Topics: Humans; Image Enhancement; Iodine Radioisotopes; Parathyroid Diseases; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes

Parathyroid carcinoma is a rare clinical entity accounting for only 4 per cent of all cases of parathyroid neoplasia. Nonfunctioning parathyroid carcinoma is even rarer. Previously, virtually all patients with these lesions were treated for a nonspecific neck mass. However, in the present case, a preoperative diagnosis of nonfunctioning parathyroid carcinoma was made based on the technetium pertechnetate/thallium 201 subtraction scan. The authors report on the 14th case of nonfunctioning parathyroid carcinoma, a review of the literature, and guidelines for the preoperative and operative evaluation of neck masses suspected to be parathyroid carcinoma.

Topics: Adult; Carcinoma; Humans; Male; Parathyroid Neoplasms; Parathyroidectomy; Prognosis; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroidectomy

The increasing use of automated blood chemistry screens for serum calcium levels along with improved methods in measuring parathyroid hormone (PTH) levels have made the diagnosis of parathyroid disease a common clinical problem. Parathyroid adenomas account for the majority of primary hyperparathyroidism with diffuse hyperplasia and parathyroid carcinoma occurring less frequently. Early scintigraphic techniques to identify enlarged parathyroids used selenomethionine-75 which was considered to be incorporated into PTH. In general, the sensitivity of scanning the neck using this tracer was related to the size of the enlarged parathyroid, but in large series, the overall sensitivity was less than 50%. Recent work by Ferlin et al, using a Technetium-99m/Thallium-201 subtraction scintigraphic technique has yielded a sensitivity of 92% in identifying pathologically enlarged parathyroid glands. Winzelberg et al modified this technique to allow imaging the mediastinum plus simplifying the subtraction method. In a prospective study with high-resolution sonography, similar sensitivities and specificities were found with sonography and scintigraphy. Tl-201/Tc-99m pertechnetate subtraction scintigraphy appears to be an accurate technique in identifying pathologic parathyroid enlargement. Its ultimate role in the evaluation of patients with suspected hyperparathyroidism still needs to be determined.

Topics: Adenoma; Animals; Cesium Radioisotopes; Dogs; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Rats; Selenomethionine; Sodium Pertechnetate Tc 99m; Thallium

Approximately 5 to 10% of parathyroid adenomas are located within the thin, fibrous capsule of the thyroid gland. These subcapsular adenomas can complicate minimally invasive parathyroidectomy. The small incision used in this procedure limits the view of the surgical bed. Palpation is less sensitive when the adenoma is covered by the thyroid capsule. If a subcapsular parathyroid adenoma can be identified on preoperative parathyroid scintigraphy, nuclear medicine physicians can recommend exploration of the thyroid capsule early, leading to an easier, more efficient operation. The objective of this observational study was to identify the scintigraphic appearance of subcapsular parathyroid adenomas.. A total of 109 patients with primary hyperparathyroidism underwent preoperative dual-phase Tc-99m sestamibi parathyroid scintigraphy at our tertiary care center from October 2002 to March 2004. Tc-99m pertechnetate was used as a supplemental technique when deemed necessary for optimal interpretation. Retrospective chart review identified 16 surgically proved subcapsular parathyroid adenomas. Parathyroid scintigraphy was reviewed.. Subcapsular parathyroid adenomas tend to conform to the expected shape of the thyroid gland. In this small series, subcapsular parathyroid adenomas followed 1 of 3 patterns on lateral images: (1) focal convex distortion of the posterior wall of the thyroid, (2) polar lentiform configuration, and (3) compression of the posterior thyroid parenchyma.. Subcapsular parathyroid adenomas often have a distinct appearance on scintigraphy. Preoperative identification of this type of parathyroid adenoma can direct a subcapsular surgical approach, optimizing the efficiency of the minimally invasive parathyroidectomy.

Topics: Adenoma; Humans; Parathyroid Neoplasms; Preoperative Care; Prognosis; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

The purpose of the present study was to assess the utility of the intraoperative gamma probe technique in a group of 128 patients suffering from primary hyperparathyroidism (PH).. In view of surgery, these patients were homogeneously subjected to a diagnostic protocol comprising double tracer scintigraphy ((99mTc)-Pertecnetate/(99mTc)-MIBI) and neck echotomography, carried out in a single session. They were then all operated on by the same surgical team.. In 97 patients with scintigraphic and echographic evidence of single parathyroid enlargement and normal thyroid gland, mini-invasive radio-guided surgery (MRS) was planned. In 94 of these 97 patients (96%) MRS was carried out successfully by removal of a single parathyroid adenoma (PA) through a small cutaneous incision of 2-2.5 cm; in the remaining 3/97 patients (3.1%), it proved necessary to convert to bilateral surgical exploration of the neck following intraoperative diagnosis of a parathyroid carcinoma in 2 cases and of multiglandular pathology (MGP) suggested by the persistence of elevated values of intraoperative parathormone (PTH) in 1 case. It should be pointed out that the use of IGP enabled us to carry out limited surgical exploration in 18 of 23 patients who had previously undergone operation on the thyroid and/or parathyroids. In a second group of 31 patients with presumed preoperative diagnosis of MGP (5 cases) or nodular goitre concomitant with PH (26 cases), IGP was used in the course of standard bilateral surgical exploration of the neck and enabled us to locate: an ectopic parathyroid gland in the thymus in 1 case of MGP, a PA in the deep levels of the neck in 2 cases with goitre and an ectopic PA at the bifurcation of the carotid in 1 other case with goitre. It should however be specified that in certain other patients with goitre it proved difficult intraoperatively to distinguish thyroid nodes from a PA adhering to the thyroid.. On the basis of the data to emerge from the present study we can conclude that: 1) in patients with PH presenting a scintigraphic and echographic picture indicating single PA and normal thyroid with high probability, the IGP technique proves effective in carrying out an MRS; 2) 37 MBq of (99mTc)-MIBI are an adequate dose for the correct performance of MRS; 3) a rapid intraoperative dose of PTH is to be recommended so as to confirm complete removal of the hyperfunctioning parathyroid tissue; 4) MRS may be employed successfully also in those patients previously subjected to thyroid or parathyroid surgery for the purpose of limiting the surgical trauma connected to reintervention and, therefore, to reducing the risk of complications; 5) IGP would not appear to be recommendable in patients with PH and concomitant goitre, with the possible exception of ectopic PA.

Topics: Adenoma; Humans; Hyperparathyroidism; Neck; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Ultrasonography

In the last decade, surgery of primary hyperparathyroidism (HPT) due to a solitary adenoma has moved on from the traditional wide bilateral neck exploration (BNE) to more limited approaches such as unilateral neck exploration and minimally invasive parathyroidectomy.. To define the role of intraoperative gamma probe and injection of a low (99m)Tc-MIBI dose in performing minimally invasive radio-guided surgery (MIRS) in HPT patients with a solitary parathyroid adenoma.. From September 1999 to July 2002, 214 patients with primary HPT entered the study. All patients were preoperatively investigated by a (99m)Tc-pertechnetate/MIBI subtraction scan and high-resolution neck ultrasound. The intraoperative technique we developed differs from other previously described techniques being based on the injection of a low (37 MBq) MIBI dose in the operating theatre a few minutes before the beginning of intervention.. On the basis of scan/ultrasound findings 147 patients were selected for a MIRS and 144 of them (98%) were successfully treated by this approach: a solitary parathyroid adenoma was removed through a small 2-2.5 cm skin incision with a mean operative time of 35 min, and a mean hospital stay of 1.2 days. In the other 67 patients with scan/ultrasound evidence of concomitant nodular goiter (n=45) or multi-gland disease (n=13) or with a negative scan (n=9), the gamma probe was utilized during a traditional BNE. A low 37 MBq MIBI dose proved to be sufficient to perform a MIRS; moreover it delivered to the patient and surgeon a low, negligible, radiation exposure dose.. The combination of a (99m)Tc-pertechnetate/MIBI subtraction scan and neck ultrasound appears to be an accurate imaging protocol in selecting primary HPT patients as candidates for a MIRS. A MIBI dose as low as 37 MBq injected in the operating theatre just before the start of surgery appears to be adequate to perform radio-guided surgery.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Intraoperative Care; Male; Middle Aged; Minimally Invasive Surgical Procedures; Parathyroid Neoplasms; Parathyroidectomy; Preoperative Care; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

The most common radionuclide procedures for parathyroid imaging are (99m)Tc-MIBI/ (99m)Tc pertechnetate subtraction scintigraphy and (99m)Tc-MIBI double-phase imaging, with estimation of MIBI wash-out rate. Those two methods are by some authors regarded as complementary techniques, yielding the best evaluation of parathyroid gland if performed conjointly. By such an approach it seems reasonable to substitute the visual assessment of neck scintigrams and semiquantitative evaluation of MIBI wash-out rate with a single, common procedure. The aim of this study was application of the Artificial Neural Network (ANN) simulated by the computer program to detection and localisation of pathological parathyroid tissue in the planar neck scintigrams.. The applied algorithm was based on simultaneous data processing in sets of 3 single pixels, each of them belonging to one of the three consecutive neck scintigrams generated 20 min. after (99m)TcO(4 )- administration, 10 min. after (99m)Tc-MIBI injection and 120 min. after (99m)Tc-MIBI injection, respectively. Those scintigrams were aligned which each other according to the same vertical and horizontal co-ordinates. The training patterns were obtained from 25 patients by searching for maximum count numbers within small ROIs drawn in selected scintigraphic areas, arbitrarily classified and coded in a numerical scale. In 10 pts the results of ANN simulation were compared with those obtained by common conventional assessment of two radionuclide parathyroid examinations: subtraction method and (99m)Tc-MIBI double-phase imaging.. The training patterns processed by the neural network showed a close relationship with the results of visual assessment of original neck scintigrams, with R square coefficient R(2) = 0.717, and standard error equal to 0.243. Similar comparison between original data and results of multidimensional regression analysis yielded weaker relationship, with R(2) = 0.543 and standard error 0.567. Parametric images obtained by the neural network presented regions with homogeneously distributed, relatively high activity, greater than or equal to 750 cts/pixel, visualized in areas of confirmed abnormal parathyroid location. In all 10 patients with suspected parathyroid adenoma results obtained by ANN simulation agreed with those by conventional methods. In five of these cases no parathyroid abnormalities were found. In the remaining 5 subjects results of both approaches were positive but the abnormalities were depicted more distinctly and visualised more clearly in parametric images received by ANN than in original scans.. Application of trained ANN enables objective and quantitative detection and localisation of parathyroid adenoma and is a good alternative for conventional radionuclide imaging procedures used in diagnosing parathyroid abnormality. Including in neural network simulation not only scintigraphic data, but also clinical symptoms and/or some other indicators of parathyroid abnormality, parathormone level first of all, should be a next step in developing a procedure for assessing parathyroid abnormality, of high diagnostic accuracy.

Topics: Adenoma; Adult; Aged; Algorithms; Expert Systems; Female; Humans; Image Interpretation, Computer-Assisted; Male; Middle Aged; Nerve Net; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

Technetium-99m sestamibi imaging for parathyroid adenoma localization has been performed using both dual-tracer subtraction and double-phase single-tracer washout techniques. The relative accuracy of these two techniques is uncertain. We have developed a modified imaging technique which combines both approaches and have directly compared them in a series of patients with surgically explored hyperparathyroidism. Initial injection of (99m)Tc-pertechnetate 50 MBq was followed by continuous dynamic imaging of the anterior neck for 30 min. (99m)Tc-sestamibi 1,000 MBq was injected intravenously at the midpoint of the acquisition. Delayed images were performed after 2 h. We blindly reviewed 88 consecutive cases of surgically explored hyperparathyroidism that had undergone preoperative scintigraphic localization with this procedure. Images were reformatted to display subtraction-only, early/delayed sestamibi-only and combined images. Scans were reviewed in random order. Of the 68 cases with solitary parathyroid adenoma, the sestamibi-only images gave correct localization in 49 (72%) while there was a statistically significant improvement in accuracy using the subtraction-only images (58 of 68, 85%, P=0.05) and the combined images (61 of 68, 90%, P=0.0015). Reader confidence was also greater with the subtraction-only and combined images than with the sestamibi-only images. Scan performance with parathyroid hyperplasia was less satisfactory. Although the largest gland was usually correctly identified, hyperplasia was difficult to distinguish from a solitary adenoma. Dual-tracer subtraction parathyroid imaging is superior to double-phase sestamibi-only imaging. The washout data may provide additional information in some cases, however, and an approach that combines both techniques may be optimal.

Topics: Adenoma; Diagnosis, Differential; Female; Humans; Hyperparathyroidism; Hyperplasia; Image Enhancement; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi

An 80-year-old woman with osteoporosis without fractures was referred with asymptomatic primary hyperparathyroidism and elevated calcitonin level. Ultrasound, 99m Tc-pertechnetate scintigraphy, 99m Tc-MIBI scintigraphy, and CT revealed a suspicious thyroid nodule and enlarged submandibular lymph nodes. However, no parathyroid adenoma was depictable. 18 F-choline PET/CT showed increased uptake of the proximal esophagus, but neither CT nor US revealed a parathyroid lesion, and only 18 F-choline PET/US fusion imaging confirmed a paraesophageal parathyroid adenoma. Resection of both medullary thyroid carcinoma and ectopic parathyroid adenoma through a single cervicotomy was conducted (thyroidectomy, neck dissection, extirpation of parathyroid adenoma); parathyroid hormone and calcitonin dropped to normal. Multiple endocrine neoplasia IIa syndrome was suspected.

Topics: Adenoma; Aged, 80 and over; Calcitonin; Carcinoma, Neuroendocrine; Choline; Female; Humans; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Positron Emission Tomography Computed Tomography; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Neoplasms

A 51-year-old man with a palpable neck mass and elevated parathyroid hormone was referred to our department for parathyroid scintigraphy. After injection of 740 MBq 99mTc-MIBI, a dual-phase scan was obtained, which revealed a persistent and intense focal hyperactivity in the left side of the neck (compatible with the neck mass). Thyroid scan with 99mTcO4- also showed increased uptake of the mass, similar to a hot thyroid nodule. After surgery, parathyroid carcinoma was confirmed pathologically. This case demonstrates a rare presentation of parathyroid carcinoma as a hot nodule in thyroid scan, which has been attributed to hypervascularity of the lesion.

Topics: Biological Transport; Female; Humans; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m

Topics: Biological Transport; Female; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Sodium Pertechnetate Tc 99m

The conventional approach for preoperative parathyroid localization with the dual

Topics: Adenoma; Humans; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi

A 73-year-old man displaying primary hyperparathyroidism with severe hypercalcemia (Ca: 4.1 mmol/l, PTH > 600 pmol/l) was referred for preoperative localization of a parathyroid adenoma. Tc-pertechnetate and Tc-sestaMIBI dual tracer scintigraphy displayed a mild focal uptake in the projection of the right thyroid lobe with negative ultrasonography. F-Fluorocholine PET/CT was quickly performed considering this discrepancy and not only confirmed the scintigraphic findings but also revealed a second contralateral focus of increased uptake, both later confirmed by operative consideration (the two other parathyroid glands are considered normal by the surgeon), pathology, and intraoperative parathyroid hormone assessment.

Topics: Adenoma; Aged; Choline; Humans; Male; Parathyroid Neoplasms; Positron Emission Tomography Computed Tomography; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

A 46 year-old female patient presented to the hospital with ongoing and progressively increasing fatigue, severe nausea and vomiting, loss of appetite, constipation, palpitations and somnolence. Laboratory evaluation revealed a severe hypercalcaemia and overt hyperthyroidism. She was diagnosed with primary hyperparathyroidism accompanied by Graves' disease. The patient underwent total thyroidectomy and right inferior parathyroid gland adenoma excision on the 24th day of her admission to the hospital after calcium levels and free thyroid hormone levels were brought to normal ranges. We suggest that a possibility of simultaneous thyrotoxicosis and primary hyperparathyroidism in cases presenting with a hypercalcaemic crisis should be considered.

Topics: Adenoma; Female; Graves Disease; Humans; Hypercalcemia; Hyperparathyroidism, Primary; Middle Aged; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Radiopharmaceuticals; Severity of Illness Index; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroidectomy; Ultrasonography

The aim was quantitative assessment of parathyroid adenoma (PTA) uptake in dual tracer dynamic scintigraphy.. In 78 patients, median age 58 (19-80) years, surgically treated for primary hyperparathyroidism (PHPT), with parathyroid hormone median 125 (70-658) pg/ml, we performed preoperative parathyroid scintigraphy, following EANM guidelines of subtraction and double-phase protocol (2009) using two tracers: Tc-99m pertechnetate and Tc-99m MIBI. In addition to standard subtraction processing and visual interpretation of delayed MIBI planar images of neck and mediastinum in oblique sections (positions according to ultrasound PTA localisation), we developed Submarine processing software that enables selecting custom regions grid sizes ≥6 mm (as this solution was not present in commercial software) to follow time activity curve changes in thyroid tissue and PTA. Histopathology in 53/78 patients revealed PHPT and in 25/78 patients thyroid nodular disease only, and thyroid malignancy occurred in total of 15/78 (19 %) patients. PHPT group included 44 solitary PTA, 8 patients with hyperplasia and one parathyroid carcinoma. The median macroscopic volume of PTA was 717.5 (15-6125) mm(3). Concomitant PHPT and thyroid nodular disease occurred in 24/53 patients and among them 8 patients had thyroid malignancies.. PTA showed typical pattern of late peak on time activity curves characterized by median start time on 15 (10-25) min, the peak amplitude mean 19 (±5) % above thyroid declining washout curve, and duration of peak 6 (4-10) min, allowing PTA to "emerge" like submarine, independent from thyroid tissue and lesions. The ratio of PTA-to-normal thyroid uptake at peak maximum was 1.35 (±0.21). The thyroid TACs results of normal 29/78 (37 %) patients, benign nodular 34/78 (44 %) patients, and malignancy in 15 (19 %) patients were all presented by declining exponential curves. The slope analysis of TACs in normal thyroid tissue, thyroid benign and malignant lesions (linear fitted logarithm of TAC) showed no difference (the same negative slope: -0.04). Submarine processing was sensitive in detection of small lesions, in hyperplasia, and concomitant thyroid nodular disease.. The novel Submarine processing confirmed specific PHPT pattern and was effective in the group with potential pitfalls of standard interpretation, increasing sensitivity and specificity of standard processing subtraction algorithm. Prolonged MIBI accumulation was present in malignant as well as benign thyroid nodules with identical TAC slope.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Algorithms; Female; Humans; Image Processing, Computer-Assisted; Male; Middle Aged; Observer Variation; Parathyroid Hormone; Parathyroid Neoplasms; Radionuclide Imaging; Reproducibility of Results; Sodium Pertechnetate Tc 99m; Software; Technetium Tc 99m Sestamibi; Young Adult

The objective of this study was to compare the dual phase MIBI scinitgraphy with MIBI and Tc-99m pertechnetate (MIBI + Tc-99m) study in defining the parathyroid adenomas, and to evaluate the effect of histologic and biochemical characteristics on the imaging of parathyroid adenomas with Tc-99m methoxyisobutylisonitrile (MIBI) scintigraphy.. Thirty-six patients with parathyroid adenomas were studied prospectively. All patients were evaluated with both MIBI and (MIBI + Tc-99m) study. MIBI uptake of adenomas correlated with oxyphill, chief cell and tumour weight of the surgically excised glands. MIBI uptake was also compared with serum calcium (Ca), phosphorus (P) and intact parathormone (iPTH) levels.. A total of 38 parathyroid adenomas were surgically excised from 36 patients. MIBI + Tc-99m identified 35 of the parathyroid lesions (92%). Whereas, MIBI study detected 30 of the 38 parathyroid adenomas (79% sensitivity) (p=0.0001). There were no false positives. Adenoma weight showed significiant correlation with MIBI uptake (p=0.001). Oxyphyill cell content also showed high correlation with MIBI uptake. Delayed images showed better correlation than the early views (Early MIBI p=0.033; Delayed MIBI; p=0.001).. MIBI + Tc-99m pertechnetate interpretation is more sensitive than only dual MIBI imaging for the detection of parathyroid adenoma. Oxyphill cell content and weight of the lesions proved to be important determinants of 99mTc-MIBI accumulation in parathyroid adenoma. We found no significant correlation between MIBI accumulation, Ca, P and iPTH serum levels (Tab. 2, Fig. 2, Ref. 15). Full Text (Free, PDF) www.bmj.sk.

Topics: Adenoma; Adolescent; Adult; Aged; Female; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Young Adult

Topics: Aged; Bone Diseases, Metabolic; Calcium; Carcinoma; Humans; Male; Neoplasm Recurrence, Local; Parathyroid Hormone; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

The most common etiologic factor of primary hyperparathyroidism is a solitary parathyroid adenoma that might be located in the mediastinum. The mediastinally located ectopic parathyroid adenomas are often out of reach with a cervical incision and require a thoracic approach. We present a case of 55 year-old female patient with a parathyroid adenoma located anterior to the ascending aorta within the thymus resulting in primary hyperparathyroidism. The patient underwent an extended thymectomy with intraoperative use of a gamma probe as an adjunct to surgical resection which provided the accurate localization of the parathyroid adenoma. Histologic diagnosis confirmed the tumor to be an ectopic parathyroid adenoma. The patient showed an uneventful postoperative period with decreased levels of both calcium and parathyroid hormone. We emphasize that the gamma probe serves as a very useful device to differentiate the ectopic parathyroid adenoma from surrounding tissues for complete surgical excision.

Topics: Adenoma; Choristoma; Female; Humans; Hyperparathyroidism, Primary; Mediastinal Diseases; Middle Aged; Parathyroid Neoplasms; Parathyroidectomy; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Treatment Outcome

Topics: Aged; Female; Humans; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi

Topics: Adenoma; Diagnosis, Differential; Humans; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Ultrasonography

To determine the sensitivity and positive predictive value (PPV) of subtraction scintigraphy (SS) vs. ultrasonography (US) of the neck combined with rapid intact parathyroid hormone (iPTH) assay in US-guided fine-needle parathyroid aspirates in preoperative localization of parathyroid adenomas and in directing surgical approach.. The results of SS for localization of parathyroid adenoma were determined in 121 patients with primary hyperparathyroidism (pHPT) and compared with findings at surgery and with the results of US alone (in patients without nodular goitre) and US in combination with the iPTH assay in US-guided fine-needle aspirates (FNAs) of suspicious parathyroid lesions (in patients with concomitant nodular goitre).. All 121 patients had biochemically documented pHPT; all were referred for first-time surgery.. SS was performed with 99mTc-sestamibi and 99mTc-pertechnetate. High-resolution US of the neck was performed by a single endocrine surgeon and combined with US-guided FNAs of suspicious parathyroid lesions in all patients with nodular goitre (n = 43).. The sensitivity and PPV of SS were significantly higher in patients without vs. with goitre (89.3% and 95.7%vs. 74.3% and 76.5%, respectively; P < 0.001). The sensitivity and PPV of US were significantly higher in patients without vs. with goitre (96% and 97.3%vs. 67.7% and 71.9%, respectively; P < 0.001). The iPTH assay of US-guided FNAs of suspicious parathyroid lesions in patients with nodular goitre significantly improved both the sensitivity and PPV of US imaging (90.7% and 100%, respectively), allowing for an accurate choice of surgical approach in 118 (97.5%) of 121 patients. SS was more accurate than US alone in detection of ectopic parathyroid adenomas. However, US alone was characterized by a higher sensitivity in detection of small parathyroid adenomas (< 500 mg) at typical sites (P < 0.01).. Both the sensitivity and PPV of SS and US alone are comparable, with significantly less accurate results obtained in patients with goitre. In cases of equivocal results of US and/or in patients with concomitant goitre, an iPTH assay in US-guided FNAs of suspicious parathyroid lesions may be used to establish the nature of the mass, distinguish between parathyroid and nonparathyroid tissue (goitre, lymph nodes) and improve the accuracy of US parathyroid imaging, allowing for successful directing of surgical approach in a majority of patients.

Topics: Adenoma; Adolescent; Adult; Aged; Biopsy, Fine-Needle; Chi-Square Distribution; Female; Goiter, Nodular; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Parathyroidectomy; Predictive Value of Tests; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Reproducibility of Results; Sensitivity and Specificity; Signal Processing, Computer-Assisted; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Nodule; Ultrasonography, Doppler

Dual tracer scintigraphy has become the procedure of choice for preoperative localization of parathyroid adenomas. The typical protocol used by most laboratories is to initially perform a Tc-99m sestamibi (MIBI) study with early and delayed (2-3 hours) washout phase images. This is followed by a thyroid-specific Tc-99m pertechnetate study. A potential pitfall exists if the delayed phase of the initial MIBI study shows an intense, abnormal focus of retention. This focus may interfere with interpretation of the subsequent pertechnetate study because of a "shine through" effect. To differentiate a parathyroid adenoma from a thyroid adenoma, it may be necessary to repeat the thyroid-specific pertechnetate scan on a separate day after the dual tracer study.

Topics: Adenoma; Aged; Artifacts; Diagnosis, Differential; Diagnostic Errors; Female; Humans; Image Enhancement; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Neoplasms

Minimally invasive parathyroid surgery in patients with primary hyperparathyroidism (PHPT) demands high imaging accuracy. By increasing blood flow to the parathyroid adenoma before injection of a perfusion marker, we intended to improve the parathyroid scintigraphy. We have named the technique stimulated parathyroid scintigraphy (SPS).. Twenty minutes after injection of 100 MBq (99m)Tc-pertechnetate a thyroid scintigram was performed in 25 patients with PHPT. During the thyroid scintigraphy sodium citrate was infused which lowered plasma calcium by a mean of 14 +/- 1.3%. Then 700 MBq (99m)Tc-sestamibi was injected and another scintigram of the neck was obtained. Perchlorate was given at the end of the sestamibi scintigram to increase the wash-out of (99m)Tc-pertechnetate from the thyroid gland, and after 2 h a delayed scintigram was obtained. A subtraction of the thyroid scintigram from the initial sestamibi scintigram was performed. The results of SPS and a conventional (99m)Tc-sestamibi dual-phase parathyroid scintigraphy were compared with the operative findings. In nine patients the parathyroid adenoma was also localized with ultrasound and the flow pattern before and after citrate infusion was visualized with Doppler technique.. Eighty-eight per cent of the adenomas were localized correctly with the SPS technique compared with 62% at the conventional parathyroid scintigraphy. Tissue perfusion of the nine adenomas increased after citrate infusion.. SPS has a high accuracy and it is easy to perform. If only subtraction SPS is performed the whole examination can be completed within an hour, which is acceptable for same day surgery.

Topics: Adenoma; Chi-Square Distribution; Female; Humans; Hyperparathyroidism; Hypocalcemia; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Ultrasonography

Sixty-two-year-old man was admitted to hospital for increased serum level of calcium (3.85 mmol/l) and incipient renal failure (urea 7.2 mmol/l, kreatinin 117 mumol/l). The reason of hypercalcaemia was intensive explored. Serum level of intact PTH was 383.6 pg/ml. We performed two-dimensional early and delayed (2 hours) scintigram after intravenous administration of 750 MBq 99mTc-sestamibi, i.e. double-phase technique. There was detected focus (diameter 20 mm) of increased sestamibi uptake with slow wash-out in distal part right thyroid lobe. Planar scintigraphy obtained after intravenous administration of 185 MBq 99mTc-pertechnetate detected focus of increased 99mTc-pertechnetate uptake in the same point too. Patient underwent right thyroid lobectomy. There was colloid nodular goiter. Under right thyroid lobe was detected spherical particle. This particle was ablated (diameter 20 mm, weight 4 gram). It was parathyroid adenoma. One month after ablation of parathyroid adenoma serum level of PTH was 23.1 pg/ml and serum level of calcium was 2.52 mmol/l. There was overlap of scintigraphy image of parathyroid adenoma under distal part of right thyroid lobe on 99mTc-sestamibi two-dimensional scintigram and scintigraphy image of hyperplastic node with increased activity in distal part of right thyroid lobe on 99mTc-pertechnetate two-dimensional scintigram.

Topics: Adenoma; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Gland

The incidence of parathyroid carcinoma is approximately 0.5% to 5% in patients with primary hyperparathyroidism. Recurrent parathyroid carcinoma is treated with surgical resection of all sites of disease to ameliorate systemic manifestations of hyperparathyroidism, primarily hypercalcemia. This study investigates the role of parathyroid scintigraphy and computed tomography (CT) imaging in recurrent parathyroid carcinoma.. A retrospective chart review was performed on 8 patients diagnosed with recurrent parathyroid carcinoma at our tertiary care institution between 1975 and 2001. Surgical reports, histopathology, parathyroid scintigraphy, and CT findings were recorded. Surgical reports and radiologic studies were compared for concordance of recurrence sites.. There were 32 imaging studies before reoperation: 15 parathyroid scintigraphy and 17 CTs. Of 15 sites of recurrence potentially seen on scintigraphy, 10 were true-positive (67%). Of 17 sites of recurrence potentially seen on CT, 9 were true-positive (53%). Of the 8 false-negatives on CT, 7 of these recurrences were in the surgical bed (88%). There were 9 instances in which CT and scintigraphy were performed preoperatively for comparison and correlation. CT and scintigraphic findings were incongruent in 7 of 9 of these cases (78%).. Successful surgical intervention for recurrent parathyroid carcinoma requires accurate preoperative localization studies and complete excision of metastases. Our data supports combined analysis of parathyroid scintigraphy and CT for patients with recurrent disease before reoperation. Additionally, our review suggests that sensitivity may be optimized with SPECT parathyroid scintigraphy and close correlation with CT.

Topics: Aged; False Negative Reactions; False Positive Reactions; Humans; Middle Aged; Neoplasm Recurrence, Local; Parathyroid Glands; Parathyroid Neoplasms; Preoperative Care; Radiopharmaceuticals; Retrospective Studies; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed

Topics: Adenoma; Aged; Female; Goiter, Nodular; Humans; Iodine Radioisotopes; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyrotoxicosis

Topics: Adenoma; Diagnosis, Differential; Female; Graves Disease; Humans; Hyperparathyroidism; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

Primary hyperparathryoidism is a PTH hypersecretion caused by the parathyroid glands. In most cases (85%), the origin is to be due to the existence of a parathyroid adenoma, despite the intrinsic difficulty in being localized under certain circumstances. From some time now, we can count with the invaluable help of a nuclear medicine technique, namely the parathyroid scintigraphy with Technetium 99m-sestamibi (Tc99m-MIBI), a technique which is easy to perform, cheap and with excellent results, and which additionally can provide us with the above mentioned necessary information regarding location. We present here the case of a patient suffering from primary hyperparatyiroidism, in whom both the disease and the precise location of the hyperfunctioning tissue were identified by means of the parathyroid scintigraphy. Another nuclear medicine procedure, the one known as bone scintigraphy, also contributed meaningfully to the correct diagnosis in the same patient.

Topics: Adenoma; Adult; Female; Humans; Hyperparathyroidism; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Treatment Outcome

The authors' aim was to evaluate the role of MIBI SPECT acquired just after planar pertechnetate-MIBI (TcO(4)-MIBI) subtraction scintigraphy in planning radioguided surgery in a patient with persistent primary hyperparathyroidism after initial surgery performed to treat a retrotracheal parathyroid adenoma (PA).. A 73-year-old man with persistent primary hyperparathyroidism after a previous left parathyroidectomy and left thyroid lobectomy is described. The patient was examined in our center in a single-day preoperative imaging protocol based on findings of planar TcO(4)-MIBI subtraction scintigraphy, MIBI SPECT, high-resolution neck ultrasound, and computed tomography.. Neck ultrasound did not reveal enlarged parathyroid glands. Findings of a neck-chest computed tomographic scan were also inconclusive. Instead, planar scintigraphy clearly depicted a single focus of MIBI uptake over the thyroid gland in a median position. The SPECT examination precisely localized a PA in the retrotracheal space. The day after imaging, the patient underwent unilateral left cervical surgical exploration. A 16 x 21 mm PA was easily detected using the gamma probe technique after injection of a low dose of 37 MBq (1 mCi) Tc-99m MIBI, and the PA was rapidly removed with limited surgical trauma. Rapid serum PTH and calcium levels normalized after intervention and remained in the normal range during subsequent follow-up.. The current data indicate the importance of preoperative imaging with MIBI scintigraphy in patients with primary hyperparathyroidism and strongly support the utility of MIBI SPECT acquisition in PAs located deep in the neck and in ectopic sites. Furthermore, the gamma probe can help the surgeon to detect the PA during surgery and to minimize the surgical trauma in patients who have had previous thyroid or parathyroid surgery.

Topics: Adenoma; Aged; Humans; Hyperparathyroidism; Male; Parathyroid Neoplasms; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Surgery, Computer-Assisted; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon

Because ectopic parathyroid adenoma (PA) is a frequent cause of failed initial surgery, an imaging approach with accurate preoperative localization is recommended by some authors in patients with primary hyperparathyroidism (HPT).. The authors describe a 52-year-old woman in whom primary HPT was diagnosed incidentally during a screening program for osteoporosis. The peculiarity of this case is that the patient was examined before operation in a single-day multimodal imaging protocol based on the combination of high-resolution cervical ultrasound, planar Tc-99m pertechnetate-MIBI scans, and an MIBI-SPECT-computed tomographic (CT) image fusion study. An ectopic PA was accurately located in the upper middle mediastinum, close to the lower margin of the sternal notch.. Guided by the MIBI-SPECT-CT fusion images, the surgeon performed a limited median sternotomy and easily removed the PA that was revealed before operation. To confirm the completeness of resection, a bilateral neck exploration was performed through the same incision, with identification of three normally sized parathyroid glands.. Our experience suggests the utility of multimodality imaging procedures for the accurate preoperative localization of PAs, particularly when they are present in ectopic mediastinal locations. Such procedures, including the MIBI-SPECT-CT image fusion study, can be performed in a single day.

Topics: Adenoma; Choristoma; Female; Humans; Hyperparathyroidism; Mediastinal Diseases; Middle Aged; Parathyroid Neoplasms; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Compounds; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon; Tomography, X-Ray Computed

A prospective study was performed to evaluate the efficacy of technetium-99m-sestamibi and technetium-99m-pertechnetate subtraction scanning and US for imaging parathyroid glands in primary hyperparathyroidism. Sixty-three patients were surgically treated for primary hyperparathyroidism (HPT). Preoperative scintigraphy and US were performed in all cases. Bilateral neck exploration was carried out on each patient. Results of radionuclide studies and US were compared with surgical and histological findings. In 57 patients with primary HPT the radionuclide scanning gave true-positive results. Four false-negative and two false-positive scintigrams were obtained. The sensitivity and the positive predictive value (PPV) of scintigraphy were 93 and 97%, respectively. Forty-one cases were correctly localized by the US. Seventeen US results were false negative and five were false positive. The sensitivity and the PPV for US were 71 and 89%, respectively. There was a statistically significant difference between the sensitivity of the scintigraphy compared with the US ( p=0.001). Sensitivities of radionuclide scans and US were higher for adenomas (100 and 83%) than for hyperplastic glands (75 and 40%). The sensitivity of technetium-99m-sestamibi and technetium-99m-pertechnetate subtraction scintigraphy was significantly higher compared with US. This sensitive method could help surgeons in performing a rapid and directed parathyroidectomy.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Treatment Outcome; Ultrasonography

Topics: Adenoma; Aged; Humans; Hypercalcemia; Hyperparathyroidism; Intraoperative Care; Male; Mediastinal Neoplasms; Parathyroid Glands; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Radiopharmaceuticals; Reoperation; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi

The diagnostic value of scintigraphy using a dual tracer and high-resolution neck ecotomography in the preoperative localisation of parathyroid enlargements was evaluated in a group of consecutive patients suffering from primary hyperparathyroidism (HPT) who were uniformly studied and subsequently operated by the same surgical team.. Scintigraphic imaging and high-resolution neck ecotomography were carried out in a single session on 143 patients. Scintigraphic imaging was performed using a dual tracer, 99mTc-pertechnetate/99mTc-MIBI), modified by the addition of potassium perchlorate (KCL04) to achieve a rapid washout of 99mTc04 from the thyroid and, consequently, to achieve good quality and rapid MIBI images. In a limited number of patients (21 cases) SPECT was also performed. Limited surgery was planned in patients with evidence of single parathyroid lesions and with normal thyroid parameters, in the form of either unilateral or with mini-invasive surgery (91 cases). Patients with eco-scintigraphic evidence of multiglandular parathyroid pathology or the coexistence of a nodular thyroid goitre, or in patients suffering from MEN or familial HPT, or lastly those with negative eco-scintigraphic results under-went more extensive surgery with bilateral exploration of the neck (52 cases). A single parathyroid lesion was diagnosed during surgery in 90 out of 91 patients undergoing planned unilateral or mini-invasive exploration of the neck. Therefore, in our experience, the predictive value of preoperative imaging as a mean of identifying single parathyroid lesions was 98.9% with a clear impact on the choice of conservative surgery. After the removal of the parathyroid to which preoperative imaging referred, it was only necessary in one patient to extend surgical exploration to the other side of the neck to remove another enlarged parathyroid owing to persistent high PTH.. The sensitivity of scintigraphy and high-resolution neck ecotomography in pa-tients with a single adenoma was 94% and 83.7% respectively, whereas it was 76.9% and 64.5% respectively in the group of patients with multiglandular pathology. It is worth underlining that in all 31 patients with associated nodular thyroid pathology, the evaluation of thyroid scintigraphic imaging using 99mTc04 and high-resolution neck ecotomography enabled the preoperative diagnosis of thyroid pathology, therefore guiding the surgeon towards more extensive surgery. SPECT enabled the parathyroid adenoma to be correctly localised in a deep site in 5 patients, in the neck in 3 cases and at the mediastinum in 2 patients, providing additional data that helped the surgeon to plan surgery.. In conclusion, in our experience: a) an integrated diagnostic approach based on scintigraphy 99mTc04 & KCLO4/MIBI and high-resolution neck ecotomography was an extremely accurate mean of identifying patients with single parathyroid lesions before surgery, enabling them to undergo limited surgery, b) scintigraphy with a dual tracer might be the elective methods for studying patients with HPT because it allows the contemporary diagnosis of possible thyroid diseases. This aspect is extremely important in geographical areas with a high predominance of nodular thyroid pathology, c) SPECT scintigraphic analysis may be useful in some patients with suspected parathyroid adenoma localised in a deep seat, allowing a more precise identification of the latter and better surgical planning.

Topics: Adenoma; Adult; Aged; Carcinoma; Female; Follow-Up Studies; Humans; Hyperparathyroidism; Male; Mediastinum; Middle Aged; Multiple Endocrine Neoplasia Type 1; Neck; Parathyroid Neoplasms; Parathyroidectomy; Perchlorates; Potassium Compounds; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon; Ultrasonography

The contribution of nuclear-medical mapping using 99mTc-MIBI (MIBI) and the use of an intraoperative probe in primary hyperparathyroidism (I degrees HPT) surgery was evaluated prospectively in a series of patients undergoing parathyroidectomy.. Fifty-four patients, who were operated between May 1999 and July 2000, under-went a systematic preoperative evaluation using scintigraphy with a dual tracer 99Tc04/MIBI and image subtraction, and high-resolution neck ecotomography. Surgery was performed using a mini-invasive technique through an incision measuring 2-2.5 cm at the base of the neck in 46 patients; the other 8 patients underwent open surgery with bilateral exploration of the neck. MIBI was injected intravenously in the operating theatre following the induction of anesthesia and after 32 minutes on average, radioactivity was measured using a manual gamma probe. Radioactivity was also counted intraoperatively at the tip of the lung contralateral to the pathological gland, a parameter used as the base activity (B), in the presumed seat of the hyperfunctioning parathyroid (P), in correspondence with healthy thyroid tissue (T) and any associated thyroid nodes (N). Radioactivity was also recorded at the level of the empty parathyroid compartment after removal of the corresponding gland, and on the parathyroid removed ex vivo .. The ratio between the three main parameters, T/B, P/B and P/T was respectively 1.6 (range=1.5 - 1.8), 2.7 (range=1.6-4.0) and 1.6 (range=1.1-2.8). In 4 cases (7.4%), the small size of the parathyroids, adjacent to thyroid nodes, meant that the parathyroid measurement of MIBI was smaller than the thyroid measurement. The histological finding was consistent with: single parathyroid adenoma in 49 cases, multiple adenomas in 3 cases, parathyroid carcinoma in 2 cases. Rapid intraoperative PTH normalised in all patients.. The significant difference in radioactivity levels recorded in the patients, showed that the technique is useful to the surgeon as a means of intraoperative assay for hyperfunctioning parathyroids, even if it cannot obviously replace experience or the value of preoperative scientigraphic and ecotomographic imaging.

Topics: Adenoma; Adult; Aged; Carcinoma; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Parathyroidectomy; Prospective Studies; Radiology, Interventional; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Ultrasonography

A series of 253 consecutive patients with proved primary hyperparathyroidism due to parathyroid tumours was reviewed. There were 68 (26.9%) men and 185 (73.1%) women, with a median age of 57 years (range 13-82 years). All patients, prior to successful parathyroidectomy, underwent one or more preoperative localization procedures such as: neck ultrasonography (US) in 191 (75.5%), (201)Tl/(99m)Tc-pertechnetate subtraction scintigraphy (TPS) in 144 (56.9%), CT scan in 92 (36.4%), (99m)Tc-sestamibi/(99m)Tc-pertechnetate subtraction scintigraphy (MPS) in 90 (35.6%), selective venous sampling (SVS) with parathyroid hormone (PTH) assay in 30 (11.9%), and magnetic resonance imaging (MRI) in 6 (2.4%) patients. The results were compared with operative and histological findings that showed 235 (92.9%) solitary parathyroid adenomas, 13 (5.1%) carcinomas and 5 (2.0%) double adenomas. Sensitivity and positive predictive value were 82.9% and 93.8% for US, 83.6% and 91.8% for TPS, 81.3% and 98.7% for CT scan, 85.1% and 96.1% for MPS, 65.4% and 80.9% for SVS, and 80.0% and 80.0% for MRI respectively. No different results (P=NS) were found using US, TPS, MPS or CT scan, whereas SVS and MRI sensitivity was lower (P<0.05). The combination of MPS and US was 94.0% sensitive (P<0.05) but when TPS, CT scan or MRI were also used overall sensitivity did not improve significantly (P=NS). In conclusion, MPS should be used as the starting preoperative localization procedure, while US and MPS together represent the most reliable noninvasive localization tool. If MPS and US are negative or not in agreement, further studies are not cost-effective and the patient should undergo bilateral neck exploration.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Calcium; Female; Humans; Hyperparathyroidism; Magnetic Resonance Imaging; Male; Middle Aged; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Tomography, X-Ray Computed; Ultrasonography

Topics: Humans; Parathyroid Glands; Parathyroid Neoplasms; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Thallium; Thallium Radioisotopes; Tomography, Emission-Computed, Single-Photon

The main purposes of this study were: (a) to investigate the efficacy of an imaging protocol based on the combination of 99mTcO4/MIBI scintigraphy and neck ultrasound (US) in selecting patients with primary hyperparathyroidism (HPT) for unilateral neck exploration, and (b) to help define the role of the intraoperative MIBI gamma probe (IMGP) technique in the performance of minimally invasive radio-guided surgery (MIRS). One hundred and forty-three consecutive patients with primary HPT were enrolled in the study. We used a modified 99mTcO4/MIBI scintigraphic procedure which included the oral administration of potassium perchlorate to cause rapid 99mTcO4 washout from the thyroid tissue, thereby permitting the acquisition of high-quality early MIBI images. A single-photon emission tomography (SPET) acquisition was also obtained in 21 patients, of whom seven had an enlarged parathyroid gland (EPG) in the mediastinum at planar scintigraphy and 14 had discordant scan/US findings for the presence of a cervical EPG. Neck US was performed in the same session as scintigraphy using a small-parts, high-resolution 10-MHz transducer. All patients were then operated on by the same surgical team. Quick PTH assay (QPTH) was used to measure PTH intraoperatively to confirm successful parathyroidectomy. In patients with scan/US evidence of a solitary EPG and with a normal thyroid gland, limited, unilateral neck surgery or, more recently, MIRS was planned (n=91). In patients with scan/US evidence of multiglandular disease (MGD) (n=21) or concomitant nodular goitre (n=24) or in patients with a negative scan/US evaluation (n=7), extensive bilateral neck exploration was planned (n=52). In 87 of the 91 patients (95.6%) in whom preoperative imaging indicated the presence of a solitary EPG and a normal thyroid gland, a single parathyroid adenoma was found at surgery, and these patients were treated by unilateral neck exploration or MIRS. In the remaining four patients of this group, conversion to bilateral neck exploration was required because parathyroid carcinoma (n=3) or MGD (n=1) was diagnosed at operation. In some cases SPET was helpful in better localising the EPG. In particular, in 5 of the 21 patients evaluated, SPET localised an EPG deep in the neck or mediastinum and at surgery a parathyroid adenoma was found in the paratracheal or para-oesophageal space. In 43 of the 46 patients (93.5%) who were candidates for MIRS, the IMGP technique allowed parathyroidectomy to be perf

Topics: Adenoma; Adult; Aged; Female; Gamma Cameras; Humans; Hyperparathyroidism; Intraoperative Period; Male; Middle Aged; Minimally Invasive Surgical Procedures; Parathyroid Glands; Parathyroid Neoplasms; Parathyroidectomy; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon; Ultrasonography

Topics: Adenoma; Adult; Humans; Hypercalcemia; Male; Mediastinal Neoplasms; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m

Tl-201 and Tc-99m subtraction imaging is a well-established technique for detecting parathyroid adenomas. We report a case of a brown tumor of the upper sternum mimicking an ectopic mediastinal parathyroid adenoma on Tl-201 and Tc-99m subtraction imaging in a patient with hyperparathyroidism. This brown tumor showed Tl-201 uptake but not Tc-99m uptake and thus did not subtract out in this scan.

Topics: Adenoma; Adult; Female; Fibrous Dysplasia of Bone; Humans; Hyperparathyroidism; Mediastinum; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Sternum; Subtraction Technique; Thallium Radioisotopes

We set up a modified technetium-99m (Tc-99m) pertechnetate/Tc-99m MIBI (Tc-MIBI) subtraction scintigraphy for parathyroid imaging by introducing the use of potassium perchlorate (KCLO4). Initially, the effect of KCLO4 on technetium thyroid wash-out was evaluated in five healthy volunteers: 40-minute dynamic studies of the thyroid were obtained 20 minutes after the injection of technetium 150 MBq (4 mCi), both in baseline conditions and after the oral administration of 400 mg KCLO4. After an average latency time of 10.5 minutes, KCLO4 administration resulted in fast and relevant technetium thyroid wash-out with a mean half-time of 16.2 minutes (the half-time was 142.8 minutes in baseline conditions), and a 40-minute reduction of thyroid activity of 78% (it was 14% in baseline conditions). Based on these findings, a new Tc-MIBI subtraction procedure was established as follows: 1) 150 MBq technetium (4 mCi) injection; 2) 400 mg KCLO4 administered orally; 3) patient neck immobilization; 4) acquisition of a 5-minute technetium thyroid scan; 5) 500 MBq MIBI (13.5 mCi) injection; 6) acquisition of a sequence of seven MIBI images, each lasting 5 minutes; and 7) processing (image realignment when necessary, background subtraction, normalization of MIBI images to the maximum pixel count of the technetium image, and subtraction of the technetium image from the MIBI images). In addition, high-resolution neck ultrasound (US) was performed in all cases on the same day as the scintigraphic evaluation. Eighteen consecutive patients with primary hyperparathyroidism were enrolled in the study. Tc-MIBI scintigraphy revealed a single adenoma in all cases and US showed this finding in 15 of 18 cases (83.3%). Furthermore, in three patients, a thyroid nodule associated with hyperparathyroidism was detected by technetium thyroid scans and neck US. In all patients, the parathyroid adenoma was easily identified on both the 20- to 40-minute MIBI and subtracted (MIBI-Tc) images. Regarding the scintigraphic parameters, no difference was found between parathyroid adenomas located in the region of the thyroid bed or in ectopic sites and in parathyroid adenomas with a retrothyroid location. Surgical findings confirmed the presence of a single parathyroid adenoma in all cases. In the three patients with a concomitant thyroid nodule, thyroid lobectomy was performed. These preliminary data suggest that 1) double-tracer subtraction scintigraphy, combined with neck US, appears to be the pref

Topics: Adenoma; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Perchlorates; Potassium Compounds; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Time Factors

Technetium-99m-((99m)Tc-) tetrofosmin, a cationic, lipophilic complex like (99m)Tc-sestamibi, has proved to be a potential tracer for parathyroid scintigraphy despite some differences in washout behavior from the thyroid gland. Previous results comparing a double-phase technique with single-proton emission computed tomography (SPECT) or with subtraction techniques demonstrated a high detection rate, especially when SPECT and subtraction techniques were used, whereas the double-phase protocol revealed only moderate results. In this study, a direct comparison was made between (99m)Tc-tetrofosmin/pertechnetate subtraction and SPECT to elucidate the optimal protocol for tetrofosmin parathyroid imaging.. Twenty-three patients who were biochemically suspected of parathyroid adenoma or hyperplasia due to primary or tertiary hyperparathyroidism were included in our study. In all patients, serum calcium, phosphate, and intact parathormone levels were analyzed in a single blood sample before (99m)Tc-tetrofosmin/pertechnetate subtraction scintigraphy and SPECT. Ultrasound of the neck was performed in all patients to exclude false-positive results due to thyroid adenomas. All patients underwent parathyroidectomy with intraoperative revision of all parathyroid glands, and the histological results were compared with preoperative findings.. Both imaging modalities, ie, subtraction scintigraphy and SPECT, correctly identified 20 of 23 (87%) histologically confirmed adenomas preoperatively. The positive predictive value was calculated to be 95% and 100%, respectively, for these two methods. Subtraction scintigraphy and SPECT showed concordant results in 19 patients (18 positive, 1 false-negative) and discordant results in 4 patients (2 positive with subtraction, 2 with SPECT). The combined use of subtraction scintigraphy and SPECT techniques revealed a sensitivity of 95.7% (22/23) and a positive predictive value of 95%. The whole procedure can be performed in less than 90 minutes per patient. Whereas subtraction scintigraphy tended to show more false-positive retentions due to thyroid adenomas, the interpretation of SPECT may be difficult in small adenomas with missing thyroid/parathyroid differential washout.. Both imaging modalities, subtraction scintigraphy with pertechnetate and SPECT, are highly sensitive methods for parathyroid adenoma localization with (99m)Tc-tetrofosmin. However, our study did demonstrate that a combination of both modalities can further improve the diagnostic accuracy. Especially in an endemic goiter area, additional ultrasound may be required to avoid false-positive results due to thyroid adenomas.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Female; Goiter, Endemic; Humans; Hyperparathyroidism; Male; Middle Aged; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Neoplasms; Parathyroidectomy; Predictive Value of Tests; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Tomography, Emission-Computed, Single-Photon; Ultrasonography

We report the case of a patient with a laryngeal carcinoma in whom asymptomatic hyperparathyroidism was also detected during the preoperative work-up. A planar (201)Thallium/(99m)Tc-pertecnetate subtraction scintigraphy was performed in order to locate the suspected parathyroid adenoma. The study showed a single area of increased (201)Thallium uptake just above the thyroid isthmus, likely due to the laryngeal tumor. The scintigraphic study was repeated using (99m)Tc-Sestamibi and (99m)Tc-pertechnetate and employing the SPECT technique. Both SPECT studies made it possible to identify correctly the parathyroid adenoma, located inferiorly and in a posterior position to the lower third of the right thyroid lobe. The laryngeal tumor and parathyroid adenoma could be excised in a single surgery session. This case is of interest due to the rarity of the coexistence of two neck tumors and the clear advantage shown by the SPECT technique with (99m)Tc-Sestamibi over the planar technique with 201Thallium.

Topics: Adenoma; Aged; Carcinoma, Squamous Cell; Humans; Hyperparathyroidism; Laryngeal Neoplasms; Laryngectomy; Male; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Parathyroidectomy; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Tomography, Emission-Computed, Single-Photon

Two cases of papillary thyroid carcinoma coexisting with a parathyroid adenoma are reported. A double-tracer pertechnetate-MIBI subtraction scan combined with neck ultrasound correctly visualized the site of the parathyroid adenoma despite the presence of thyroid nodule(s) located in the opposite thyroid lobe in one case and in both thyroid lobes in the other case. In both patients, the papillary thyroid carcinoma was cold with Tc-99m pertechnetate and hot with MIBI. Total thyroidectomy and parathyroidectomy of a solitary parathyroid adenoma were performed in both patients. Pertechnetate-MIBI subtraction scanning associated with neck ultrasound appears to be a useful imaging technique to detect parathyroid adenoma before operation in patients with concomitant thyroid nodular disease. A MIBI-hot and Tc-99m pertechnetate-cold thyroid nodule can indicate the possible presence of a malignant lesion.

Topics: Adenoma; Aged; Carcinoma, Papillary; Female; Humans; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thyroid Neoplasms; Thyroid Nodule

A 37-year-old male with a persistent increased parathyroid hormone level, after subtotal thyroidectomy and parathyroidectomy, was referred for scintigraphic localization of a possible ectopic parathyroid adenoma. Tc-99m pertechnetate and Tc-99m MIBI scintigraphy were performed on separate days. There was marked uptake of both tracers in the mediastinum, which at surgery was confirmed to be an extrathyroidal parathyroid adenoma. Hypervascularity was suggested as a possible explanation for rare cases of pertechnetate avid parathyroid adenomas. And Tc-99m MIBI scintigraphy proved to be a successful imaging procedure for ectopic parathyroid tissue.

Topics: Adenoma; Adult; Choristoma; Humans; Male; Mediastinal Neoplasms; Mediastinum; Parathyroid Glands; Parathyroid Neoplasms; Radioactive Tracers; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

The aim of the study was to quantitatively compare the scintigraphic images of the thyroid and abnormal parathyroid glands obtained with technetium-99m tetrofosmin and thallium-201 in patients with hyperparathyroidism. Forty-six patients with hyperparathyroidism underwent (201)Tl (74 MBq), (99m)Tc-pertechnetate (74 MBq) and (99m)Tc-tetrofosmin (555-740 MBq) scintigraphy in a single session. Image analysis included the computation of the thyroid/background ratio in the whole study population and the parathyroid/background ratio, parathyroid/thyroid ratio and diagnostic sensitivity in 17 patients who underwent parathyroid surgery. The pertechnetate subtraction technique was used. (201)Tl and (99m)Tc-tetrofosmin showed a similar thyroid/background ratio (1.79+/-0.41 and 1.81+/-0. 47, respectively, P=NS); however, (99m)Tc-tetrofosmin showed a higher parathyroid/background ratio than (201)Tl (2.06+/-0.54 vs 1. 79+/- 0.50, P=0.007). Despite the superior quality of (99m)Tc-tetrofosmin images, both tracers showed identical sensitivity in detecting enlarged parathyroid glands in patients with primary hyperparathyroidism (89%) and in those with secondary hyperparathyroidism (50%).

Topics: Adenoma; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Male; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroid Gland

The aim of the work was to study the diagnostic value of Tc-99m tetrofosmin to localize anomalous parathyroid glands in patients with hyperparathyroid disease.. We studied 31 patients, 19 with primary and 12 with secondary hyperparathyroid disease. Five of these patients were renal graft recipients. All patients underwent surgery. Each patient was injected with 555 to 740 MBq (15 to 20 mCi) Tc-99m tetrofosmin. Subsequently, radionuclide images were acquired 15 and 120 minutes after injection using a low-energy, all-purpose, parallel-hole collimator. Pertechnetate thyroid scintigraphy was obtained in nine cases (24 to 48 h later) when the thyroid activity made it difficult to identify the parathyroid glands.. All cases showed tracer uptake as early as 15 minutes after injection. In the group of patients with primary hyperparathyroid disease, 15 showed focal uptake in a parathyroid gland, and surgery revealed an adenoma in the same location. In one patient with hyperplasia, scintigraphy identified only two of four diseased glands. In the three remaining cases, scintigraphy showed focal uptake in the lower parathyroid gland, whereas at surgery the abnormal gland was located in the upper pole. In the secondary hyperparathyroidism group, seven patients showed diffuse tracer uptake in two or more glands, and histologic analysis confirmed hyperplasia in all of them. Five cases showed focal uptake, with three evaluated after surgery (uptake in the only remaining gland); one of them was a renal graft recipient, and the remaining patient had chronic renal failure and was receiving hemodialysis.. Our results suggest that Tc-99m tetrofosmin may be a suitable tracer for preoperative detection and screening of anomalous parathyroid glands. The earlier images at 15 minutes were better than those at 120 minutes. Tc-99m tetrofosmin is cleared more slowly from the normal thyroid than is Tc-99m sestamibi, and both of these tracers may give better results than the old pertechnetate TI-201 subtraction technique.

Topics: Adenoma; Adult; Aged; Evaluation Studies as Topic; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Hyperplasia; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Renal Dialysis; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Thyroid Gland; Time Factors

Topics: Adenoma; Diagnosis, Differential; Esophagus; Female; Humans; Magnetic Resonance Imaging; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Gland

In primary hyperparathyroidism (pHPT), parathyroidectomy is the treatment of choice, but anatomic variations of ectopic glands may cause surgical failure. Reliable preoperative noninvasive localization procedures would have a positive impact on the operative time and increase recovery rate. We retrospectively evaluated 186 patients with pHPT who were studied before successful parathyroidectomy by double tracer scintigraphy (99mTc-pertechnetate+201TI chloride or 99mTc-pertechnetate +99mTc-sestamibi, 160 patients), ultrasonography (148 patients) and computerized tomography (CT) scan (92 patients). During bilateral neck exploration, 159 (85.5%) single adenomas, 6 (3.2%) parathyroid carcinomas, and 3 (1.6%) double adenomas were found. Moreover, 18 (9.7%) patients had diffuse chief cells parathyroid hyperplasia. Removed parathyroid glands were in ectopic sites in 41 (22.0%) cases, mainly localized in the upper mediastinum or behind the esophagus. The overall sensitivity was 83.5 and 85.2% for 99mTc-pertechnetate+201TI chloride and 99mTc-pertechnetate+99mTc-sestamibi scintigraphy respectively, 80.4% for CT scan and 81.1% for ultrasonography. In patients with ectopic glands, sensitivity was 81.2, 79.5, 73.3 and 81.6% respectively. In 36 out of 41 patients with ectopic glands in whom the removed parathyroids were correctly localized, mean operative time was 95 min, and in 5 patients without preoperative localization it was 260 min. In conclusion, in pHPT, preoperative localization of an enlarged parathyroid is helpful, especially in ectopic adenomas and in anatomic variations in location, and it has been proved to reduce operative time and morbidity rate.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Carcinoma; Evaluation Studies as Topic; Female; Humans; Hyperparathyroidism; Intraoperative Period; Male; Middle Aged; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Retrospective Studies; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium; Thallium Radioisotopes; Tomography, X-Ray Computed; Ultrasonography

Primary hyperparathyroidism is a disease of uncertain etiology that results from hypersecretion of parathyroid hormone (PTH) by the parathyroid gland. In most institutions, the preferred imaging protocol utilizes a dual-phase technique with Tc-99m sestamibi which is reported to be more sensitive than earlier protocols involving TI-201 with Tc-99m pertechnetate subtraction. The purpose of this study is to evaluate the accuracy and clinical utility of Tc-99m sestamibi dual-phase scintigraphy for localizing hyperfunctioning parathyroid tissue.. We retrospectively reviewed thirty-nine consecutive hyperparathyroid patients who received a dual-phase Tc-99m sestamibi parathyroid scan. Thirty-seven of the subjects subsequently underwent a bilateral neck exploration and parathyroidectomy. Each scan interpretation was then correlated with the histopathologic diagnosis and the patients' post-surgical clinical course.. The sestamibi dual-phase imaging protocol correctly localized 21 of 25 parathyroid adenomas and identified 8 out of 10 cases of hyperplasia. Our overall sensitivity and specificity were 83% and 75%, respectively. In addition, four of the adenomas were successfully localized intraoperatively using a gamma probe.. Parathyroid imaging with sestamibi appears to be superior to TI-201/Tc-99m pertechnetate subtraction based on the reported results of both techniques at various institutions. Dual-phase sestamibi imaging appears to be useful and cost-effective for presurgical localization of hyperfunctioning parathyroid tissue. In addition, sestamibi imaging in conjunction with an intraoperative probe is a very promising technique that has the potential to provide both localization information of a suspected parathyroid adenoma and to facilitate its surgical removal by reducing operation time.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Hyperplasia; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Parathyroidectomy; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes

The aim of the work was to study the diagnostic value of 99mTc-tetrofosmin to localize anomalous parathyroid glands in patients with hyperparathyroidism.. We have studied 33 patients: 12 with primary and 21 with secondary hyperparathyroidism, 9 of them renal graft recipients. Sixteen patients underwent surgery, 12 with primary and 4 with secondary hyperparathyroidism. All patients were injected with 740 MBq of 99mTc-tetrofosmin. Subsequently at 15, 30 and 60 minutes images were acquired for 300 seconds using a pin-hole collimator. A pertechnetate thyroid scintigraphy was obtained in 7 cases (24-48 h later) when the thyroid activity made difficult the identification of parathyroid glands.. In the group of patients with primary hyperparathyroidism, all cases showed a focal uptake in lower right localization. In the secondary hyperparathyroidism group, 12 patients showed diffuse tracer uptake in two or more glands and histology confirmed hyperplasia in four of them. Seven cases showed a greater focal uptake in a gland: two of them were renal graft recipients and three were chronic renal failure cases in haemodyalisis, and two were evaluated postsurgery showing uptake in the remnant parathyroid gland. The two remaining patients had a normal scintigraphy and corresponded to two false negative cases. In conclusion, our results suggest that 99Tc-tetrofosmin may be used as a suitable tracer for preoperative detection and screening of anomalous parathyroid glands.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Hyperplasia; Kidney Failure, Chronic; Kidney Transplantation; Male; Middle Aged; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Postoperative Complications; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Thyroid Gland

The efficacy of 99mTc-tetrofosmin for the detection of parathyroid lesions was investigated prospectively in patients with hyperparathyroidism referred for surgical treatment.. Twenty-seven patients with primary and 18 with tertiary hyperparathyroidism were studied. Twelve patients had undergone one or more previous neck explorations. Static imaging with 201Tl was performed first, immediately followed by a 30-min 99mTc-tetrofosmin dynamic study. Delayed views of up to 3 hr postinjection were also obtained. Technetium-99m-pertechnetate was used for thyroid delineation. The tetrofosmin/99mTc-pertechnetate subtraction scan (TF/TC), the single-tracer washout technique and the thallium/technetium subtraction (TL/TC) were compared. Quantification of relative uptakes of tracers in the thyroid and abnormal parathyroids was accomplished by measuring activity within regions of interest. Kinetics of tetrofosmin in the thyroid and abnormal parathyroids were studied by evaluating the plots of the parathyroid to thyroid ratios against time as well as by calculation of the half-clearance times from the slow component of the time-activity curves.. The overall sensitivity, specificity and accuracy of TF/TC and TL/TC were 76%, 92% and 83% and 52%, 85% and 65%, respectively. The respective sensitivities were 87% and 70% for adenomas and 72% and 46% for hyperplasia. The parathyroid-to-thyroid activity ratios of tetrofosmin were significantly higher than those of thallium (p < 0.001). The tetrofosmin single-tracer washout study was less accurate than the subtraction technique (overall sensitivity and specificity, 70% and 69%, respectively). The washout properties of tetrofosmin in abnormal parathyroids were not substantially different from those in the thyroid, with a few exceptions (p = 0.4). No correlation of half-clearance times with parathyroid size, degree of early uptake, parathyroid hormone levels or histology could be established. Comparing adenomas to hyperplasia in respect to tetrofosmin retention, a statistically significant difference was observed (p = 0.005).. Technetium-99m-tetrofosmin is suitable for parathyroid imaging. The kinetic properties of this agent in parathyroid and thyroid tissues do not warrant differential washout protocols. The diagnostic impact of the observed difference in tetrofosmin kinetics between parathyroid adenomas and hyperplasia requires further investigation.

Topics: Adenoma; Female; Humans; Hyperparathyroidism, Secondary; Hyperplasia; Male; Middle Aged; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Prospective Studies; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes; Thyroid Gland; Time Factors

The authors report two cases of parathyroid imaging with double-phase Tc-99m sestamibi used in conjunction with Tc-99m pertechnetate that detected parathyroid hyperplasia when the wash out rate of MIBI from the glands paralleled normal thyroid tissue. Routine use of thyroid images for comparison may avoid this pitfall. The authors also observed that Tc-99m sestamibi has early uptake in brown tumors.

Topics: Adult; Female; Humans; Hyperparathyroidism; Hyperplasia; Lipoma; Male; Multiple Endocrine Neoplasia Type 1; Parathyroid Neoplasms; Pseudohypoparathyroidism; Radiography; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Gland; Tomography, Emission-Computed, Single-Photon

Topics: Adenoma; Humans; Hyperparathyroidism; Methods; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Neoplasms; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Time Factors; Tomography, Emission-Computed, Single-Photon

This study retrospectively reviews 60 cases of primary hyperparathyroidism, 21 of whom underwent technetium 99 sestamibi scanning and 10 of whom underwent thallium 201/technetium 99 pertechnetate scanning preoperatively. The sestamibi and thallium scans demonstrated an 89.5% and a 62.5% sensitivity rate for adenoma, respectively. Neither scan demonstrated hyperplastic glands well. Although the scans localized adenomatous glands to the correct side well, the ability to localize them more discretely was 68.4% and 62.5%, respectively. In cases of solitary adenoma the effect of an accurate preoperative scan on operative time for bilateral exploration was not significant, whereas the experience of the attending surgeon was significant. Also, the cost of the scans at our institution was greater than the cost of the time saved in performing even unilateral neck exploration. Thus preoperative radionuclide scanning is not cost-effective for the initial exploration of patients with primary hyperparathyroidism and is insufficiently sensitive to make routine unilateral neck exploration for adenoma consistently effective.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Cost-Benefit Analysis; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Retrospective Studies; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes

Parathyroid scintigraphy with the new myocardial perfusion radiopharmaceutical 99mTc-tetrofosmin was compared with 99mTc-sestamibi scintigraphy using early and delayed imaging.. The two preparations were administered on different days to the same 16 patients suffering from primary hyperparathyroidism. Anterior view gamma camera planar imaging (10-min acquisition) was performed in the period between 5 min and 3 hr after administration of the radiopharmaceutical. For most of the patients, a pertechnetate image of the thyroid was available for eyeball comparison when reading the tetrofosmin and sestamibi images. Imaging results were compared with those from histopathological examination after surgery.. On early images, all the adenomas visualized with sestamibi were equally well seen with tetrofosmin and vice versa. In 6 of 11 scintigraphically detected neck adenomas, delayed imaging improved the adenoma visualization with sestamibi. In contrast, this differential washout was never seen with tetrofosmin. Histopathological examination of excised tissue specimens after neck exploration (15 patients) or thoracotomy (one patient) revealed a parathyroid adenoma in all 16 patients. Our 12 scintigraphic findings were true-positives, while the remaining four scintigraphies were false-negatives, giving a diagnostic sensitivity of 75% with both preparations. The mediastinal adenoma was detected in a patient with a history of two unsuccessful neck explorations and one unsuccessful thoracotomy.. Tetrofosmin has the same success rate as sestamibi for detection of parathyroid adenomas on scintigrams acquired immediately after injection. In contrast to sestamibi, delayed imaging has no diagnostic impact. Moreover, the thyroid/ parathyroid differential washout of sestamibi failed in 5 of 11 neck adenomas here detected, indicating that delayed sestamibi washout is an unreliable diagnostic criterion. Therefore, whether sestamibi or tetrofosmin is preferred for parathyroid scintigraphy, thyroid scintigraphy seems mandatory.

Topics: Adenoma; Aged; Female; Humans; Hyperparathyroidism; Male; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thyroid Gland; Time Factors

The ability of 99mTc-pertechnetate/sestamibi subtraction, double-phase 99mTc-sestamibi and 99mTc-sestamibi SPECT imaging to localize abnormal parathyroid tissue was compared.. Fifty-five consecutive patients had parathyroid imaging before surgery for hyperparathyroidism. Imaging consisted of 99mTc-pertechnetate pinhole images of the neck followed by 99mTc-sestamibi pinhole images of the neck and parallel-hole images of the neck and chest (early images). Within 2.5-4.0 hr later pinhole images of the neck, parallel-hole and SPECT images of the neck and chest were obtained (late images). Nodular foci of increased sestamibi activity were considered abnormal.. The sensitivity for abnormal parathyroid glands by visual comparison of early images and pertechnetate images was 72%-75%, late images and pertechnetate images was 73%-78% and double-phase (early and late) sestamibi images was 62%-65%; computer subtraction of pertechnetate from early images was 71%-74%; and SPECT imaging was 79%. The sensitivity for parathyroid adenomas was 89%-98%, while the sensitivity for hyperplastic parathyroid glands was only 47%-58%.. Late imaging, computer subtraction and SPECT may not be necessary since they provided only marginal improvements on visual comparison of early sestamibi with pertechnetate images. Double-phase sestamibi imaging was less sensitive, so baseline thyroid imaging with pertechnetate is recommended.

Topics: Adenoma; Evaluation Studies as Topic; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radiopharmaceuticals; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon

Topics: Adenoma; Carcinoma, Papillary; Choristoma; Female; Goiter, Nodular; Humans; Hyperparathyroidism; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes; Thyroid Neoplasms

We retrospectively studied the results of diagnostic imaging using 3 different modalities to determine their usefulness for preoperative localization of the parathyroid, and whether accurate preoperative localization information could be used to modify the surgical approach for parathyroidectomy in patients with primary hyperparathyroidism.. Images of 37 parathyroid adenomas or hyperplasias in 35 patients with primary hyperparathyroidism were obtained using ultrasonography, computed tomography, and subtraction scintigraphy (using thallium 201 [thallous chloride] and either iodine 123 or technetium 99m pertechnetate [99mTcO4-]).. Approximately three fourths of the adenomas or hyperplasias were successfully identified by ultrasound (76.7%) and computed tomography (76.4%), even when the weight of the tumor was less than 500 mg. However, subtraction scintigraphy was of limited use (61.3% successfully identified). A combination of these modalities gave excellent results for detecting adenomas and hyperplasias, leading to an accurate prediction rate of 96.0%.. We conclude that using the combination of these 3 imaging modalities is very useful for the detection of parathyroid adenomas and hyperplasias, and that with such accurate localization information, the unilateral approach alone, or even simple excision of the parathyroid tumors might be feasible, enabling less invasive surgical treatment.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Hyperplasia; Iodine Radioisotopes; Male; Middle Aged; Organ Size; Parathyroid Glands; Parathyroid Neoplasms; Preoperative Care; Radionuclide Imaging; Retrospective Studies; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Tomography, X-Ray Computed; Ultrasonography

The purpose of this study was to directly compare the efficacy of Tc-99m MIBI with TI-201/Tc-99m pertechnetate scintigraphy for localizing parathyroid adenomas in patients with primary hyperparathyroidism. Of 21 patients suspected of having primary hyperparathyroidism who had undergone both studies, 14 had subsequent surgery and pathologic correlation. Based on the surgical and pathologic results, Tc-99m MIBI yielded 13 true-positive and 1 false-negative result. Thallium-201/ Tc-99m pertechnetate imaging yielded eight true-positive, four false-negative, and two nondiagnostic studies because of lack of Tc-99m pertechnetate uptake from thyroid hormone suppression. In conclusion, Tc-99m MIBI scintigraphy is an accurate method for localizing parathyroid adenomas in patients with primary hyperparathyroidism and the results suggest that it is superior to using TI-201/Tc-99m pertechnetate.

Topics: Adenoma; Adolescent; Adult; Aged; False Negative Reactions; Female; Humans; Hyperparathyroidism; Image Enhancement; Injections, Intravenous; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sensitivity and Specificity; Single-Blind Method; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Thyroid Gland; Thyroid Hormones

The aim of this study was to evaluate whether 99Tcm-tetrofosmin is a suitable agent for parathyroid scintigraphy. Ten patients with hyperparathyroidism and two normal subjects underwent parathyroid scintigraphy with both 99Tcm-tetrofosmin and 201TI. Thyroid image subtraction was performed with 99Tcm-pertechnetate. In the 10 patients with hyperparathyroidism, the scintigraphic results were compared with the surgical findings, which showed seven parathyroid adenomas, two parathyroid adenomas with a co-existing thyroid adenoma, and one thyroid carcinoma. Both 99Tcm-tetrofosmin and 201T1 revealed eight true-positive results, one false-negative results and one false-positive result, with concordance in 8 of 10 patients. The image quality with 99Tcm-tetrofosmin of both the raw and 99Tcm-pertechnetate subtracted images was always superior compared with that with 201T1. On the basis of the diagnostic results and the favourable dosimetric characteristics, we conclude that 99Tcm-tetrofosmin is a suitable agent for parathyroid scintigraphy.

Topics: Adenoma; Adult; Aged; False Negative Reactions; False Positive Reactions; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroid Neoplasms

The uptake of Tc-99m tetrofosmin (TF) is reported in a case of parathyroid adenoma. A 65-year-old woman was studied on different days with TF, Tc-99m sestamibi (MIBI) and Tl-201 chloride (Tl). TF and MIBI injections were preceded by oral administration of potassium perchlorate. Clear identification of the adenoma was observed in all scans. No further information was obtained using a subtraction technique with Tc-99m pertechnetate. Regarding the thyroid/parathyroid ratio, different kinetics between TF and MIBI appear to be demonstrated. In particular, thyroid washout was observed with MIBI but not with TF.

Topics: Adenoma; Aged; Female; Humans; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thyroid Gland

Preoperative localization of abnormal parathyroid tissue in patients with persistent or recurrent hyperparathyroidism is recommended as a standard of care. A high percentage of these patients have ectopic tissue in the mediastinum. Tc-99m MIBI imaging alone for detection of ectopic parathyroid tissue in the mediastinum does not provide a sufficient number of anatomic landmarks, which makes communication regarding the exact location of any area of abnormal uptake difficult. We report the use of concomitant Tc-99m RBC and Tc-99m MIBI imaging for precise anatomic localization of ectopic mediastinal parathyroid tissue in 4 patients. It is thought that this combination of studies allows improved communication with referring physicians, surgeons, and radiologists for planning both surgical approach and correlative imaging studies. It is hoped that in the future this combination of studies may obviate the need for other imaging studies.

Topics: Adenoma; Aged; Choristoma; Communication; Erythrocytes; Female; General Surgery; Humans; Hyperparathyroidism; Hyperplasia; Image Enhancement; Interprofessional Relations; Male; Mediastinal Diseases; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Patient Care Planning; Radiology; Radiopharmaceuticals; Recurrence; Referral and Consultation; Sodium Pertechnetate Tc 99m; Technetium; Technetium Tc 99m Sestamibi; Tomography, Emission-Computed, Single-Photon

Topics: Adenoma; Adult; Choristoma; Female; Humans; Lymphatic Diseases; Organophosphorus Compounds; Organotechnetium Compounds; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Radiopharmaceuticals; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thymus Gland

The cost effectiveness of preoperative localization in cases of primary hyperpara-thyroidism has not been established. We analyzed the potential savings in operative time after localization with technetium 99m (99mTc) sestamibi scan.. Thirty-three patients had localization of a solitary adenoma with 99mTc-sestamibi. Measurement was made of the time required for adenomectomy, unilateral neck exploration (UNE), unilateral neck exploration and confirmation of one contralateral parathyroid gland (UNEC), or bilateral neck exploration (BNE).. The total operative time in minutes was 76.4 +/- 18.8 for adenomectomy; 87.5 +/- 20.4 for UNE; 105.6 +/- 25.0 for UNEC; and 117.9 +/- 26.7 for BNE. The time difference was significant between adenomectomy versus UNE, UNEC, and BNE. There were also significant time differences between UNE versus UNEC and BNE.. The preoperative localization of a solitary parathyroid adenoma may optimize operative time with UNE, saving approximately 30 minutes.

Topics: Adenoma; Adult; Aged; Biopsy; Cost-Benefit Analysis; Female; Humans; Hyperparathyroidism; Iodine Radioisotopes; Male; Middle Aged; Neck; Parathyroid Glands; Parathyroid Neoplasms; Parathyroidectomy; Preoperative Care; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Time Factors

The authors describe two patients in whom parathyroid adenomas were successfully localized with a Tc-99m sestamibi/pertechnetate subtraction technique, but who did not exhibit differential sestamibi retention on delayed imaging. Although the frequency of this occurrence is unclear, it suggests that some parathyroid adenomas will be missed if reliance is placed on sestamibi retention alone without simultaneous thyroid imaging.

Topics: Adenoma; Adult; Female; Humans; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi

Since 1985 we have practised scan directed unilateral cervical exploration for patients with primary hyperparathyroidism (HPT) on the basis of a solitary parathyroid adenoma, and who had a pre-operative thallium-technetium subtraction scintigram demonstrating one focus of activity (positive scan). Between 1985 and 1993, a total of 160 patients with proven HPT and a technically satisfactory scintigram underwent neck exploration. Of these, 96 had positive preoperative scans, 81 (84.4%) of which accurately predicted the site of the tumour subsequently retrieved at operation. Seventy-four (77.6%) with positive scans, and 80 of the entire group, underwent unilateral cervical exploration with removal of a presumed single adenoma. Seventy-eight (97.5%) of these patients were cured of their HPT; two patients demonstrated mild persistent hypercalcaemia. Median operating time was significantly reduced for patients having unilateral as opposed to bilateral operation. Our results suggest that, when positive, thallium-technetium subtraction scintigraphy will accurately predict the site of a solitary parathyroid adenoma in a high proportion of patients and will thus permit a unilateral parathyroid exploration in these individuals. The usefulness of the technique is limited by its low sensitivity for small tumours.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Preoperative Care; Prospective Studies; Radionuclide Imaging; Retrospective Studies; Sodium Pertechnetate Tc 99m

Radionuclide parathyroid scans are widely used to localize abnormal parathyroid glands. They are especially valuable for identifying ectopic glands, including those in the mediastinum. Two patients with hyperparathyroidism who had mediastinal glands that were not identified because only the neck was scanned prompted our review of the technique of parathyroid scanning at hospitals in our region and of the frequency of mediastinal parathyroid glands identified by scanning at our own institution. The nuclear medicine departments at 72 area hospitals were surveyed. Parathyroid scans were performed at 51 of these hospitals but only 13 (25%) routinely scanned the mediastinum and chest. At our institution 480 parathyroid scans were performed during a 9-year period. Twenty-six mediastinal parathyroid glands were identified by routine scanning of both the neck and mediastinum. Most of these glands could be removed through a cervical incision. However, four required formal thoracotomy and two thoracoscopy.. A radionuclide parathyroid scan limited to the neck is an incomplete study. Scans that do not include the thorax will miss mediastinal glands that occurred in 5 per cent of the patients in our series. Despite this, radionuclide parathyroid scanning was limited to the neck in 75 per cent of surveyed hospitals. This practice increases the chance for failed surgical exploration and increases potential patient morbidity.

Topics: Adenoma; Adult; Choristoma; Female; Humans; Hyperparathyroidism; Male; Mediastinal Diseases; Neck; Nuclear Medicine Department, Hospital; Organizational Policy; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Recurrence; Retrospective Studies; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thoracic Diseases; Thoracostomy; Thoracotomy

Technetium99m (Tc) sestamibi(mibi) has been proposed as an alternative to the standard radionuclide imaging technique of thallium 201 chloride-99mTc pertechnetate subtraction scan (TTS) in patients with primary hyperparathyroidism. In the present study, mibi was evaluated as an alternative to TTS in 37 patients who had either mibi-99mTc pertechnetate subtraction scans, mibi-iodine123 (I) subtraction scans or mibi single isotope washout scans. There were 30 females and 7 males with an average age of 57 years (range, 27-78 years). Parathyroid adenomas were found in 35 patients and hyperplasia in 2. Twenty-eight mibi scans were positive and 25 of these correctly localized the parathyroid abnormality for a sensitivity of 68% (25 of 37) and a positive predictive value of 89% (25 of 28). There were 3 false-positives (8%) and 9 false-negatives (25%). The scan was not helpful in either patient with parathyroid gland hyperplasia. Mibi-123I subtraction was the most accurate scan and was diagnostic clinically in all 7 patients studied. Mibi scans were significantly more likely to identify inferior rather than superior adenomas (P = 0.01). Twenty-seven of the 37 patients also had a TTS which was correct in only 37% of cases while the mibi scan was correct in 68% (P = 0.02). However, routine use of nuclear scanning with mibi was still not supported by these data. Further clinical evaluation of various techniques may improve accuracy. Since mibi was significantly more accurate than TTS, it should be considered preferentially when radionuclide imaging is used in patients with recurrent hyperparathyroidism.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Hyperplasia; Male; Middle Aged; Neck; Parathyroid Glands; Parathyroid Neoplasms; Predictive Value of Tests; Radionuclide Imaging; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

Topics: Adenoma; Adult; Choristoma; Female; Humans; Hypothyroidism; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroid Gland; Tongue Diseases

Topics: Humans; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

This report describes a rare case of parathyroid carcinoma associated with an adenoma. Nuclear imaging provided the most specific information about localization of the primary carcinoma and cervical metastasis, but failed to demonstrate evidence of a parathyroid adenoma. This could be explained by a partial inhibition of hormonal biosynthesis due to the high level of circulating parathormone produced by the carcinoma.

Topics: Adenoma; Carcinoma; Humans; Hyperparathyroidism; Male; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes

Enlarged cystic parathyroid glands, whether hyperfunctioning or nonfunctioning, are rare and their accurate preoperative diagnosis is a difficult task. The authors report two cases of patients with cystic neck masses studied by Tl-201-Tc-99m pertechnetate subtraction scintigraphy, computerized tomography, and ultrasonography. The diagnostic consensus of preoperative studies was that these lesions were thyroid nodules or parathyroid adenomas. Surgical removal and histopathologic examination of these masses revealed a cystic parathyroid gland and a cystic parathyroid adenoma, respectively. When a fluid-filled lesion in the neck deep to the lower pole of the thyroid gland is encountered, the possibility of a parathyroid cyst should be considered so that further diagnostic tests can be properly performed.

Topics: Adenoma; Adult; Aged; Cysts; Diagnostic Imaging; Female; Humans; Male; Parathyroid Diseases; Parathyroid Neoplasms; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Tomography, X-Ray Computed

When mild asymptomatic hypercalcemia occurs in a patient with hyperthyroidism, it may or may not be due to concurrent hyperparathyroidism and at times only the control of the hyperthyroidism will resolve the problem. Moreover, the presence of hyperfunctioning thyroid nodules will interfere with Tl-201/Tc-99m pertechnetate parathyroid scintigraphy. Initial treatment of hyperthyroidism with I-131 in this situation controls hyperthyroidism and permits successful localization of parathyroid adenomas, which may then be excised--a result that was achieved in three cases.

Topics: Adenoma; Adult; Aged; Female; Goiter, Nodular; Humans; Hypercalcemia; Iodine Radioisotopes; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroid Gland

Between 1983 and 1992 thallium-technetium subtraction scintigraphy (TTS) was performed on 74 patients with clinical and biochemical evidence of hyperparathyroidism. Twenty-five of the 53 investigations since 1988 were conducted on patients with renal failure with a suspicion of secondary hyperparathyroidism. In a retrospective study we have evaluated radioisotope scintigraphy for patients with adenoma and for renal failure patients with possible parathyroid hyperplasia. Thirty of 74 patients underwent neck exploration. Scintigraphy detected 17 of 24 parathyroid adenomas (sensitivity 71%). In contrast, in six renal patients who came to operation, scintigraphy localised only 5 of 20 hyperplastic parathyroid glands (sensitivity 25%) and in one renal patient we localised a parathyroid adenoma. A review of the literature shows low detection rates for hyperplasia by TTS to be a common observation. Based on these findings a rational approach is offered for parathyroid localisation in renal patients prior to neck exploration.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Algorithms; Female; Humans; Hyperparathyroidism, Secondary; Hyperplasia; Kidney Failure, Chronic; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Topics: Adult; Carcinoma; Deoxyglucose; Female; Fluorine Radioisotopes; Fluorodeoxyglucose F18; Humans; Parathyroid Neoplasms; Preoperative Care; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Tomography, Emission-Computed; Tomography, X-Ray Computed

Technetium-99m methoxyisobutylisonitrile (MIBI), like thallium-201, has recently been introduced as a myocardial perfusion agent and is now also showing very promising results in parathyroid scintigraphy. The results of 201Tl/99mTc-pertechnetate and 99mTc-MIBI/99mTc-pertechnetate subtraction scintigraphy, ultrasonography and computed tomography are presented in a series of 43 patients operated on for hyperparathyroidism. All four imaging modalities were confirmed to be reliable, scintigraphy being the most accurate. Sensitivities ranged from 81% to 95%, that of 99mTc-MIBI being the highest. Moreover this tracer, which has more favourable physical and also biochemical properties, yielded images of superior quality. This allowed localization of the lesion by visual inspection only in as many as 86% of the patients with positive 99mTc-MIBI/99MTc-pertechnetate subtraction scintigraphy. We believe that the higher sensitivity, superior image quality and lower cost of 99mTc-MIBI imaging will make 99mTc-MIBI the new radiopharmaceutical of choice for parathyroid scintigraphy (when one take into account the stability of labelling with large activities it is possible to perform three or four cardiac studies together with one parathyroid scintigraphic examination using one lyophilized vial).

Topics: Adenoma; Diagnostic Imaging; Humans; Hyperparathyroidism; Parathyroid Neoplasms; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes

To evaluate the efficacy of combined Tc-99m-pertechnetate and Tc-99m-sestamibi radionuclide scanning for imaging abnormal parathyroid glands in hyperparathyroid disease in a prospective study.. Established methods to localize abnormal parathyroid glands lack accuracy for routine use. Tc-99m-sestamibi used in conjunction with iodine-123 has excellent potential for preoperative imaging in patients with hyperparathyroid disease. An alternative method for parathyroid imaging was studied using Tc-99m-pertechnetate and Tc-99m-sestamibi.. Thirty patients with hyperparathyroid disease had Tc-99m-pertechnetate and Tc-99m-sestamibi subtraction radionuclide scanning to visualize abnormal parathyroid glands before surgery. The patients had surgery and pathologic confirmation of all parathyroid glands.. In 23 patients with primary hyperparathyroidism, 12 of 13 solitary adenomas were visualized. Six of nine patients with diffuse hyperplasia had bilateral uptake consistent with diffuse hyperplasia. Three of nine patients had negative scans. One patient previously operated on for diffuse hyperplasia had only one gland scanned. Seven patients with renal failure-associated hyperparathyroid disease were scanned: five had bilateral uptake of Tc-99m-sestamibi consistent with hyperplasia, and two who had been previously operated on had localization of remaining abnormal parathyroid glands.. Tc-99m-pertechnetate combined with Tc-99m-sestamibi subtraction radionuclide scanning is less cumbersome to implement than iodine-123 combined with Tc-99m-sestamibi scanning. It has a high sensitivity for imaging solitary parathyroid adenomas or persistent solitary hyperplastic glands. However it does not have the resolution necessary to delineate all parathyroid glands in diffuse hyperplasia.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Hyperplasia; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Prospective Studies; Radionuclide Imaging; Renal Insufficiency; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi

A case of a parathyroid adenoma is presented in which the conventional Tl-201 minus Tc-99m subtraction technique failed to localize the adenoma because of prior iodide administration and a low Tl-201 uptake. Ultrasonography and CT could not provide useful data either. However, a Tc-99m methoxylisobutylisonitrile (MIBI) scintigram clearly delineated the adenoma and the thyroid tissue.

Topics: Adenoma; Aged; Aged, 80 and over; Amiodarone; Female; Humans; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium Tc 99m Sestamibi; Thallium Radioisotopes; Thyroid Gland

The efficiency of USI of the neck, scintigraphy of the parathyroid glands (PTG) with selen-methionine and selective catheterization of veins (SCV) of the neck and mediastinum for preoperative determination of the localization of the source of hyperproduction of the parathyroid hormone was analyzed on the basis of results of examination of 149 patients including 51 patients with primary hyperparathyroidism confirmed during the operation. It was noted that none of the methods of topical diagnostics used in the work is thought to be universal for different clinical situations. A method of their complex use is proposed which foresee USI of the neck as the first step. In case of insufficient information of the results of USI the authors propose SCV of the neck and mediastinum as a method of choice which allows the size and level of the altered PTG to become more exact and which makes further search with the help of other methods of topical diagnostics more purposeful and effective.

Topics: Adolescent; Adult; Aged; Child; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radiography; Radionuclide Imaging; Selenomethionine; Sodium Pertechnetate Tc 99m; Ultrasonography

Primary or relapsing hyperparathyroidism should not be considered a result only of benign conditions like adenoma or hyperplasia (primary or secondary). Parathyroid carcinoma is often the real cause but, because of its rarity, sometimes it is either overlooked or misdiagnosed. Even histologic classification can be erroneous. Distant metastases or ectopic location of the tumors are another potential cause of misdiagnosis, especially when management is decided without the help of diagnostic imaging modalities, particularly those related to the functional aspect of the tumors or their metastases, such as the Tl-201/Tc-99m subtraction scan and the Tl-201 whole body scan.

Topics: Adult; Carcinoma; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Seventy-nine patients with primary hyperparathyroidism, whose average preoperative blood calcium level was 11.6 mg/dl, underwent thallium-technetium dual isotope scintigraphy of the thyroid and parathyroids. For patients who had surgery, the detection and localization rate of parathyroid disease or the sensitivity was low (0.53), but the positive predictive value for the location was high (0.80). Correct localization correlated positively with the weight of the tumor but not significantly with the parathyroid hormone blood level nor with the blood calcium level. Unprocessed data alone were sufficient to predict correctly the location in two thirds of the detected cases. Computer processing increased the sensitivity without decreasing the specificity. Those results, at variance with earlier published data but congruent with another more recent study, require a reevaluation of the role of this scintigraphic technique in the management of hyperparathyroidal patients.

Topics: Adenoma; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Predictive Value of Tests; Preoperative Care; Radionuclide Imaging; Sensitivity and Specificity; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

To improve the sensitivity of thallium-technetium subtraction scintigraphy for preoperative localization procedure of enlarged parathyroid glands in primary hyperparathyroidism, we administered calcitonin intramuscularly 4 hours before the scintigraphy in 14 consecutive patients. Injection of calcitonin reduced plasma levels of ionized calcium from 1.47 +/- 0.10 mmol/l to 1.41 +/- 0.09 mmol/l (p less than 0.01). Concomitantly, serum levels of intact parathyroid hormone increased from 6.4 +/- 2.5 pmol/l to 7.9 +/- 2.6 pmol/l (p less than 0.001). The scintigram after calcitonin injection visualized 11 adenomas (sensitivity 78%) compared to only 9 (sensitivity 64%) in conventional scintigrams. In addition, 5 of the adenomas were more distinctly imaged in the scintigram after calcitonin injection, whereas in only one patient was the conventional scintigram better. Thus, the calcitonin injection improved the scintigram in 7 cases and was inferior in only one case (p = 0.031). We conclude that stimulation of parathyroid hormone secretion with calcitonin results in a better preoperative localization of enlarged parathyroid glands in primary hyperparathyroidism.

Topics: Adenoma; Aged; Calcitonin; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Hormone; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Preoperative localization of parathyroid tumors by computed tomography (CT), thallium-201/technetium-99m pertechnetate subtraction scintigraphy (Tl-201/Tc-99m), ultrasonography (US), and magnetic resonance imaging (MRI) was compared in patients with hyperparathyroidism (HPT) to examine the characteristics of each method. A total of 87 patients with HPT were divided into two groups according to the time when they were examined. Patients in group I were examined before MRI had been introduced in our hospital, and a 2.5-MHz transducer probe was used for US. Those in group II were examined by MRI and US using a 7.5-MHz transducer probe. Group I included 45 patients (36 with primary hyperparathyroidism [PHPT] and 9 with secondary hyperparathyroidism [SHPT]), and group II included 42 patients (15 with PHPT and 27 with SHPT). In both PHPT and SHPT and SHPT of group I and PHPT of group II, there was no significant difference in detection rates between all diagnostic methods. In patients with SHPT in group II, the detection rate was significantly higher for CT than for Tl-201/Tc-99m and MRI (both p less than 0.01), and for US than for Tl-201/Tc-99m (p less than 0.01). In both groups I and II, the detection rate of each study method was significantly higher in patients with PHPT than in those with SHPT (all p less than 0.01). Compared with group I, the rate was significantly improved in group II, in both types of patients. Regarding the location of the parathyroid tumor, the detection rate of CT was significantly higher for upper parathyroid glands than for lower glands, whereas that of US and Tl-201/Tc-99m was significantly higher for lower glands. The detection rate sharply increased when the tumor weight reached 250 mg (CT, US) or 1,000 mg (Tl-201/Tc-99m, MRI).

Topics: Adult; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Magnetic Resonance Imaging; Male; Middle Aged; Parathyroid Neoplasms; Preoperative Care; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Tomography, X-Ray Computed; Ultrasonography

The authors describe a patient with primary hyperparathyroidism who had a large mediastinal parathyroid adenoma that avidly concentrated both Tc-99m pertechnetate and Tl-201. This unusual finding is presented as another potential reason for false-negative findings in Tc-99m/Tl-201 subtraction scintigraphy in hyperparathyroidism.

Topics: Adenoma; False Negative Reactions; Female; Humans; Hyperthyroidism; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes

Dual radionuclide imaging using a combination of 201Tl with either 99mTcO4- or 123I is recognized as a useful procedure in the preoperative localization of parathyroid adenomas. Recently, 99mTc-sestamibi (MIBI) has been introduced for myocardial perfusion imaging as an alternative to 201Tl. The purpose of this prospective study was to evaluate parathyroid scan using early and late imaging following MIBI injection. Twenty-three patients (21 F, 2 M, mean age: 57 yr) with a clinical and biologic diagnosis of hyperparathyroidism were submitted to a MIBI study prior to surgical exploration of the neck. Cervico-thoracic planar imaging (anterior view, 10 min/view) was performed at 15 min and at 2-3 hr after an intravenous injection of 20-25 mCi of MIBI. A positive MIBI scan for parathyroid adenoma was defined as an area of increased focal uptake which persisted on late imaging, contrary to the uptake in the normal thyroid tissue which progressively decreases over time (differential washout). Surgical exploration of the neck, performed between 1 day and 72 days (average: 16 days) after the MIBI study, showed a parathyroid adenoma in 21 patients and hyperplasia in two patients. MIBI scan correctly detected and localized 19/21 adenomas (90%). In conclusion, parathyroid imaging using a single radionuclide with MIBI (early and late study with differential washout analysis) is a promising procedure in the preoperative detection and localization of parathyroid adenomas in patients with primary hyperparathyroidism.

Topics: Adenoma; Evaluation Studies as Topic; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Prospective Studies; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium Tc 99m Sestamibi; Thallium Radioisotopes

The aim of this study was to evaluate the use of scintigraphy with thallium-201 chloride (201 Tl) and technetium-99m pertechnetate (99mTc) in the diagnosis of the localization of the pathological parathyroid glands in primary hyperparathyroidism and compare the results with those of high resolution ultrasonography.. Twelve patients of 56.1 +/- 7.8 years of age diagnosed with primary hyperparathyroidism were studied between March 1987 and June 1990. High resolution ultrasonography with a 7.5 MHz transducer and scintigraphy of digital subtraction with 201Tl-99mTc were carried out preoperatively in all the patients. None of the patients had had previous cervical surgery and diagnosis was proven following surgery by histopathologic study.. Ultrasonography detected 9 out of 11 adenomas and 3 out of 4 hyperplastic glands. Scintigraphy identified 9 adenomas and only 2 of the hyperplastic glands. With this latter technique there was one false positive. The sensitivity of ultrasonography was 80% and that of scintigraphy was 73% with specificity being 100% vs 96.9%, respectively.. Subtraction 201 Tl-99mTc scintigraphy is useful in the diagnosis of the localization of pathologic parathyroid glands in patients with no previous cervical surgery although in this series this technique did not surpass that of high resolution ultrasonography.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Middle Aged; Parathyroid Neoplasms; Prospective Studies; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium; Ultrasonography

Topics: Humans; Male; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes; Thyroid Neoplasms

Pre-operative thallium-technetium subtraction scintigraphy of 50 patients with primary hyperparathyroidism, which was subsequently proven on histology to be due to an adenoma, was compared with operative findings. Six scans were negative and seven uninterpretable. Of the remaining 37 patients, 34 had correct scan prediction of the anatomical locations of the adenomas. On examination of the origins of the adenomas, all six scintigraphic predictions of upper adenomas corresponded to tumours arising from the upper gland found at operation. Of the 25 lower predictions, there was one false positive and 16 were correct, i.e. of lower gland origin, but eight were found to originate from the upper gland. This misinterpretation is though to be due to the prolapse of an adenoma arising from the upper gland towards the lower pole of the thyroid, thereby mimicking a lower lesion on the scan.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; Diagnosis, Differential; Female; Humans; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

The rationale for using the thallium-technetium subtraction scan as a preoperative localizing study in previously untreated patients with primary hyperparathyroidism is presented. The concept of unilateral parathyroidectomy is also presented, and the role of preoperative localizing studies in this approach to parathyroid surgery is carefully analyzed.

Topics: Adenoma; Humans; Hyperparathyroidism; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Between 1983 and 1988, a total of 224 99mTc/201Tl subtraction parathyroid scintigraphy studies were performed in 214 patients (136 women, 78 men, average age 50, +/- 15 years) with clinical and biochemical signs of hyperparathyroidism. Of the 214 patients, 113 underwent surgical exploration, and 127 benign parathyroid lesions were found, 48 of which were correctly localized by scintigraphy (sensitivity 38%). We detected 30 of 71 adenomas (42%) and 18 of 56 hyperplastic glands (32%). Additionally, the scans localized 2 of 6 parathyroid carcinomas in 5 patients. Overall, 83 parathyroid lesions were missed. There was no significant difference in size between detected and missed lesions. Previous neck surgery (65 of 113 patients) was not a significant detriment to scan sensitivity; but correct detection did depend upon the anatomic site of the lesion: 39% (n = 109) were detected in the typical site, 44% (n = 9) intrathyroidal, and 11% (n = 9) in the anterior and/or superior mediastinum. In conclusion, these results show only limited value for this 99mTc/201Tl subtraction scintigraphy protocol as the initial procedure for localization of abnormal parathyroid tissue prior to surgical exploration.

Topics: Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Eighty six consecutive thallium-technetium subtraction parathyroid scans performed over a three year period for hypercalcaemia have been evaluated. Twelve had chronic renal failure, 11 had hypercalcaemia due to non-hyperparathyroid causes and in 10 the imaging study was technically inadequate. The remaining 53 technically adequate studies performed for hypercalcaemia clinically thought to be possibly due to hyperparathyroidism have been analysed. Of 20 (38%) positive scans, 13 came to surgery (10 correctly localized parathyroid adenomas, 2 with multiple gland hyperplasia, and 1 papillary carcinoma of the thyroid). Of 33 (62%) negative scans, 9 had surgical exploration on the basis of strong clinical grounds and all had parathyroid adenomas. Multiple biochemical parameters have been assessed in relation to a positive outcome on scan. The adjusted calcium-phosphate product and the ratio of the adjusted calcium-phosphate product to creatinine (Ca x P/Cr) were both significantly lower in the scan positive group (P less than 0.01). The scan positive group had a significantly higher mean level of PTH (P less than 0.001) and lower mean level of phosphate (P less than 0.001). The present experience shows that parathyroid imaging is useful in localizing parathyroid adenomas in 50% of cases (10 out of 19). This figure is at the lower end of the range of previously published results. It is less effective in demonstrating multiple gland hyperplasia. The decision as to whether to undertake surgical exploration when the scan is negative has been based successfully on clinical judgement. We feel that an analysis of this nature is important, as it gives insights into the practical relevance of parathyroid imaging in the context of routine clinical work.

Topics: Adenoma; Humans; Hypercalcemia; Hyperparathyroidism; Kidney Failure, Chronic; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Phosphates; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Thirty-six patients with primary hyperparathyroidism were studied preoperatively by thallium-201 and technetium-99m pertechnetate subtraction (Tl-201/Tc-99m) scintigraphy, high-resolution real time ultrasonography and computed tomographic (CT) scanning. None of the patients had had previous surgical treatment of the parathyroid or thyroid glands. All of the patients underwent systematic bilateral exploration of the neck. All of the patients were successfully explored and 41 abnormal parathyroid glands were identified. Five patients had two adenomas. In six instances, adenomas were identified in ectopic anatomic sites. The sensitivity of correctly localizing the abnormal glands with these techniques was 49 per cent for the Tl-201/Tc-99m scintigraphy, 34 per cent for ultrasonography and 41 per cent for CT scanning. The Tl-201/Tc-99m scintigrams detected two of the six ectopically located adenomas, CT detected one, while ultrasound detected none. The five patients with multiple adenomas were not accurately identified as having multiple gland enlargement by any of these studies. Therefore, preoperative localization studies with these three techniques did not provide reliable information for initial bilateral exploration of the neck.

Topics: Adenoma; Evaluation Studies as Topic; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Predictive Value of Tests; Prospective Studies; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes; Tomography, X-Ray Computed; Ultrasonography

Between January 1983 and March 1986, 75 consecutive patients underwent cervical exploration for primary hyperparathyroidism. Each patient had a thallium-technetium subtraction isotope scan of the neck performed preoperatively. Of 71 patients with technically satisfactory scans, 68 came to 'first-time' neck exploration while three underwent reoperation for persistent hypercalcaemia. At primary cervical operation 53 of the 68 patients each had a solitary adenoma as the cause of their hyperparathyroidism. In 28 (53%) of these individuals the scintigram accurately predicted the site of the parathyroid tumour ('helpful' scans). The technique was 'unhelpful' in 17 patients (32%) with false-positive scans and in eight patients (15%) with false-negative scans. There was a highly significant difference between the median weight of adenomas removed from patients with helpful scans (1.05 g) and that of adenomas retrieved from individuals with unhelpful scans (0.47 g), (P less than 0.001). Since 1 January 1985 we have adopted a policy of 'scan-directed' unilateral neck exploration for patients with hyperparathyroidism on the basis of solitary adenoma and in whom the isotope scan was positive. The mean operating time for these patients (n = 18, mean operating time 1.24 h) was significantly shorter than that for patients with unhelpful scans (n = 14, mean operating time 1.55 h, P less than 0.01) who were submitted to standard bilateral cervical operation. Subtraction scanning was helpful, in terms of localization of enlarged parathyroid glands, in only three of eight patients with multigland hyperplasia. The investigation was of positive help in locating the adenoma in two of three individuals submitted to cervical re-exploration for persistent hyperparathyroidism.

Topics: Adenoma; False Negative Reactions; False Positive Reactions; Humans; Hyperparathyroidism; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Topics: Adenoma; Goiter, Nodular; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Parathyroid Glands; Parathyroid Neoplasms; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes; Thyroid Gland; Time Factors; Tomography, Emission-Computed

Topics: Adult; False Positive Reactions; Female; Humans; Mediastinal Neoplasms; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

Topics: Adenoma; Humans; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium Radioisotopes

The authors report, probably for the first time, a successful pre-operative localization of 7 mm intrathyroidal parathyroid adenoma which was successfully removed by using parathyroid imaging using a dual tracer (T1-201 and Tc-99m) and subtraction technique.

Topics: Adenoma; Humans; Male; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium; Thallium Radioisotopes; Thyroid Neoplasms

Forty five thallium-technetium parathyroid scans were performed preoperatively in patients with a high suspicion of parathyroid adenoma or hyperplasia. The patients were imaged after sequential IV injection of 201Tl-thallous chloride (74 MBq) and 99mTc-pertechnetate (222 MBq) using a gamma camera with a pinhole collimator. According to surgical findings, the prevalence of parathyroid abnormalities was 42/45: single (34 patients) and double (1 patient) adenomas, hyperplasia (7 patients, 16 hyperplastic glands). Three methods of analysis of scintigraphic images were compared. Method one was the visual comparison of the thallium and the technetium images. Method two used the subtraction image obtained after normalisation. Method three used a new image comparison method which performs the geometric and gray level registrations of the two images and generates the image of the significant differences. Three observers were involved in the evaluation procedures. Surgery and histological examinations were taken as the gold standard. Results show that the sensitivity is increased by applying method three. The interobserver reproducibility of the results is also higher for method three. We conclude that an adequate image subtraction technique significantly increases the diagnostic value of parathyroid scintigraphy.

Topics: Adenoma; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium; Thallium Radioisotopes

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Hyperplasia; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Preoperative Care; Prospective Studies; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium Radioisotopes

The specificity of thallium/technetium imaging for the localization of parathyroid tumors has remained high. False-positive findings usually arise from an incorrectly perceived mismatch. In these case reports, false-positive findings resulted from the presence of intrathyroidal fetal adenomas. Benign thyroid adenomas appear to represent a common source of false-positive finding for parathyroid tumor in thallium/technetium imaging.

Topics: Adenoma; Aged; Diagnostic Errors; Female; Humans; Male; Middle Aged; Multiple Endocrine Neoplasia; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium; Thyroid Neoplasms

A 53-yr-old man with hypercalcemia was referred after an unsuccessful operative attempt to find a parathyroid adenoma. Metabolic evaluation showed relatively suppressed levels of parathyroid hormone with an elevation of serum 1,25-dihydroxyvitamin D. Thallium-technetium dual isotope imaging revealed localized mediastinal thallium uptake. A vascular mediastinal lesion was then demonstrated by arteriography, with subsequent surgical removal of a mass that proved to be lymphocyte predominant Hodgkin's disease. This case is noteworthy for the finding of isolated lymphocyte predominant Hodgkin's disease in the chest, the association of elevated serum 1,25-dihydroxyvitamin D with hypercalcemia that resolved postoperatively, and the uptake of thallium by the tumor.

Topics: Calcitriol; Calcium; Hodgkin Disease; Humans; Hypercalcemia; Male; Mediastinal Neoplasms; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

Tl-201/I-123 subtraction scintigraphy was performed in 17 patients with clinical symptoms and biochemical measurements suggestive of primary hyperparathyroidism. Nineteen abnormal sites were identified. These results were correlated with PTH measurements and surgical findings. Three sites were considered unrelated to the parathyroid glands, two corresponding to palpable thyroid nodules and one to muscle uptake of unknown origin. One scintigram did not reveal either of two abnormal glands while two others were considered falsely positive in view of surgical failure. Fourteen sites corresponded to abnormal parathyroid gland at surgery; five glands, weighing more than 2000 mg, could be correctly located on the Tl-201 scintigraphy prior to the subtraction procedure; six glands, weighing between 500 and 2000 mg, were easily localized after the subtraction procedure; three glands, weighing between 180 and 200 mg, were correctly localized after further manipulation of the subtraction procedure. In a patient with parathyroid hyperplasia, one gland, weighing 150 mg, was not located and another was not found upon surgery. Overall sensitivity was 87.5%. A positive correlation between PTH levels, tumor weight, and ease of detection on scintigraphy was found. This correlation was particularly useful in excluding large abnormal uptake related to thyroid disorder or artifact. The results suggest that Tl-201/I-123 parathyroid scintigraphy could become an alternative to Tl-201/Tc-99m parathyroid scintigraphy, with possibly improved detection of low weight abnormal parathyroid glands.

Topics: Adenoma; Aged; Female; Humans; Hyperparathyroidism; Iodine Radioisotopes; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

The thallium 201/technetium 99m pertechnetate radionuclide study is becoming widely accepted as a means of localizing abnormal or aberrantly located parathyroid tissue. We describe a case in which ectopic retrosternal thyroid tissue appeared as a parathyroid adenoma on thallium-201/technetium-99m pertechnetate scan. Physicians who use this radionuclide study should be aware of the possibility of false-positive images within the mediastinum.

Topics: Adenoma; Adult; Choristoma; Diagnosis, Differential; Female; Humans; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium; Thyroid Gland

A case of a parathyroid cyst with adenoma was seen on Tl-201/Tc-99m subtraction imaging. The literature regarding parathyroid cysts and the subtraction technique for parathyroid adenoma imaging was reviewed.

Topics: Adenoma; Cysts; Humans; Male; Middle Aged; Parathyroid Diseases; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

The merit of the preoperative localization of parathyroid tumors with thallium-technetium subtraction imaging is a subject of current debate in the treatment of primary hyperparathyroidism. Eighty patients with hyperparathyroidism underwent preoperative subtraction scintigraphy with 201Tl Cl and 99mTcO4; scan results were correlated with the operative identification and histopathology of the resected parathyroid tissue. The true-positive, false-positive and false-negative rates of these scans were compared between patients with tumors in normal and ectopic anatomic locations and between patients undergoing an initial and reoperative neck exploration. The scan was clearly valuable in patients with one or more prior neck explorations. True-positive scans were obtained in seven (77%) of nine such patients. The scan was also valuable in patients who had ectopic tumors (six mediastinal, seven intrathyroid, and two in the carotid sheath). Twelve (80%) of these 15 ectopic tumors were correctly localized either prior to their first operation or before subsequent explorations. In contrast, only 33 (50%) of 65 patients had a true-positive scan prior to their first operation and when the tumor was not in an ectopic location. In summary, in this series, the thallium-technetium scan was correct in only 50 per cent of patients undergoing an initial operation. However, it was positive in 77 per cent of patients who had at least one prior neck exploration and in 80 per cent of patients with an ectopic parathyroid tumor. These results support the selective use of this valuable imaging and localization tool.

Topics: Adenoma; Adult; Aged; Aged, 80 and over; False Negative Reactions; False Positive Reactions; Female; Humans; Hyperparathyroidism; Hyperplasia; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Preoperative Care; Radioisotopes; Radionuclide Imaging; Reoperation; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Topics: Adenoma; Aged; Diagnosis, Differential; Female; Humans; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

In an effort to localize parathyroid lesions preoperatively, scanning with radioactive thallium and technetium was performed in 20 patients considered clinically to have hyperparathyroidism. In the 11 found at surgery to have single parathyroid adenomas, scanning correctly localized the lesion in 10; in the other patient the lesion was in the unscanned mediastinum. Preoperative scanning was not as rewarding in the seven patients with parathyroid hyperplasia. A thyroid lesion was the source of an abnormality seen on the parathyroid scan in one patient, while neck scanning and surgical exploration were negative in another. Comparison of the patients who had parathyroid adenomas localized in the neck with a control group of similar patients who did not undergo preoperative scanning showed that the average surgical time was reduced by 50% with preoperative localization and there was a decrease in the number of nonparathyroid tissue biopsies.

Topics: Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

During the period from July 1983 through October 1984, a group of 38 patients with elevated serum calcium, parathormone (PTH) and/or clinical suspicion of hyperparathyroidism were studied by TI-201 Tc-99m dual tracer parathyroid imaging (DTPI). Seventeen of 18 parathyroid lesions were identified correctly. There was one false-negative, and the size of the adenoma missed by DTPI was less than 1.0 cm in diameter (1.0 x 0.5 x 0.2). There was one true-negative case. The other fifteen with negative scans are being followed clinically. Because of the small population studied, statistical analysis was not ascertained. However, this simple, noninvasive procedure has become a very useful diagnostic tool for the detection and localization of parathyroid lesions causing hyperparathyroidism, and the DTPI should be used in conjunction with ultrasonography and CT scanning in the preoperative evaluation in primary and secondary hyperparathyroidism.

Topics: Adenoma; Humans; Hyperplasia; Parathyroid Diseases; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

Parathyroid carcinoma is a slow growing tumor, and the patients most often die from complications to the hypercalcemia. Therefore, any attempt should be made to remove local recurrence and metastasis surgically, as medical treatment is disappointing. A case treated with extensive vascular surgery to the neck is reported.

Topics: Adult; Carcinoma; Carotid Arteries; Humans; Hypercalcemia; Male; Neoplasm Recurrence, Local; Parathyroid Hormone; Parathyroid Neoplasms; Reoperation; Sodium Pertechnetate Tc 99m

Topics: Adenoma; Female; Humans; Middle Aged; Neoplasms, Multiple Primary; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium; Thyroid Neoplasms

In a prospective study of 201Tl-99mTc subtraction scintigraphy, 61 hyperparathyroid patients were investigated prior to neck exploration. At surgery, 46 adenomatous and 28 hyperplastic parathyroid glands were excised. We examined the relationship between the pathological category of these glands, their mass, uptake of 201Tl thallous chloride, and the frequency of true-positive and false-negative scintigraphic findings. The variation of sensitivity with parathyroid mass was found to be similar for both adenomatous and hyperplastic glands, with a detection threshold that lay in the range 0.3-0.8 g. The higher overall sensitivity for the detection of adenomas (85%) compared with hyperplasias (44%) was due to the smaller mean weight of the latter. When the parathyroid uptake of thallium was quantified scintigraphically, the practical detection limit of subtraction scanning was found to be an uptake of 0.015%. For glands greater than 1.5 g in weight, uptake increased linearly with mass, and specific uptakes were within the range 0.01-0.04%/g. Below lg, certain small glands had much higher specific uptakes, up to 0.2%/g. The range of specific uptakes found was similar for both adenomatous and hyperplastic categories. Multinodular or diffuse goitre was a cause of failure in 10% of investigations. In a further 5%, a solitary thyroid nodule gave rise to a false-positive result.

Topics: Adenoma; False Negative Reactions; Humans; Hyperplasia; Parathyroid Glands; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Parathyroid scintigraphy using a double-tracer (T1-201, Tc-99m) subtraction technique depicted 17 of 23 (74%) parathyroid adenomas in patients with and without previous neck operations. High-resolution (10-MHz) ultrasound (US) depicted 18 (78%) of these adenomas. Average tumor size depicted by US was 17 X 10 X 8 mm (excluding a giant adenoma) and 19 X 10 X 9 mm by scintigraphy. Alone, neither modality was particularly sensitive in the depiction of primary hyperplasia of the parathyroid glands, but combined techniques were more effective than the use of a single modality. With both US and T1-201 scintigraphy, only two of 23 cases of parathyroid adenoma in the neck were missed, and none of the eight cases of secondary hyperplasia were missed. In 11 patients who had previously undergone neck surgery, parathyroid tumors were identified in eight by either US or double-tracer scintigraphy. Preoperative parathyroid imaging with double-tracer scintigraphy and high-resolution US is suggested for patients with hyperparathyroidism, particularly in those patients who have had previous parathyroid surgery.

Topics: Adenoma; Humans; Hyperparathyroidism; Parathyroid Neoplasms; Prospective Studies; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium; Ultrasonography

Eleven patients who had clinical and biochemical evidence of primary hyperparathyroidism were studied using dual isotope technetium-thallium parathyroid subtraction imaging. The parathyroid scans correctly identified all surgically proven parathyroid adenomas. Three abnormal foci also were identified that were not parathyroid adenomas. These were caused by adenocarcinoma metastatic to a lymph node, primary papillary carcinoma of the thyroid, and parathyroid hyperplasia. This report also demonstrates the importance of surgically examining all abnormal sites of uptake.

Topics: Adenoma; Humans; Hyperparathyroidism; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

The dual tracer radionuclide method using Tl-201 and Tc-99m subtraction imaging has proven to be effective for evaluation of parathyroid lesions. Ninety-two percent sensitivity for detection of parathyroid adenomas has been reported. The importance of dynamic or early imaging, however, has not been emphasized. A case of surgically proven parathyroid adenoma was detected using dynamic scanning after Tl-201 injection and was less apparent on delayed image due to rapid washout.

Topics: Adenoma; Female; Humans; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium; Time Factors

Topics: Adenoma; Female; Humans; Male; Parathyroid Neoplasms; Prospective Studies; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

The presence of diffuse or multinodular goitre can lead to a false negative study of 10 to 20% of parathyroid investigations when the thallium-pertechnetate subtraction technique is used. A simple quantitative index is described that aids recognition of scintiscans whose diagnostic value may be limited by goitre. The index, referred to as the thallium thyroid index (TTI), is obtained from the ratio of thyroidal thallium counts above background to the mean background count density (expressed as counts cm-2) measured in regions just above and below the thyroid image. It correlates linearly with thyroid mass over the range 7 to 50 g, and goitre is likely to adversely affect the diagnostic quality of parathyroid scintiscans for values of TTI greater than 30 cm2 (corresponding to thyroid masses exceeding 35 g). TTI is insensitive to the time of commencement of image acquisition for times between 2 to 30 min following injection of the patient, and its correlation with thyroid mass has been confirmed by independent series of scans in two centres.

Topics: Adenoma; Adult; Female; Goiter; Humans; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

Primary hyperparathyroidism can be diagnosed by laboratory values, yet localization of the adenomas preoperatively has always presented difficulties. Dual isotope scintigraphy with technetium Tc 99m sodium pertechnetate and thallium Tl-201 chloride has recently been used for the localization of parathyroid adenomas. In this paper, we review our experience with scintigraphy in 53 patients suspected of having hyperparathyroidism. Based on favorable results, we recommend this technique for preoperative detection of parathyroid adenomas.

Topics: Adenoma; Adolescent; Adult; Aged; Aged, 80 and over; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

The technetium-thallium subtraction scintigram was utilized preoperatively in 14 consecutive patients explored for primary hyperparathyroidism. The scintigram accurately identified the site of a parathyroid adenoma in 12 of 13 patients.

Topics: Adenoma; Humans; Hyperparathyroidism; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Thallium-201/technetium-99m pertechnetate subtraction scintigraphy of the parathyroid glands was performed in a prospective study of 33 patients who had undergone bilateral neck exploration for elevated serum calcium and serum parathyroid hormone levels. In 31 cases, the Tl-201/Tc-99m subtraction technique yielded an overall sensitivity of 81%, specificity of 99%, and accuracy of 94% for identifying solitary parathyroid adenomas. Tl-201/Tc-99m subtraction scintigraphy correctly identified 73% of parathyroid adenomas weighing less than 499 mg, 79% of those weighing 500-1,499 mg, and 100% of adenomas weighing more than 1,500 mg. In a subgroup of 24 patients with solitary parathyroid adenomas who underwent both scintigraphy and high-resolution sonography, the sensitivity, specificity, and accuracy of both procedures were similar.

Topics: Adenoma; Humans; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium; Ultrasonography

We describe the application of thallium-technetium subtraction scintigraphy in nine patients with failed previous parathyroid surgery or with tertiary hyperparathyroidism due to chronic renal failure. The technique successfully located all adenomas, but only 45% of hyperplastic glands. The series included three abnormal glands located retrosternally. The technique appeared to be more useful in patients with primary hyperparathyroidism than in tertiary hyperparathyroidism, possibly related to differences in gland mass. We conclude that this method of scintigraphy is a valuable adjunct to the management of patients with parathyroid disorders, particularly those requiring revision surgery.

Topics: Adenoma; Humans; Hyperparathyroidism; Hyperplasia; Parathyroid Glands; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Among numerous methods utilized for preoperative localization of hyperfunctioning ectopic parathyroid tissue, the technetium-thallium scan appears to be a major advance. Eight patients are presented where this method located ectopic parathyroid tissue in the neck, in the mediastinum, within the pericardium, and within the thyroid gland. To date, these findings have been confirmed operatively in five of the eight patients. On the basis of our limited experience, the authors believe that this is a valuable method in the preoperative localization of ectopic parathyroid tissue, especially in patients with persistent or recurrent hyperparathyroidism following a thorough neck exploration.

Topics: Adenoma; Aged; Female; Head and Neck Neoplasms; Humans; Male; Mediastinal Neoplasms; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Reoperation; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Twenty-two patients, all with surgically proven primary hyperparathyroidism, were studied by TI-201 thallous chloride and Tc-99m pertechnetate subtraction imaging. Fifteen parathyroid adenomata and one hyperplastic gland between 0.33 and 14.8 g were correctly localized in 16 patients. Two adenomata and seven hyperplastic or histologically normal parathyroids between 0.1 g and 1.4 g in seven patients were not localized. One patient had a correctly localized 13.0-g adenoma with a nonlocalized 0.3 g hyperplastic parathyroid gland and there were two false positive localizations. Sensitivity was 64% (glands), and 73% (patients). There was only fair correlation with parathormone (PTH) levels, but these were elevated in all but four of the patients with correctly localized parathyroids. The authors conclude that the imaging procedure is useful but its sensitivity is limited by difficulty in localizing correctly small glands, particularly those of less than 0.5 g, which comprised 29% of those excised.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Noninvasive diagnostic imaging modalities have played an increasingly important role in preoperative localization of parathyroid lesions. The radionuclide method using TI-201 and Tc-99m subtraction imaging is quite successful in detecting such lesions, with a reported sensitivity of 92%. A case of surgically proven primary hyperparathyroidism, caused by an unusually large parathyroid adenoma and detected by the dual tracer method, is presented.

Topics: Adenoma; Female; Humans; Hyperparathyroidism; Middle Aged; Parathyroid Hormone; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

Dual radionuclide imaging of the neck (Tc-99m pertechnetate and TI-201 thallous chloride) was performed in 22 patients with chemical evidence of hyperparathyroidism (elevated blood calcium and parathormone [PTH] levels). Of these, 19 of 22 had localization of a TI-201 "excess" area on radiothallium-radiotechnetium subtraction images. In 13 patients who have had operative confirmation at this writing, the dual radionuclide imaging was positive in 12 (12/13 = 92.3%). One patient had two parathyroid adenomas, both of which were seen on the images; thus, overall detection was 13 out of 14 or 92.8%. The parathyroid adenomas visualized weighed from 0.06 to 3.0 g; the one not detected weighed 0.25 g. In three patients with parathyroid hyperplasia secondary to renal disease, the subtraction imaging detected eight of 12 glands (66.7%). The forearm bone mineral content and bone density were determined in eight patients with parathyroid adenomas; results were abnormally low in five of these eight. One of the three patients with secondary hyperparathyroidism had an abnormally low radial bone mass. The combination of dual radionuclide imaging and radial bone mass determination may present a useful approach in both localizing abnormal parathyroid tissue and in examining its functional consequences.

Topics: Adenoma; Adult; Aged; Bone and Bones; Densitometry; Female; Humans; Hyperparathyroidism; Hyperparathyroidism, Secondary; Male; Middle Aged; Minerals; Parathyroid Hormone; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Radius; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Ninety-five percent of primary hyperparathyroidism is caused by either a solitary hyperfunctioning adenoma or chief cell hyperplasia. While there is a great deal of variation in the location of the parathyroid glands, 90-95% of all abnormal parathyroid tissue will be identified at initial exploration regardless of the preoperative localization procedure. Adenomas not identified at initial exploration are likely to be ectopic. Reexploration is a difficult and time-consuming procedure. The challenge, therefore, is to develop a reliable, noninvasive test that will locate aberrant parathyroid tissue preoperatively with the goal of simplifying the surgical procedure and reducing the incidence of reexploration. A radiopharmaceutical which localizes selectively in parathyroid tissue would be ideal. Currently, no single radiopharmaceutical is adequate. Recently, dual isotope subtraction scintigraphy using T1-201 chloride and Tc-99m pertechnetate has yielded promising results. The authors have investigated this procedure in 42 patients, 25 of whom to date have had surgical exploration. Of the 25 adenomas or focal hyperplasia sites found at surgery, 23 (92%) were correctly located preoperatively. There were two false-negative sites and five false-positive sites. The purpose of this paper is not only to describe the methods used and results obtained but also to discuss the merits and limitations of the technique in comparison with other imaging modalities so that its role, in today's climate of cost containment, may better be defined.

Topics: Adenoma; False Negative Reactions; False Positive Reactions; Humans; Hyperparathyroidism; Parathyroid Glands; Parathyroid Neoplasms; Posture; Preoperative Care; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Ten patients with biochemical and clinical evidence of primary hyperparathyroidism were studied scintigraphically using a double-radionuclide subtraction technique. Preoperative imaging was performed with Sodium pertechnetate Tc 99m and thallium chloride Tl 201 using a gamma camera with a pinhole collimator. The data were stored in a matrix of 64 X 64. The avidity of 201Tl for nodules of the parathyroid gland was demonstrated on analogue and digital images both with and without the subtraction of thyroid tissue. In our ten patients, this technique detected nine out of ten histologically proven adenomas, and missed a relatively small lesion embedded within the thyroid of one patient. This method may have considerable advantages over non-specific or invasive radiodiagnostic methods, and may facilitate the diagnosis and planning of the surgical approach in cases of primary hyperparathyroidism.

Topics: Adenoma; Adult; Aged; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Topics: Adenoma; Adolescent; Adult; Aged; Child; Female; Humans; Male; Middle Aged; Parathyroid Neoplasms; Preoperative Care; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Image subtraction techniques, in conjunction with [75Se]selenomethionine (75Se) scintigraphy, have recently been suggested to be a potentially valuable tool for localization of parathyroid abnormalities. With use of these techniques, we prospectively studied 15 patients scheduled for parathyroid operations. Postoperatively, all were normocalcemic. Anterior scintiscans of the neck were divided into quadrants, and regions of enhanced uptake were assigned to one or more quadrants. On this basis, by chance alone a minimum of 25% of single-gland enlargements would be assigned to the correct quadrant of the neck. We found that by use of 75Se scanning only 8 of 22 abnormal glands (36%) were assigned to the quadrant of the neck in which they were found intraoperatively. In no case was a clearly visualized focus of parathyroid activity encountered. These results do not justify the continued use of 75Se scintigraphy with or without image subtraction in the preoperative localization of parathyroid glands.

Topics: Adenoma; Evaluation Studies as Topic; Humans; Hyperparathyroidism; Hyperplasia; Parathyroid Glands; Parathyroid Neoplasms; Preoperative Care; Prospective Studies; Radioisotopes; Radionuclide Imaging; Recurrence; Reoperation; Selenium; Selenomethionine; Sodium Pertechnetate Tc 99m; Subtraction Technique; Technetium; Thyroid Gland

A novel method for localization of abnormal parathyroid glands involving color-processing of nuclear scintigrams of the neck after injection of Thallium-201 and Technetium pertechnetate is presented with surgical correlation. Preoperative localization of single parathyroid adenomas was successful in 88% of previously unoperated patients and in 85.7% of those with adenomas not located at previous surgery. Eighty-three per cent of glands with secondary hyperplasia, 66% of glands with primary hyperplasia, and one carcinoma were localized. No abnormal studies were seen in non-hyperparathyroid hypercalcemia, and no false positive studies were seen. Localization appeared related to larger adenomas (300-5000 mg), although one of 60 mg was localized. Color-comparison dual-isotype scintigraphy was useful for localization of parathyroid adenomas and hyperplastic glands and exceeded the reported sensitivity of either ultrasonography or computerized tomography. It deserves wider evaluation in preoperative management of at least hyperparathyroidism of the primary or persistent types.

Topics: Adenoma; Calcium; Humans; Parathyroid Glands; Parathyroid Hormone; Parathyroid Neoplasms; Phosphorus; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium; Thallium

201Tl-thallous chloride/99mTc sodium pertechnetate subtraction scanning is a simple and accurate means to demonstrate enlarged parathyroid glands. We report a case in which the intra-operative location of a mediastinal adenoma was greatly facilitated by using a probe radiation detector following intravenous injection of 201Tl-thallous chloride. We believe this is the first reported use of this technique in parathyroid surgery.

Topics: Adenoma; Female; Humans; Mediastinal Neoplasms; Middle Aged; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

An evaluation of double isotope subtraction scanning with 201Tl and 99mTc was performed in 14 patients with primary hyperparathyroidism. Twelve of 13 adenomas and seven of seven hyperplastic glands were localized correctly by preoperative scanning. The technique appears useful for the identification of abnormal parathyroid glands before operation.

Topics: Adenoma; Adolescent; Adult; Aged; Computers; Female; Humans; Hyperparathyroidism, Secondary; Hyperplasia; Male; Middle Aged; Parathyroid Diseases; Parathyroid Glands; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Thallium

99mTechnetium-201Thallium subtraction scanning was performed in 24 patients with primary (N = 5) and secondary (N = 19) hyperparathyroidism. The preoperative scintigraphy (N = 12) detected 21 of 23 enlarged glands surgically removed and was helpful for detecting abnormal location especially in the mediastinum. Postoperative scanning in patients with recurrent hyperparathyroidism confirmed the excessive growth of the remaining half parathyroid after subtotal parathyroidectomy or a missing fifth parathyroid after total parathyroidectomy and autotransplantation. False negative results were due to tumor hyperplasia. The technique is recommended prior to repeated exploration in patients presenting persistent disease to predict the location of adenomas generally unsuccessfully detected by ultrasonography and computed tomography.

Topics: Adenoma; Adult; Female; Humans; Hyperparathyroidism; Male; Middle Aged; Parathyroid Glands; Parathyroid Neoplasms; Radioisotopes; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Subtraction Technique; Thallium

Topics: Adenoma; Aged; Humans; Male; Mediastinal Neoplasms; Parathyroid Glands; Parathyroid Neoplasms; Radionuclide Imaging; Sodium Pertechnetate Tc 99m; Technetium