Preoperative Parathyroid Scintigraphic Lesion Localization: Accuracy of Various Types of Readings

Purpose: To retrospectively compare the accuracy of various parathyroid scintigraphy readings for single-gland disease (SGD) and multigland disease (MGD) in patients with primary hyperparathyroidism, with histologic analysis as the reference standard.

Materials and Methods: Institutional review board approval was obtained for this HIPAA-compliant study. Records of 462 patients with primary hyperparathyroidism who underwent preoperative imaging with a technetium 99m (99mTc) sestamibi and 99mTcO4− protocol that consisted of early and late pinhole 99mTc sestamibi, pinhole thyroid imaging, image subtraction, and single photon emission computed tomography (SPECT) were retrospectively reviewed. An experienced nuclear medicine physician without knowledge of other test results or of the final diagnoses graded images on a scale from 0 (definitely normal) to 4 (definitely abnormal). Early pinhole 99mTc sestamibi images, late pinhole 99mTc sestamibi images, subtraction images, SPECT images, early and late pinhole 99mTc sestamibi images, all planar images, and all images—including SPECT images—were read in seven sessions. Receiver operating characteristic curves were generated for each session and were used to calculate sensitivity, specificity, and accuracy.

Results: A total of 534 parathyroid lesions were excised. Of the 462 patients, 409 had one lesion, whereas 53 had multiple lesions. Reading all images together was more accurate (89%, P = .001) than was reading early (79%), late (85%), subtraction (86%), and SPECT (83%) images seperately; however, it was not significantly more accurate than reading planar images (88%) or early and late images together (87%). Reading all images was significantly less sensitive in the detection of lesions with a median weight of 600 mg or less than in the detection of lesions with a median weight of more than 600 mg (86% vs 94%, P = .004). Per-lesion sensitivity for reading all images was significantly higher for SGD than for MGD (90% vs 66%, P < .001). Sensitivity of reading all images together in the identification of patients with MGD was 62%.

Conclusion: Reviewing early, late, and subtraction pinhole images together with SPECT images maximizes parathyroid lesion detection accuracy. Test sensitivity is adversely affected by decreasing lesion weight and MGD.

© RSNA, 2008

References

  • 1 Melton LJ 3rd. The epidemiology of primary hyperparathyroidism in North America. J Bone Miner Res 2002; 17(suppl 2): N12–N17.
  • 2 Ferris RL, Simental AA Jr. Molecular biology of primary hyperparathyroidism. Otolaryngol Clin North Am 2004;37(4):819–831.
  • 3 Bilezikian JP, Silverberg SJ, Gartenberg F. Clinical presentation of primary hyperparathyroidism. In: Bilezikian JP, Marcus R, Levine MA, eds. The parathyroids. New York, NY: Raven, 1994; 457–470.
  • 4 Mariani G, Gulec SA, Rubello D, et al. Preoperative localization and radioguided parathyroid surgery. J Nucl Med 2003;44:1443–1458.
  • 5 Attie JN, Wise L, Mir R, Ackerman LV. The rationale against routine subtotal parathyroidectomy for primary hyperparathyroidism. Am J Surg 1978;136:437–444.
  • 6 Shaha AR, Jaffe BM. Cervical exploration for primary hyperparathyroidism. J Surg Oncol 1993;52(1):14–17.
  • 7 Denham DW, Norman J. Cost-effectiveness of preoperative sestamibi scan for primary hyperparathyroidism is dependent solely upon the surgeon's choice of operative procedure. J Am Coll Surg 1998;186:293–305.
  • 8 Bergson EJ, Sznyter LA, Dubner S, Palestro CJ, Heller KS. Sestamibi scans and intraoperative parathyroid hormone measurement in the treatment of primary hyperparathyroidism. Arch Otolaryngol Head Neck Surg 2004;130:87–91.
  • 9 Rubello D, Pelizzo MR, Boni G, et al. Radioguided surgery of primary hyperparathyroidism using the low-dose 99mTc-sestamibi protocol: multiinstitutional experience from the Italian study group on radioguided surgery and immunoscintigraphy (GISCRIS). J Nucl Med 2005;46:220–226.
  • 10 Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 2002;235:665–672.
  • 11 Pattou F, Huglo D, Proye C. Radionuclide scanning in parathyroid disease. Br J Surg 1998;85:1605–1616.
  • 12 Irvin GL 3rd, Dembrow VD, Prudhomme DL. Clinical usefulness of an intraoperative “quick parathyroid hormone” assay. Surgery 1993;114:1019–1023.
  • 13 Gauger PG, Agarwal G, England BG, et al. Intraoperative parathyroid hormone monitoring fails to detect double parathyroid adenomas: a 2-institution experience. Surgery 2001;130:1005–1010.
  • 14 Van der Wall H, Carmalt H, Fogelman I. 99mTc-sestamibi and minimally invasive radioguided surgery for primary hyperparathyroidism. J Nucl Med 2005;46:198–199.
  • 15 Cherry SR, Sorensen JA, Phelps ME. The gamma camera: performance characteristics. In: Physics in nuclear medicine. Philadelphia, Pa: Saunders, 2003; 227–251.
  • 16 Maxon HR, Elgazzar AH. Parathyroid imaging. In: Gelfand MJ, Thomas SR, eds. Effective use of computers in nuclear medicine. New York, NY: McGraw-Hill, 1988; 485–496.
  • 17 Hundley JC, Woodrum DT, Saunders BD, Doherty GM, Gauger PG. Revisiting lithium-associated hyperparathyroidism in the era of intraoperative parathyroid hormone monitoring. Surgery 2005;138:1027–1031.
  • 18 Gruden JF, Ouanounou S, Tigges S, Norris SD, Klausner TS. Incremental benefit of maximum-intensity-projection images on observer detection of small pulmonary nodules revealed by multidetector CT. AJR Am J Roentgenol 2002;179:149–157.
  • 19 Lorberboym M, Minski I, Macadziob S, Nikolov G, Schachter P. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma. J Nucl Med 2003;44:904–908.
  • 20 Clark PB, Perrier ND, Morton KA. Detection of an intrathymic parathyroid adenoma using single-photon emission CT 99mTc sestamibi scintigraphy and CT. AJR Am J Roentgenol 2005;184(3 suppl):S16–S18.
  • 21 Ruf J, Seehofer D, Denecke T, et al. Impact of image fusion and attenuation correction by SPECT-CT on the scintigraphic detection of parathyroid adenomas. Nuklearmedizin 2007;46(1):15–21.
  • 22 Katz SC, Wang GJ, Kramer EL, Roses DF. Limitations of technetium 99m sestamibi scintigraphy localization for primary hyperparathyroidism associated with multiglandular disease. Am Surg 2003;69:170–175.
  • 23 Billotey C, Sarfati E, Aurengo A, et al. Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy. J Nucl Med 1996;37:1773–1778.
  • 24 Sfakianakis GN, Irvin GL 3rd, Foss J, et al. Efficient parathyroidectomy guided by SPECT-MIBI and hormonal measurements. J Nucl Med 1996;37:798–804.
  • 25 Gayed IW, Kim EE, Brousssard WF, et al. The value of 99mTc-sestamibi SPECT/CT over conventional SPECT in the evaluation of parathyroid adenomas or hyperplasia. J Nucl Med 2005;46:248–252.
  • 26 Sharma J, Mazzaglia P, Milas M, et al. Radionuclide imaging for hyperparathyroidism (HPT): which is the best technetium-99m sestamibi modality? Surgery 2006;140:856–865.
  • 27 Chen H, Mack E, Starling JR. A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg 2005;242:375–383.
  • 28 Krausz Y, Bettman L, Guralnik L, et al. Technetium-99m-MIBI SPECT/CT in primary hyperparathyroidism. World J Surg 2006;30:76–83.
  • 29 Rodgers SE, Hunter GJ, Hamberg LM, et al. Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography. Surgery 2006;140:932–941.
  • 30 Proye CA, Carnaille B, Bizard JP, Quievreux JL, Lecomte-Houcke M. Multiglandular disease in seemingly sporadic primary hyperparathyroidism revisited: where are we in the early 1990s? a plea against unilateral parathyroid exploration. Surgery 1992;112:1118–1122.

Article History

Published in print: 2008