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).

Abstract

UNLABELLED:

This study evaluated the accuracy of (99m)Tc-sestamibi scintigraphy and neck ultrasonography in patients with primary hyperparathyroidism (PHPT) and the role of intraoperative hand-held gamma-probes in minimally invasive radioguided surgery (MIRS) of patients with a high likelihood of a solitary parathyroid adenoma (PA). The study was undertaken under the aegis of the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS).

METHODS:

Clinical records were reviewed for 384 consecutive PHPT patients undergoing radioguided surgery using a low dose of (99m)Tc-sestamibi. Selection of patients for MIRS instead of traditional bilateral neck exploration was based on preoperative imaging indicating a solitary PA. (99m)Tc-Sestamibi (37-110 MBq, or 1-3 mCi) was injected in the operating theater 10-30 min before the start of the intervention. Either 11-mm collimated (309 patients) or 14-mm collimated (75 patients) gamma-probes were used. Intraoperative quick parathyroid hormone (IQPTH) assay was used on 308 patients (80.2%).

RESULTS:

MIRS was successfully performed on 268 (96.8%) of 277 patients. Conversion to bilateral neck exploration was necessary in 9 patients (3.3%) because of either persistently high IQPTH levels after removal of the preoperatively visualized PA (4 patients), intraoperative frozen-section diagnosis of parathyroid carcinoma (2 patients), or hard-to-remove PA (3 patients). MIRS, which was performed under locoregional anesthesia in 72 patients, required a mean operating time of 37 min and a mean hospital stay of 1.2 d. MIRS was successfully performed also on 32 (78.0%) of 41 patients who had previously undergone thyroid or parathyroid surgery. No major surgical complications were observed in the MIRS group, and there were only 24 cases (11%) of transient postoperative hypocalcemia. The probe was of little help in patients with concomitant (99m)Tc-sestamibi-avid thyroid nodules and not helpful at all in patients with negative scan findings preoperatively. IQPTH measurement helped to disclose some cases of multigland parathyroid disease.

CONCLUSION:

(99m)Tc-Sestamibi scintigraphy, especially if combined with neck ultrasonography, is highly accurate in selecting PHPT candidates for MIRS. The low-dose (99m)Tc-sestamibi protocol (which entails a low-to-negligible radiation exposure to the surgical team) is safe and effective for MIRS. MIRS plays a limited role in patients with concomitant (99m)Tc-sestamibi-avid thyroid nodules and should be discouraged in patients with negative (99m)Tc-sestamibi finding preoperatively. IQPTH can be recommended during MIRS to facilitate intraoperative identification of previously undiagnosed multigland parathyroid disease.

• Authors: Domenico Rubello, Maria Rosa Pelizzo, Giuseppe Boni, Riccardo Schiavo, Luca Vaggelli, Giuseppe Villa, Sergio Sandrucci, Andrea Piotto, Gianpiero Manca, Pierluigi Marini, Giuliano Mariani
• Journal: Journal of nuclear medicine : official publication, Society of Nuclear Medicine (J Nucl Med) Vol. 46 Issue 2 Pg. 220-6 (Feb 2005) ISSN: 0161-5505 [Print] United States
• PMID: 15695779 (Publication Type: Clinical Trial, Journal Article, Multicenter Study, Validation Study)

Chemical References

• Radiopharmaceuticals
• Technetium Tc 99m Sestamibi

Topics

• Adult
• Aged
• Aged, 80 and over
• Causality
• Female
• Humans
• Hyperparathyroidism (diagnosis, diagnostic imaging, epidemiology, surgery)
• Italy (epidemiology)
• Male
• Middle Aged
• Minimally Invasive Surgical Procedures (methods)
• Parathyroidectomy (methods, statistics & numerical data)
• Postoperative Complications (diagnosis, epidemiology)
• Radionuclide Imaging
• Radiopharmaceuticals
• Surgery, Computer-Assisted (methods, statistics & numerical data)
• Technetium Tc 99m Sestamibi
• Treatment Outcome