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. 2022 Dec;407(8):3661-3669.
doi: 10.1007/s00423-022-02648-9. Epub 2022 Aug 9.

Questionable value of [99mTc]-sestamibi scintigraphy in patients with pHPT and negative ultrasound

Christina Lenschow  1 , Andreas Wennmann  1 , Anne Hendricks  1 , Christoph-Thomas Germer  1 , Martin Fassnacht  2 , Andreas Buck  3 , Rudolf A Werner  3 , Lars Plassmeier  1 , Nicolas Schlegel  4
Affiliations

Questionable value of [99mTc]-sestamibi scintigraphy in patients with pHPT and negative ultrasound

Christina Lenschow et al. Langenbecks Arch Surg. 2022 Dec.

Abstract

Purpose: A successful focused surgical approach in primary hyperparathyroidism (pHPT) relies on accurate preoperative localization of the parathyroid adenoma (PA). Most often, ultrasound is followed by [99mTc]-sestamibi scintigraphy, but the value of this approach is disputed. Here, we evaluated the diagnostic approach in patients with surgically treated pHPT in our center with the aim to further refine preoperative diagnostic procedures.

Methods: A single-center retrospective analysis of patients with pHPT from 01/2005 to 08/2021 was carried out followed by evaluation of the preoperative imaging modalities to localize PA. The localization of the PA had to be confirmed intraoperatively by the fresh frozen section and significant dropping of the intraoperative parathyroid hormone (PTH) levels.

Results: From 658 patients diagnosed with pHPT, 30 patients were excluded from the analysis because of surgery for recurrent or persistent disease. Median age of patients was 58.0 (13-93) years and 71% were female. Neck ultrasound was carried out in 91.7% and localized a PA in 76.6%. In 23.4% (135/576) of the patients, preoperative neck ultrasound did not detect a PA. In this group, [99mTc]-sestamibi correctly identified PA in only 25.4% of patients. In contrast, in the same cohort, the use of [11C]-methionine or [11C]-choline PET resulted in the correct identification of PA in 79.4% of patients (OR 13.23; 95% CI 5.24-33.56).

Conclusion: [11C]-Methionine or [11C]-choline PET/CT are superior second-line imaging methods to select patients for a focused surgical approach when previous ultrasound failed to identify PA.

Keywords: Focused surgical approach; Parathyroid adenoma; Primary hyperparathyroidism; [11C]-Choline PET/CT; [11C]-Methionine; [99mTc]-Sestamibi scan.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
ODD ratios and 95% confidence intervals were calculated to detect the reliability of [99mTc]-sestamibi compared to PET/CT
Fig. 2
Fig. 2
Proposed algorithm to localize PA for focused surgery. Based on our data, we suggest the use of this algorithm for the future. Limitations concerning the availability and economic considerations are outlined in the discussion. In case of detection of PA by ultrasound surgery can be performed without additional localization techniques. In cases PA is not detected by ultrasound [11C]-choline or [11C]-methionine PET/CT should be carried out instead of [99mTc] sestamibi scintigraphy
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