title: Planar scintigraphy with 123I/99mTc-sestamibi, 99mTc-sestamibi SPECT/CT, 11C-methionine PET/CT, or selective venous sampling before reoperation of primary hyperparathyroidism?
abstract: All patients with primary hyperparathyroidism should undergo localization studies before reoperation, but it is not known which method is most accurate. The purpose of this prospective study was to compare the performance of planar scintigraphy with (123)I/(99m)Tc-sestamibi, (99m)Tc-sestamibi SPECT (SPECT/CT), (11)C-methionine PET/CT, and selective venous sampling (SVS) in persistent primary hyperparathyroidism.
  
  
  METHODS
  Twenty-one patients referred for reoperation of persistent hyperparathyroidism were included and investigated with (123)I/(99m)Tc-sestamibi, SPECT/CT (n = 19), (11)C-methionine PET/CT, and SVS (n = 18) before reoperation. All patients had been operated on 1-2 times previously because of hyperparathyroidism. The results of the localization studies were compared with operative findings, histology, and biochemical cure.
  
  
  RESULTS
  Eighteen (86%) of 21 patients were biochemically cured. Nineteen parathyroid glands (9 adenomas, 1 atypical adenoma, and 9 hyperplastic glands) were removed from 17 patients, and 1 patient who was biochemically cured had an unclear histology result. The accuracy for localizing a pathologic parathyroid gland to the correct side of the neck was 59% (95% confidence interval [CI], 36%-79%) for (123)I/(99m)Tc-sestamibi, 19% (95% CI, 5%-42%) for SPECT/CT, 65% (95% CI, 43%-84%) for (11)C-methionine PET/CT, and 40% (95% CI, 19%-65%) for SVS (P < 0.01 for (123)I/(99m)Tc-sestamibi vs. SPECT/CT). The corresponding accuracy for the correct quadrant or more specific site was 48% (95% CI, 27%-69%) for (123)I/(99m)Tc-sestamibi, 14% (95% CI, 3%-36%) for SPECT/CT, 61% (95% CI, 39%-80%) for (11)C-methionine PET/CT, and 25% (95% CI, 9%-49%) for SVS (P < 0.02 for (123)I/(99m)Tc-sestamibi vs. SPECT/CT). In the 3 patients not cured, preoperative (123)I/(99m)Tc-sestamibi and SPECT/CT remained negative, SVS was false predictive in all, and (11)C-methionine PET/CT in 1. (11)C-methionine PET/CT accurately revealed the pathologic gland in 4 of 8 (50%) patients with a negative (123)I/(99m)Tc-sestamibi scan result, all of whom were biochemically cured after reoperation.
  
  
  CONCLUSIONS
  Planar scintigraphy with (123)I/(99m)Tc-sestamibi performs well in complicated primary hyperparathyroidism and is recommended as first-line imaging before reoperation. (11)C-methionine PET/CT provides valuable additional information if (123)I/(99m)Tc-sestamibi scan results remain negative. (99m)Tc-sestamibi SPECT/CT and SVS provide no additional information, compared with the combined results of (123)I/(99m)Tc-sestamibi and (11)C-methionine PET/CT imaging.
authors.affiliation: Division of Endocrinology, Department of Medicine, University of Helsinki, Helsinki, Finland. camilla.schalin-jantti@hus.fi
authors.forename: Camilla
authors.initials: C
authors.lastname: Schalin-Jäntti
authors.forename: Eeva
authors.initials: E
authors.lastname: Ryhänen
authors.forename: Ilkka
authors.initials: I
authors.lastname: Heiskanen
authors.forename: Marko
authors.initials: M
authors.lastname: Seppänen
authors.forename: Johanna
authors.initials: J
authors.lastname: Arola
authors.forename: Jukka
authors.initials: J
authors.lastname: Schildt
authors.forename: Mika
authors.initials: M
authors.lastname: Väisänen
authors.forename: Lassi
authors.initials: L
authors.lastname: Nelimarkka
authors.forename: Irina
authors.initials: I
authors.lastname: Lisinen
authors.forename: Ville
authors.initials: V
authors.lastname: Aalto
authors.forename: Pirjo
authors.initials: P
authors.lastname: Nuutila
authors.forename: Matti J
authors.initials: MJ
authors.lastname: Välimäki
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D006961:Hyperparathyroidism / Q000097:blood / Q000000981:diagnostic imaging* / Q000473:pathology / Q000601:surgery*; D007457:Iodine Radioisotopes; D008297:Male; D008715:Methionine; D008875:Middle Aged; D064847:Multimodal Imaging; D049268:Positron-Emission Tomography; D012086:Reoperation; D017256:Technetium Tc 99m Sestamibi; D014057:Tomography, X-Ray Computed; D014680:Veins / Q000378:metabolism*
chemical_list: D007457:Iodine Radioisotopes; C086242:carbon-11 methionine; D017256:Technetium Tc 99m Sestamibi; D008715:Methionine
keywords: 11C-methionine PET/CT; 123I/99mTc-sestamibi; PTH; SPECT-CT; persistent; primary hyperparathyroidism; reoperation; selective venous sampling