Diagnostic performance of ultrasound versus 99mTc-sestamibi scintigraphy in preoperative depiction and localization of parathyroid adenoma in patients with primary hyperparathyroidism

Year 2025, Volume: 11 Issue: 1, 88 - 97, 04.01.2025

Ercüment Gürlüler

https://doi.org/10.18621/eurj.1598853

Abstract

Objectives: To evaluate diagnostic performance of ultrasound (US) and 99mTc-sestamibi scintigraphy (MIBI) in preoperative depiction and localization of parathyroid adenoma in patients with primary hyperparathyroidism (PHPT)

Methods: A total of 645 patients (mean age: 52.3 [range; 18-81] years, 72.9% were females) who underwent parathyroidectomy for PHPT due to histopathologically-confirmed adenoma were included in this retrospective cohort study. The accuracy of preoperative US and MIBI in the depiction and localization of parathyroid adenomas was evaluated with respect to intraoperative localization.

Results: Preoperative MIBI was more accurate than preoperative US in identifying upper right (6.2% vs. 2.6%) and upper left (7.5% vs. 3.8%) orthotopic adenomas, and ectopic adenomas (1.5% vs. 0.7%). Failure to identify an adenoma was less commonly noted on preoperative MIBI than on preoperative US (26.9% vs. 32.8%). The US mainly failed to diagnose the adenomas located in the upper left (27.4%), lower left (25.9%) and upper right (19.3%) orthotopic sites, while MIBI mainly missed those located in the lower left (36.2%), lower right (24.7%) and upper left (20.1%) orthotopic sites. True-positive depiction rates on the preoperative US (60.4% for ≤250 mg, 80.3% for ≥901 mg) and MIBI (56.7% for ≤250 mg, 86.7% for ≥901 mg) were increased as the parathyroid weight increased.

Conclusions: Our findings indicate inconclusive results in the identification of parathyroid adenoma in nearly one-third of cases with both US and MIBI and the side-specific and site-specific variations in their performance. Hence, the combined use of these imaging modalities may be of great clinical value in the precise preoperative depiction and localization of parathyroid adenomas.

Keywords

Primary hyperparathyroidism, preoperative imaging, ultrasound, 99mTc-sestamibi scintigraphy, parathyroid adenoma, localization

Ethical Statement

Written informed consent was obtained from each participant. This study was conducted in accordance with the ethical principles stated in the “Declaration of Helsinki” and approved by the Bursa Uludag University Clinical Research Ethics Committee (Date of Approval: 19/09/2023; Protocol No: 2023-17/60).

References

• 1. Masi L. Primary Hyperparathyroidism. Front Horm Res. 2019;51:1-12. doi: 10.1159/000491034.
• 2. Wilhelm SM, Wang TS, Ruan DT, et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016;151(10):959-968. doi: 10.1001/jamasurg.2016.2310.
• 3. Ahmadieh H, Kreidieh O, Akl EA, El-Hajj Fuleihan G. Minimally invasive parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IOPTH) and preoperative imaging versus bilateral neck exploration for primary hyperparathyroidism in adults. Cochrane Database Syst Rev. 2020;10(10):CD010787. doi: 10.1002/14651858.CD010787.pub2.
• 4. Tay D, Das JP, Yeh R. Preoperative Localization for Primary Hyperparathyroidism: A Clinical Review. Biomedicines. 2021;9(4):390. doi: 10.3390/biomedicines9040390.
• 5. Udelsman R, Åkerström G, Biagini C, et al. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3595-3606. doi: 10.1210/jc.2014-2000.
• 6. Lu R, Zhao W, Yin L, et al. Efficacy of ultrasonography and Tc-99m MIBI SPECT/CT in preoperative localization of parathyroid adenomas causing primary hyperthyroidism. BMC Med Imaging. 2021;21(1):87. doi: 10.1186/s12880-021-00616-1.
• 7. Van den Bruel A, Bijnens J, Van Haecke H, et al. Preoperative imaging for hyperparathyroidism often takes upper parathyroid adenomas for lower adenomas. Sci Rep. 2023;13(1):7568. doi: 10.1038/s41598-023-32707-0.
• 8. Szczepanek-Parulska E, Filipowicz D, Czepczyński R, et al. Clinical, Biochemical, and Sonographic Factors Influencing Performance of Parathormone Washout Measurement vs. 99mTc-MIBI Scintigraphy in the Preoperative Diagnostics of Parathyroid Adenomas. J Clin Med. 2023;12(12):4097. doi: 10.3390/jcm12124097.
• 9. Tawfik AI, Kamr WH, Mahmoud W, Abo Shady IA, Mohamed MH. Added value of ultrasonography and Tc-99m MIBI SPECT/CT combined protocol in preoperative evaluation of parathyroid adenoma. Eur J Radiol Open. 2019;6:336-342. doi: 10.1016/j.ejro.2019.11.002.
• 10. Iwen KA, Kußmann J, Fendrich V, Lindner K, Zahn A. Accuracy of Parathyroid Adenoma Localization by Preoperative Ultrasound and Sestamibi in 1089 Patients with Primary Hyperparathyroidism. World J Surg. 2022;46(9):2197-2205. doi: 10.1007/s00268-022-06593-y.
• 11. Blanco-Saiz I, Goñi-Gironés E, Ribelles-Segura MJ, et al. Preoperative parathyroid localization. Relevance of MIBI SPECT-CT in adverse scenarios. Endocrinol Diabetes Nutr (Engl Ed). 2023;70 Suppl 2:35-44. doi: 10.1016/j.endien.2022.11.025.
• 12. Adkisson CD, Koonce SL, Heckman MG, Thomas CS, Harris AS, Casler JD. Predictors of accuracy in preoperative parathyroid adenoma localization using ultrasound and Tc-99m-Sestamibi: a 4-quadrant analysis. Am J Otolaryngol. 2013;34(5):508-516. doi: 10.1016/j.amjoto.2013.05.001.
• 13. Bijnens J, Van den Bruel A, Vander Poorten V, et al. Retrospective real-life study on preoperative imaging for minimally invasive parathyroidectomy in primary hyperparathyroidism. Sci Rep. 2022;12(1):17427. doi: 10.1038/s41598-022-18219-3.
• 14. Demir B, Binnetoglu A, Sahin A, Yavuz DG. Single Center Experience in the Surgical Management of Primary Hyperparathyroidism. Clin Exp Otorhinolaryngol. 2020;13(3):285-290. doi: 10.21053/ceo.2019.01361.
• 15. Ozkaya M, Elboga U, Sahin E, et al. Evaluation of conventional imaging techniques on preoperative localization in primary hyperparathyroidism. Bosn J Basic Med Sci. 2015;15(1):61-66. doi: 10.17305/bjbms.2015.207.
• 16. Okudan B, Seven B, Coskun N, Albayrak A. Comparison between single-photon emission computed tomography/computed tomography and ultrasound in preoperative detection of parathyroid adenoma: retrospective review of an institutional experience. Nucl Med Commun. 2019;40(12):1211-1215. doi: 10.1097/MNM.0000000000001104.
• 17. Nafisi Moghadam R, Amlelshahbaz AP, Namiranian N, et al. Comparative diagnostic performance of ultrasonography and 99mTcsestamibi scintigraphy for parathyroid adenoma in primary hyperparathyroidism; systematic review and meta- analysis. Asian Pac J Cancer Prev. 2017;18(12):3195-3200. doi: 10.22034/APJCP.2017.18.12.3195.
• 18. Moreno MA, Callender GG, Woodburn K, et al. Common locations of parathyroid adenomas. Ann Surg Oncol. 2011;18(4):1047-1051. doi:10.1245/s10434-010-1429-x.
• 19. De Simone B, Del Rio P, Catena F, et al. Preoperative localization of parathyroid adenoma in video-assisted era: is cervical ultrasound or 99mTc Sesta MIBI scintigraphy better? Minerva Chir. 2017;72(5):375-382. doi: 10.23736/S0026-4733.17.07359-X.
• 20. Kaur P, Gattani R, Singhal AA, Sarin D, Arora SK, Mithal A. Impact of preoperative imaging on surgical approach for primary hyperparathyroidism: Data from single institution in India. Indian J Endocrinol Metab. 2016;20(5):625-630. doi: 10.4103/2230-8210.190540.
• 21. Acín-Gándara D, Pereira-Pérez F, Medina-García M, Sebastián-Viana Tomás. Factors influencing the sensitivity of ultrasound and gamma location of the parathyroid adenoma. Cir Esp (Engl Ed). 2020;98(1):18-25. doi: 10.1016/j.ciresp.2019.09.002.
• 22. Kocaöz S, Yazıcıoğlu MÖ, Çomçalı B, et al. Use of preoperative ultrasonography adenoma size measurements for accurate localization estimation in parathyroid adenomas. Arch Curr Med Res. 2024;5(1):28-35. doi: 10.47482/acmr.1325481.
• 23. Stucken EZ, Kutler DI, Moquete R, Kazam E, Kuhel WI. Localization of small parathyroid adenomas using modified 4-dimensional computed tomography/ultrasound. Otolaryngol Head Neck Surg. 2012;146(1):33-39. doi: 10.1177/0194599811427243.
• 24. Keidar Z, Solomonov E, Karry R, Frenkel A, Israel O, Mekel M. Preoperative [99mTc]MIBI SPECT/CT interpretation criteria for localization of parathyroid adenomas-correlation with surgical findings. Mol Imaging Biol. 2017;19(2):265-270. doi:10.1007/s11307-016-1013-2.
• 25. Özdemir E, Genç M, Aydos U, et al. Comparison of 99mTc-MIBI planar scintigraphy, SPET/CT and ultrasonography in detection of parathyroid adenoma in patients with primary hyperparathyroidism. Hell J Nucl Med. 2020;23(1):21-26. doi: 10.1967/s002449912002.
• 26. Zafereo M, Yu J, Angelos P, et al. American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism. Head Neck. 2019;41(7):2398-2409. doi: 10.1002/hed.25781.
• 27. Assante R, Zampella E, Nicolai E, et al. Incremental Value of Sestamibi SPECT/CT Over Dual-Phase Planar Scintigraphy in Patients with Primary Hyperparathyroidism and Inconclusive Ultrasound. Front Med (Lausanne). 2019;6:164. doi: 10.3389/fmed.2019.00164.
• 28. Patel CN, Salahudeen HM, Lansdown M, Scarsbrook AF. Clinical utility of ultrasound and 99mTc sestamibi SPECT/CT for preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism. Clin Radiol. 2010;65(4):278-287. doi: 10.1016/j.crad.2009.12.005.
• 29. Castellana M, Virili C, Palermo A, Giorgino F, Giovanella L, Trimboli P. Primary hyperparathyroidism with surgical indication and negative or equivocal scintigraphy: safety and reliability of PTH washout. A systematic review and meta-analysis. Eur J Endocrinol. 2019;181(3):245-253. doi: 10.1530/EJE-19-0160.
• 30. Kuzminski SJ, Sosa JA, Hoang JK. Update in Parathyroid Imaging. Magn Reson Imaging Clin N Am. 2018;26(1):151-166. doi: 10.1016/j.mric.2017.08.009.