Parathyroid imaging: how good is it and how should it be done?

Hypersecretion of parathormone in primary hyperparathyroidism is common, occurring in approximately 1 in 500 women and 1 in 2,000 men per year in their fifth to seventh decades of life. This has been suggested from the literature to be primarily the result of a parathyroid adenoma (80-85% of cases), hyperplasia involving more than 1 gland, usually with all 4 glands being involved (10-15% of cases), or the result, albeit rarely, of parathyroid carcinoma (0.5-1% of cases). Surgical removal of the hypersecreting gland is the primary treatment; this procedure is best performed by a skilled surgeon who would normally find the abnormality in 95% of cases. Imaging, however, should be used to identify the site of abnormality, potentially reducing inpatient stay and improving the patient experience. Functional imaging of parathyroid tissue using thallium was introduced in the 1980s but has largely been superceded by the use of (99m)Tc-labeled isonitriles. The optimum techniques have used (99m)Tc-sestamibi with subtraction imaging or washout imaging. A recent systematic review reported the percentage sensitivity (95% confidence intervals) for sestamibi in the identification of solitary adenomas as 88.44 (87.48-89.40), multigland hyperplasia 44.46 (41.13-47.8), double adenomas 29.95 (-2.19 to 62.09), and carcinoma 33 (33). This review does not separate the washout and subtraction techniques. The subtraction technique using (99m)Tc-sestamibi and (123)I is the optimal technique enabling the site to be related to the thyroid tissue when the parathyroid gland is in the neck in a normal position. If there is an equivocal scan then confirmation with high resolution ultrasound should be used. With ectopic glands, the combined use of single-photon emission computed tomography may then provide anatomical information to enable localization of the functional abnormality. In patients who have had surgical exploration by an experienced parathyroid surgeon in a unit with an experienced nuclear medicine team and negative sestamibi imaging, it is reasonable to image the patient with (11)C methionine. It is debatable whether patients with a high likelihood of secondary hyperparathyroidism should be imaged. The only possible justification for this is to exclude an ectopic site. There is no substitute for an experienced surgeon and an experienced imaging unit to provide a parathyroid service.

Optimization of parathyroid imaging by simultaneous dual energy planar and single photon emission tomography.

BACKGROUND: Single photon emission tomography (SPET) gives valuable 3-dimensional information, but prolongs the time of imaging and increases the possibility of patient movement. We therefore investigated a method for the optimization of SPET. METHOD: Using an in-house fabricated thyroid/parathyroid neck phantom simultaneous dual energy (DE) 1223I/99mTc imaging to localize parathyroid glands was assessed both in planar and SPET modes. RESULTS: Experiments demonstrated improved spatial resolution and contrast for planar pinhole imaging compared to parallel collimation. For DE-SPET compared to planar pinhole imaging more glands in the phantom were visualized by the improved contrast. CONCLUSION: We conclude that DE-SPET for parathyroid imaging is feasible to aid the accurate localization of parathyroid adenomas. For planar imaging pinhole collimation is superior to parallel hole collimation.