Vol 23, No 2 (2020)
Research paper
Published online: 2020-07-20

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The diagnostic value of dual-phase SPECT/CT scintigraphy based on transport kinetics of 99mTc-sestamibi confirmed with histopathological findings in patients with secondary hyperparathyroidism — practical consideration

Maria H. Listewnik1, Hanna Piwowarska-Bilska1, Krzysztof Safranow2, Marek Ostrowski3, Jacek Iwanowski1, Maria Chosia4, Bozena Birkenfeld1
Pubmed: 33007093
Nucl. Med. Rev 2020;23(2):71-77.


BACKGROUND: Dual phase 99mTc-sestamibi SPECT/CT preoperative parathyroid scintigraphy (PPS) is seldom discussed
in terms of the transport kinetics of the tracer.
Objectives: To assess the relationship between the characteristic type of tracer transport in particular PPS and histopathological
findings in patients with secondary hyperparathyroidism (sHPT).
MATERIAL AND METHODS: The study comprised 27 patients (13 females and 14 males) with sHPT. Based on tracer accumulation
in early phase (EP) and delayed phase (DP), the following types of accumulation for PPS(+) lesions were identified: EP(–)/
DP(+) (type I), EP(+)/DP(+) (type II), EP(+)/DP(–) (type III). EP(–)/DP(–) (type IV) lesions constituted PPS(–) group invisible in
SPECT/CT. Overall, 69 lesions 59 PPS(+) and 10 PPS(–) were evaluated histopathologically.
RESULTS: Among SPECT/CT PPS(+), types I, II and III occurred in 9 (15%), 49 (83%), and 1 (2%) lesions, respectively. The
frequency of histopathological diagnosis of normal and abnormal (APG — adenoma or hyperplasia) parathyroid gland, as well
as non-parathyroid (thyroid, lymph nodes, or fat) lesions differed significantly between type I, II, and III lesions (p = 0.036).
APG histopathological diagnosis was significantly more frequent in lesions with type II uptake than in lesions with type I uptake
(76% vs. 33%, p = 0.0197). Type II lesions had significantly higher odds for histopathological diagnosis of APG or NPG than
type IV, PPS(–) lesions [odds ratio = 13.1 (95% CI: 2.75 to 63.27)].
CONCLUSIONS: For SHP patients evaluated with SPECT/CT PPS accumulation type I is a weak premise for surgeon to find
parathyroid pathology. Only persistent 99mTc-sestamibi accumulation in both phases - equivocal with accumulation type II
— effectively differentiates parathyroid and non-parathyroid lesions as well as indicates with high probability the presence of
adenoma or hyperplasia. Type III consistent with washout pattern is rare in sHPT.

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  1. Chen JB, Chou FF, Yang CH, et al. Association between clinical variables and mortality after parathyroidectomy in maintenance hemodialysis patients. Am J Surg. 2017; 213(1): 140–145.
  2. Zeng M, Liu W, Zha X, et al. 99mTc-MIBI SPECT/CT imaging had high sensitivity in accurate localization of parathyroids before parathyroidectomy for patients with secondary hyperparathyroidism. Ren Fail. 2019; 41(1): 885–892.
  3. Ballinger AE, Palmer SC, Nistor I, et al. Calcimimetics for secondary hyperparathyroidism in chronic kidney disease patients. Cochrane Database Syst Rev. 2014(12): CD006254.
  4. Tominaga Y, Johansson H, Johansson H, et al. Secondary hyperparathyroidism: pathophysiology, histopathology, and medical and surgical management. Surg Today. 1997; 27(9): 787–792.
  5. Konturek A, Barczyński M, Stopa M, et al. Subtotal parathyroidectomy for secondary renal hyperparathyroidism: a 20-year surgical outcome study. Langenbecks Arch Surg. 2016; 401(7): 965–974.
  6. Yuan LL, Kan Y, Ma DQ, et al. Combined application of ultrasound and SPECT/CT has incremental value in detecting parathyroid tissue in SHPT patients. Diagn Interv Imaging. 2016; 97(2): 219–225.
  7. Olaizola I, Zingraff J, Heuguerot C, et al. [(99m)Tc]-sestamibi parathyroid scintigraphy in chronic haemodialysis patients: static and dynamic explorations. Nephrol Dial Transplant. 2000; 15(8): 1201–1206.
  8. Hindié E, Ugur O, Fuster D, et al. Parathyroid Task Group of the EANM. 2009 EANM parathyroid guidelines. Eur J Nucl Med Mol Imaging. 2009; 36(7): 1201–1216.
  9. Yang J, Hao R, Yuan L, et al. Value of dual-phase (99m)Tc-sestamibi scintigraphy with neck and thoracic SPECT/CT in secondary hyperparathyroidism. AJR Am J Roentgenol. 2014; 202(1): 180–184.
  10. 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.
  11. Yip L, Pryma DA, Yim JH, et al. Can a lightbulb sestamibi SPECT accurately predict single-gland disease in sporadic primary hyperparathyroidism? World J Surg. 2008; 32(5): 784–92; discussion 793.
  12. Sheu-Grabellus SY, Schmid KW. [Pathology of parathyroid glands: Practical aspects for routine pathological investigations]. Pathologe. 2015; 36(3): 229–236.
  13. Uchida K, Tominaga Y, Tanaka Y, et al. Renal transplantation and secondary hyperparathyroidism. Semin Surg Oncol. 1997; 13(2): 97–103, doi: 10.1002/(sici)1098-2388(199703/04)13:2<97::aid-ssu5>3.0.co;2-x.
  14. Caldarella C, Treglia G, Pontecorvi A, et al. Diagnostic performance of planar scintigraphy using ⁹⁹mTc-MIBI in patients with secondary hyperparathyroidism: a meta-analysis. Ann Nucl Med. 2012; 26(10): 794–803.
  15. Hindié E, Zanotti-Fregonara P, Just PA, et al. Parathyroid scintigraphy findings in chronic kidney disease patients with recurrent hyperparathyroidism. Eur J Nucl Med Mol Imaging. 2010; 37(3): 623–634.
  16. Spanu A, Schillaci O, Piras B, et al. SPECT/CT in hyperparathyroidism. Clin Transl Imaging. 2014; 2(6): 537–555.
  17. Carpentier A, Jeannotte S, Verreault J, et al. Preoperative localization of parathyroid lesions in hyperparathyroidism: relationship between technetium-99m-MIBI uptake and oxyphil cell content. J Nucl Med. J Nucl Med. 1998; 39(8): 1441–1444.
  18. Rutkowski B, Ciechanowski K, Durlik M, et al. Availability of different therapeutic option in patients with secondary hyperthyroidism in Poland. Forum Nefrol. 2012; 5(4): 333–338.
  19. Tominaga Y, Tanaka Y, Sato K, et al. Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism. Seminars in Surgical Oncology. 1997; 13(2): 78–86, doi: 10.1002/(sici)1098-2388(199703/04)13:2<78::aid-ssu3>3.0.co;2-z.
  20. DeLellis RA. Parathyroid tumors and related disorders. Mod Pathol. 2011; 24 Suppl 2: S78–S93.
  21. Zitt E, Lhotta K. [Management of secondary hyperparathyroidism-current impact of parathyroidectomy]. Wien Med Wochenschr. 2016; 166(7-8): 254–258.
  22. Coakley AJ, Kettle AG, Wells CP, et al. 99Tcm sestamibi--a new agent for parathyroid imaging. Nucl Med Commun. 1989; 10(11): 791–794.
  23. Taillefer R, Boucher Y, Potvin C, et al. Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med. 1992; 33(10): 1801–1807.
  24. Bénard F, Lefebvre B, Beuvon F, et al. Rapid washout of technetium-99m-MIBI from a large parathyroid adenoma. J Nucl Med. 1995; 36(2): 241–243.
  25. Perez-Monte JE, Brown ML, Shah AN, et al. Parathyroid adenomas: accurate detection and localization with Tc-99m sestamibi SPECT. Radiology. 1996; 201(1): 85–91.
  26. Lorberboym M, Minski I, Macadziob S, et al. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma. J Nucl Med. 2003; 44(6): 904–908.
  27. Fröberg AC, Valkema R, Bonjer HJ, et al. 99mTc-tetrofosmin or 99mTc-sestamibi for double-phase parathyroid scintigraphy? Eur J Nucl Med Mol Imaging. 2003; 30(2): 193–196.
  28. Vulpio C, Bossola M, De Gaetano A, et al. Usefulness of the combination of ultrasonography and 99mTc-sestamibi scintigraphy in the preoperative evaluation of uremic secondary hyperparathyroidism. Head Neck. 2010; 32(9): 1226–1235.
  29. Liu Y, Chun KJ, Freeman LM. 'Shine through' on dual tracer parathyroid scintigraphy: a potential pitfall in interpretation. Clin Nucl Med. 2005; 30(3): 145–149.
  30. Zhen L, Li H, Liu X, et al. The application of SPECT/CT for preoperative planning in patients with secondary hyperparathyroidism. Nucl Med Commun. 2013; 34(5): 439–444.
  31. Taïeb D, Ureña-Torres P, Zanotti-Fregonara P, et al. Parathyroid scintigraphy in renal hyperparathyroidism: the added diagnostic value of SPECT and SPECT/CT. Clin Nucl Med. 2013; 38(8): 630–635.
  32. Monzen Y, Tamura A, Okazaki H, et al. SPECT/CT Fusion in the Diagnosis of Hyperparathyroidism. Asia Oceania J Nucl Med Biol. 2015; 3(1): 61–65.
  33. Souberbielle JC. Measurement of Parathormone in Chronic Kidney Disease: An Easy Task? In: Delanaye P. ed. Nephrology and Clinical Chemistry: The Essential Link. Bentham Books, Belgium 2012: 91–105.
  34. Bolasco P, Serra A, Loi M, et al. Failed Switching off in the MIBI-Parathyroid Scintigraphy in a Dialyzed Patient with Secondary Hyperparathyroidism Responsive to Cinacalcet Therapy. Int J Endocrinol. 2010; 2010: 206801.
  35. Raruenrom Y, Theerakulpisut D, Wongsurawat N, et al. Diagnostic accuracy of planar, SPECT, and SPECT/CT parathyroid scintigraphy protocols in patients with hyperparathyroidism. Nucl Med Rev Cent East Eur. 2018; 21(1): 20–25.
  36. Fang Li, Tang B, Hou D, et al. Relationship between parathyroid mass and parathyroid hormone level in hemodialysis patients with secondary hyperparathyroidism. BMC Nephrol. 2015; 16: 82.
  37. Rosato L, Raffaelli M, Bellantone R, et al. Diagnostic, therapeutic and healthcare management protocols in parathyroid surgery: II Consensus Conference of the Italian Association of Endocrine Surgery Units (U.E.C. CLUB). J Endocrinol Invest. 2014; 37(2): 149–165.
  38. Del Vecchio S, Zannetti A, Aloj L, et al. MIBI as prognostic factor in breast cancer. Q J Nucl Med Mol Imaging. 2003; 47(1): 46–50.
  39. Kasai ETP, da Silva JWE, Mandarim de Lacerda CA, et al. Parathyroid glands: combination of sestamibi-(99m)Tc scintigraphy and ultrasonography for demonstration of hyperplasic parathyroid glands. Rev Esp Med Nucl. 2008; 27(1): 8–12.
  40. Kao A, Shiau YC, Tsai SC, et al. Technetium-99m methoxyisobutylisonitrile imaging for parathyroid adenoma: relationship to P-glycoprotein or multidrug resistance-related protein expression. Eur J Nucl Med Mol Imaging. 2002; 29(8): 1012–1015.
  41. Yamaguchi S, Kobayashi Y, Tsujikawa K, et al. [Usefulness of 99mTc-methoxy-isobutyl-isonitrile scintigraphy for preoperative localization of adenoma in primary hyperparathyroidism]. Hinyokika Kiyo. 2001; 47(9): 619–623.
  42. Shevtsova ON, Shevtsova VK. Mathematical Simulation of Transport Kinetics of Tumor-Imaging Radiopharmaceutical Tc-MIBI. Comput Math Methods Med. 2017; 2017: 2414878.
  43. Listewnik M, Piwowarska-Bilska H, Kurzawski M, et al. The relationship of mRNA ABCC1 expression and uptake of MIBI-Tc99m in patients with hyperparathyroidism. (Meeting Abstract). Eur J Nucl Med Mol Imaging . 2016; 43(S70): WOS:000391801600160.
  44. Xue J, Liu Y, Yang D, et al. Dual-phase 99mTc-MIBI imaging and the expressions of P-gp, GST-π, and MRP1 in hyperparathyroidism. Nucl Med Commun. 2017; 38(10): 868–874.