Influence of a negative sestamibi scan on the decision for parathyroid operation by the endocrinologist and surgeon

Reducing disparities in the treatment of hyperparathyroidism

Background

Hyperparathyroidism is common with African American patients historically experiencing disparate outcomes. With a comprehensive outreach program and systematic treatment plans, we sought to evaluate our institution's ability to reduce disparities in hyperparathyroidism.

Methods

We performed a retrospective review of prospectively collected data at a single medical center for all patients undergoing parathyroidectomy by endocrine surgeons from 2015 to 2021 for primary (PHPT) and tertiary (THPT) hyperparathyroidism. Patient demographics, pre-and post-operative clinical and biochemical data were collected and analyzed by race.

Results

Of the 757 patients included, 675 patients had PHPT with 135 (20 %) African-American (AA) and 528(78 %) female. Of 82 patients with THPT, 44 (53 %) were AA and 34 (32 %) were female. AA patients were younger than Caucasian (CA) patients with a mean age (±SD) of 56 ± 15 vs 60 ± 14 years in PHPT (p < 0.01) and 50 ± 10 vs 55 ± 10 years in THPT (p = 0.02).Median (IQR) preoperative PTH was higher in AA with PHPT 134 (97-190) vs 102 (75-144) pg/mL (p < 0.01) and in AA with THPT 285 (189-544) vs 218 (145-293) (p = 0.01) pg/mL. AA PHPT patients had significantly higher preoperative mean (±SD) calcium levels 10.9 ± 0.8 vs 10.6 ± 0.8 mg/dL(p < 0.001). Biochemical cure rates at 6 months and complication rates were not different between races.

Conclusions

AA patients with PHPT and THPT disease experienced similar cure rates to their CA counterparts despite having a more severe biochemical disease. Health care disparities may be ameliorated with treatment by high volume surgeons embedded in a comprehensive health care system.

Update in imaging tests used for the localization of parathyroid pathology

Preoperative localization of parathyroid pathology, generally a parathyroid adenoma, can be difficult in some cases due to the anatomical variants that these glands present. The objective of this review is to analyse the different imaging techniques used for preoperative localization of parathyroid pathology (scintigraphy, ultrasound, CT, MRI and PET). There is great variability between the different tests for the preoperative localization of parathyroid pathology. The importance of knowing the different diagnostic options lies in the need to choose the most suitable test at each moment and for each patient for an adequate management of primary hyperparathyroidism (PHP) with surgical criteria.

FCH-PET/CT in Primary Hyperparathyroidism With Discordant/Negative MIBI Scintigraphy and Ultrasonography

CONTEXT

The contribution of [18F]F-fluorocholine (FCH)-positron emission tomography (PET)/computed tomography (CT) in normocalcemic primary hyperparathyroidism (nPHPT) remains unknown.

OBJECTIVE

To evaluate the sensitivity and specificity of FCH-PET/CT in a cohort of osteoporotic patients with nPHPT and discordant or negative [99mTc]Tc-sestamibi scintigraphy and ultrasonography who all underwent parathyroidectomy (PTX).

DESIGN

Longitudinal retrospective cohort study in patients referred for osteoporosis with mild biological primary hyperparathyroidism.

SETTING

Tertiary referral center with expertise in bone metabolism and surgical management of hyperparathyroidism.

PATIENTS

Among 109 patients with PHPT analyzed, 3 groups were individualized according to total serum calcium (tCa) and ionized calcium (iCa): 32 patients with hypercalcemia (HtCa group), 39 patients with normal tCa and elevated iCa (NtCa group), and 38 patients with both normal tCa and iCa (NiCa). All patients had biochemical follow-up confirming or not the success of PTX.

MAIN OUTCOME MEASURES

To evaluate the performance of FCH-PET/CT in terms of sensitivity and specificity, and to compare with first-line imaging procedures in the setting of nPHPT.

RESULTS

The sensitivity of FCH-PET/CT was 67% in the hypercalcemic group, 48% in the NtCa group (P = .05 vs HtCa), and 33% in the NiCa group (P = .004 vs HtCa). Specificity ranged from 97% to 99%. FCH-PET/CT was positive in 64.3% of patients with negative conventional imaging, with biochemical resolution after PTX in 77.8% of patients. Triple negative imaging was observed in 20 patients, with PHPT resolution in 85% of these patients.

CONCLUSION

This study highlights the contribution of FCH-PET/CT in a well-phenotyped cohort of normocalcemic patients with discordant or negative findings in [99mTc]Tc-sestamibi scintigraphy and ultrasonography. However, negative imaging in nPHPT does not rule out the possibility of surgical cure by an experienced surgeon.

Surgery for primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a hypercalcemic disorder that occurs when one or more parathyroid glands produces excessive parathyroid hormone (PTH). PHPT is typically treated with surgery, and it remains the only definitive therapy, whose techniques have evolved over previous decades. Advances in preoperative localization exams and the intraoperative PTH monitoring have become the cornerstones of recent parathyroidectomy techniques, as minimally invasive techniques are appropriate for most patients. Nevertheless, these techniques, are not suitable for PHPT patients who are at risk for multiglandular disease, especially in those who present with familial forms of PHPT that require bilateral neck exploration. This manuscript also explores other conditions that warrant special consideration during surgical treatment for PHPT: normocalcemic primary hyperparathyroidism, pregnancy, reoperation for persistent or recurrent PHPT, parathyroid carcinoma, and familial and genetic forms of hyperparathyroidism.

Parathyroid Imaging: Past, Present, and Future

The goal of parathyroid imaging is to identify all sources of excess parathyroid hormone secretion pre-operatively. A variety of imaging approaches have been evaluated and utilized over the years for this purpose. Ultrasound relies solely on structural features and is without radiation, however is limited to superficial evaluation. 4DCT and 4DMRI provide enhancement characteristics in addition to structural features and dynamic enhancement has been investigated as a way to better distinguish parathyroid from adjacent structures. It is important to recognize that 4DCT provides valuable information however results in much higher radiation dose to the thyroid gland than the other available examinations, and therefore the optimal number of phases is an area of controversy. Single-photon scintigraphy with 99mTc-Sestamibi, or dual tracer 99mTc-pertechnetate and 99mTc-sestamibi with or without SPECT or SPECT/CT is part of the standard of care in many centers with availability and expertise in nuclear medicine. This molecular imaging approach detects cellular physiology such as mitochondria content found in parathyroid adenomas. Combining structural imaging such as CT or MRI with molecular imaging in a hybrid approach allows the ability to obtain robust structural and functional information in one examination. Hybrid PET/CT is widely available and provides improved imaging and quantification over SPECT or SPECT/CT. Emerging PET imaging techniques, such as 18F-Fluorocholine, have the exciting potential to reinvent parathyroid imaging. PET/MRI may be particularly well suited to parathyroid imaging, where available, because of the ability to perform dynamic contrast-enhanced imaging and co-registered 18F-Fluorocholine PET imaging simultaneously with low radiation dose to the thyroid. A targeted agent specific for a parathyroid tissue biomarker remains to be identified.

Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy

INTRODUCTION

The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative ^99mTc-sestamibi scintigraphy.

METHODS

Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative ^99mTc-sestamibi scintigraphy, operated consecutively in an endocrine surgery unit for 18 years. The cure rate, the intraoperatory PTH, the etiology and the pathological glands location were analyzed.

RESULTS

In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. 14.1% presented a multigland disease. 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum.

CONCLUSIONS

The absence of uptake in the ^99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Accuracy of 18F-Fluorocholine PET for the Detection of Parathyroid Adenomas: Prospective Single-Center Study

The purpose of this prospective study was to determine the correct localization rate (CLR) of 18F-fluorocholine PET for the detection of parathyroid adenomas in comparison to 99mTc-sestamibi imaging. Methods: This was a single-arm prospective trial. Ninety-eight patients with biochemical evidence of primary hyperparathyroidism were imaged before parathyroidectomy using 18F-fluorocholine PET/MRI. 99mTc-sestamibi imaging performed separately from the study was evaluated for comparison. The primary endpoint of the study was the CLR on a patient level. Each imaging study was interpreted by 3 masked readers on a per-region basis. Lesions were validated by histopathologic analysis of surgical specimens. Results: Of the 98 patients who underwent 18F-fluorocholine PET, 77 subsequently underwent parathyroidectomy and 60 of those had 99mTc-sestamibi imaging. For 18F-fluorocholine PET in patients who underwent parathyroidectomy, the CLR based on the masked reader consensus was 75% (95% CI, 0.63-0.82). In patients who underwent surgery and had an available 99mTc-sestamibi study, the CLR increased from 17% (95% CI, 0.10-0.27) for 99mTc-sestamibi imaging to 70% (95% CI, 0.59-0.79) for 18F-fluorocholine PET. Conclusion: In this prospective study using masked readers, the CLR for 18F-fluorocholine PET was 75%. In patients with a paired 99mTc-sestamibi study, the use of 18F-fluorocholine PET increased the CLR from 17% to 70%. 18F-fluorocholine PET is a superior imaging modality for the localization of parathyroid adenomas.

Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism

BACKGROUND

Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of ¹⁸F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism.

METHODS

Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous ¹⁸F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of ¹⁸F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard.

RESULTS

In 101 patients, ¹⁸F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. ¹⁸F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of ¹⁸F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%).

CONCLUSION

Long-term results in the first cohort in the United States to use ¹⁸F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.

Factors associated with negative 99mTc-MIBI scanning in patients with primary hyperparathyroidism

OBJECTIVE

The objective was to evaluate the clinical and biological factors associated with negative ^99mTc-MIBI scanning in patients with primary hyperparathyroidism (PHPT).

METHODS

A retrospective observational study was designed in 195 patients (mean age: 59.2 ± 13.0 years; 77% woman) with PHPT (calcium: 11,3 ± 1,1 mg/dl and PTH: 218 ± 295 pg/ml) studied in endocrinology setting between 2013 and 2020. An univariate and multivariate analysis was made to evaluate the clinical and biological factors associated with negative ^99mTc-MIBI scanning.

RESULT

50 patients (26%) with negative ^99mTc-MIBI scanning had lower PTH levels (146 ± 98 vs. 244 ± 334; p < 0,001), adenomas with smaller sonographic dimensions (maximum diameter: 1,2 ± 0,4 vs. 1,7 ± 0,9 cm; p = 0,001 and volume: 0,36 ± 0,43 vs. 1,7 ± 4,1 cm³; p < 0,001), localized more frequently in upper parathyroid glands (37% vs 14%; p = 0,005) and associated more frequently to thyroid nodules (72% vs 57%; p = 0,045) than patients with positive scanning. 116 patients were operated and parathyroid adenomas were smaller (maximum diameter: 1,3 ± 0,5 vs. 1,9 ± 1,1 cm; p = 0,008 and volume: 0,30 ± 0,20 vs. 1,2 ± 1,1 cm³; p < 0,001), less heavy (567 ± 282 vs. 1470 ± 1374 mgr.; p = 0,030) and were localized more frequently in upper situation (65% vs 16%; p < 0,001) than patients with positive scanning. In the multivariate analysis an independent association between negative ^99mTc-MIBI scanning and size of removed adenoma ≤1 cm (OR: 5,77; IC 95: 1,46-22,71) and upper adenoma localization were observed (OR: 8,05; IC 95%: 2,22-29,16).

CONCLUSIONS

One in four patients studied for PHPT had a negative ^99mTc-MIBI scanning and were independent associated with size of adenoma ≤1 cm and upper adenoma localization.

Surgical results and the location of pathological glands in the treatment of primary sporadic hyperparathyroidism with negative preoperative 99mTc-sestamibi scintigraphy

INTRODUCTION

The primary hyperparathyroidism is a frequent disease whom the surgery is the only curative treatment. The preoperative location imaging techniques could help in the surgical management. Our objective was to analyze surgical results regarding the cure rate, etiology and location of the glands responsible for the primary hyperparathyroidism in patients with negative preoperative 99mTc-sestamibi scintigraphy.

METHODS

Observational study in patients with the diagnosis of primary sporadic hyperparathyroidism with negative 99mTc-sestamibi scintigraphy, operated consecutively in an Endocrine Surgery Unit for 18 years. The cure rate, the intraoperatory parathyroid hormone (PTH), the etiology and the pathological glands location were analyzed.

RESULTS

In the study were included 120 patients. After surgery 95% of patients (n = 114) presented cure criteria of hyperparathyroidism. The 14.1% presented a multigland disease; 69% of the adenomas presented a typical perithyroid location, founding a percentage of 23.9% of ectopic adenomas in cervical location and a 7.1% in mediastinum.

CONCLUSIONS

The absence of uptake in the 99mTc-sestamibi scintigraphy should not condition the surgical indication. The success with experienced surgeons is similar to patients with positive results. The surgical indication must be established by clinical and biochemistry criteria.

Factors associated with negative 99mTc-MIBI scanning in patients with primary hyperparathyroidism

OBJECTIVE

The objective was to evaluate the clinical and biological factors associated with negative ^99mTc-MIBI scanning in patients with primary hyperparathyroidism (PHPT).

MATERIAL AND METHODS

A retrospective observational study was designed in 195 patients (mean age: 59.2±13.0years; 77% woman) with PHPT (calcium: 11.3±1.1mg/dl and PTH: 218±295pg/ml) studied in endocrinology setting between 2013 and 2020. An univariate and multivariate analysis was made to evaluate the clinical and biological factors associated with negative ^99mTc-MIBI scanning.

RESULTS

50 patients (26%) with negative ^99mTc-MIBI scanning had lower PTH levels (146±98 vs. 244±334; p<0.001), adenomas with smaller sonographic dimensions (maximum diameter: 1.2±0.4 vs. 1.7±0.9cm; p=0.001 and volume: 0.36±0.43 vs. 1.7±4.1cm³; p<0.001), localized more frequently in upper parathyroid glands (37% vs. 14%; p=0.005) and associated more frequently to thyroid nodules (72% vs. 57%; p=0.045) than patients with positive scanning. 116 patients were operated and parathyroid adenomas were smaller (maximum diameter: 1.3±0.5 vs. 1.9±1.1cm; p=0.008 and volume: 0.30±0.20 vs. 1.2±1.1cm³; p<0.001), less heavy (567±282 vs. 1470±1374mg; p=0.030) and were localized more frequently in upper situation (65% vs. 16%; p<0.001) than patients with positive scanning. In the multivariate analysis an independent association between negative ^99mTc-MIBI scanning and size of removed adenoma ≤1cm (OR: 5.77; 95% CI: 1.46-22.71) and upper adenoma localization were observed (OR: 8.05; 95% IC: 2.22-29.16).

CONCLUSIONS

One in four patients studied for PHPT had a negative ^99mTc-MIBI scanning and were independent associated with size of adenoma ≤1cm and upper adenoma localization.

The value of dynamic surgeon-directed imaging in the preoperative planning of patients with primary hyperparathyroidism

BACKGROUND

Preoperative localization plays an important role in primary hyperparathyroidism. Sestamibi scans read by the radiologist as nonlocalizing were localizing when independently interpreted by the surgeon. The ability to perform dynamic surgeon-directed imaging, a of combination scans interpreted by the surgeon and surgeon-performed ultrasound done in tandem, appeared to improve preoperative localization. The objective was to evaluate scans read by the radiologist compared with dynamic surgeon-directed imaging.

METHODS

A retrospective chart review was performed. Demographics, biochemistry, radiologist read scans, dynamic surgeon-directed imaging, operation, pathology, and follow-up results were collected. Localization rate, sensitivity, positive predictive value, and accuracy were calculated.

RESULTS

In the study, 474 charts met inclusion criteria. Only 63% of scans read by the radiologist were localizing, compared with 96% of dynamic surgeon-directed imaging. Overall dynamic surgeon-directed imaging was superior to scans read by the radiologist with 95% versus 60% sensitivity, 85% versus 85% positive predictive value, and 82% versus 54% accuracy. Dynamic surgeon-directed imaging remained superior when analyzing only those with single gland disease (n = 391). In addition, 85% of the 174 nonlocalized radiologist scans were correctly localized by dynamic surgeon-directed imaging.

CONCLUSION

The ability to perform an interpretation of both surgeon-performed ultrasound and scan interpreted by the surgeon in tandem improves the preoperative localization rate when compared with static reading of radiologist scans. This underscores the importance of having all primary hyperparathyroidism patients assessed by an experienced parathyroid surgical team, especially when the scans read by the radiologist is nonlocalizing.

Added value of 18F-fluorocholine positron emission tomography-computed tomography in presurgical localization of hyperfunctioning parathyroid glands after dual tracer subtraction scintigraphy failure: A retrospective study of 47 patients

Hyperparathyroidism is a common endocrine disorder. The precise localization of causal parathyroid gland is crucial to guide surgical treatment. Several studies report the added value of 18F-fluorocholine (FCH) positron emission tomography-computed tomography (PET/CT) as second line imaging but rely on suboptimal first-line imaging using 99mTc-sestaMIBI dual phase scintigraphy. The aim of this study is to evaluate the percentage of successful parathyroid localization with FCH PET/CT after failure of a more sensitive first-line detection protocol associating neck ultrasonography and 99mTc-Pertechnetate/99mTc-sestaMIBI dual tracer subtraction scintigraphy.We included retrospectively 47 patients who underwent a FCH PET/CT as second line imaging for biologically proven primary hyperparathyroidism from November 2016 to October 2018 in Godinot Institute (Reims, France). 99mTc-Pertechnetate/99mTc-sestaMIBI dual tracer subtraction scintigraphy and neck ultrasonography were used as first-line imaging and failed to localize the causal parathyroid lesion in all cases.FCH PET/CT demonstrated at least 1 parathyroid target lesion in 29 patients (62%). 21/29 patients underwent surgery. Target lesions corresponded histologically to hyperfunctioning parathyroid glands for all 21 patients and surgery was followed by hyperparathyroidism biological resolution. Calcium serum levels were associated to FCH PET/CT positivity (P = .002) and a trend toward significance was seen for Parathyroid hormone (PTH) levels (P = .09).FCH PET/CT is a promising tool in second-line parathyroid imaging. Large prospective studies and cost-effectiveness analyses are needed to precise its role.

Who Benefits from Treatment of Primary Hyperparathyroidism?

Parathyroidectomy (PTx) is the only definitive treatment for primary hyperparathyroidism (PHPT), but is commonly underutilized. Most patients are medically observed, whereas approximately 30% of patients are treated operatively. PTx is a low-risk surgical procedure and the most cost-effective treatment option. An international consensus statement was published in 1990 to guide clinicians in the management of patients with PHPT, particularly those with asymptomatic disease. Most patients with PHPT and low perioperative risk benefit from surgical treatment, regardless of whether they meet consensus criteria, due to fracture risk reduction, health-related quality-of-life improvements, and prevention or mitigation of disease progression.

Negative Sestamibi Scans Predict Lower Likelihood of Surgical Referral in Patients with Primary Hyperparathyroidism

99mTechnetium sestamibi scans (MIBI) can provide negative or inaccurate results in patients with biochemical primary hyperparathyroidism. Reliance on MIBI as a diagnostic modality rather than as a localization tool leads to misdiagnosis and inappropriate care. The aim of this study was to determine the impact of negative MIBI scans on referral patterns and surgical intervention. Adults with MIBI scans at our institution from January 1, 2011, to May 31, 2017, were retrospectively reviewed. Data collected include demographics, study date and results, ordering physician specialty, pre/postoperative laboratories, and operative and final pathology. Statistical analysis was performed with SPSS v24 (IBM Corp., Armonk, NY). Three hundred fifty-seven patients had a MIBI scan; 10 were excluded for incomplete data or incorrect diagnosis. One hundred eighty-six were interpreted as positive (53.6%) and 161 were interpreted as negative (46.4%). Of the 186 positive MIBI scans, 135 (72.6%) were seen by an endocrine surgeon (ES). Of these 135 patients, 111 (82.2%) underwent parathyroidectomy. Of the 161 negative MIBI scans, 69 (42.9%) were seen by an ES. Of these, 53 (76.8%) underwent parathyroidectomy. In all, 90/92 (97.8%) with a negative MIBI scan who were not seen by an ES did not have surgery. Nonendocrine surgeon physicians are more likely to use MIBI scans as diagnostic tools to assist with clinical decision-making. Patients with a negative MIBI scan not seen by an ES were significantly less likely to undergo para-thyroidectomy. Patients with primary hyperparathyroidism should be referred to an experienced parathyroid surgeon for evaluation, regardless of the MIBI result.