High Cardiac Background Activity Limits 99mTc-MIBI Radioguided Surgery in Aortopulmonary Window Parathyroid Adenomas

Overview

Journal BMC Surg

Publisher Biomed Central

Specialty General Surgery

Date 2014 Apr 25

PMID 24758398

Citations 2

Authors

Thomas Schwarzlmuller

Katrin Brauckhoff

Kristian Lovas

Martin Biermann

Michael Brauckhoff

Affiliations

Soon will be listed here.

Abstract

Background: Radioguided surgery using 99m-Technetium-methoxyisobutylisonitrile (99mTc-MIBI) has been recommended for the surgical treatment of mediastinal parathyroid adenomas. However, high myocardial 99mTc-MIBI uptake may limit the feasibility of radioguided surgery in aortopulmonary window parathyroid adenoma.

Case Presentation: Two female patients aged 72 (#1) and 79 years (#2) with primary hyperparathyroidism caused by parathyroid adenomas in the aortopulmonary window were operated by transsternal radioguided surgery. After intravenous injection of 370 MBq 99mTc-MIBI at start of surgery, the maximum radioactive intensity (as counts per second) was measured over several body regions using a gamma probe before and after removal of the parathyroid adenoma. Relative radioactivity was calculated in relation to the measured ex vivo radioactivity of the adenoma, which was set to 1.0. Both patients were cured by uneventful removal of aortopulmonary window parathyroid adenomas of 4400 (#1) and 985 mg (#2). Biochemical cure was documented by intraoperative measurement of parathyroid hormone as well as follow-up examination. Ex vivo radioactivity over the parathyroid adenomas was 196 (#1) and 855 counts per second (#2). Before parathyroidectomy, relative radioactivity over the aortopulmonary window versus the heart was found at 1.3 versus 2.6 (#1) and 1.8 versus 4.8 (#2). After removal of the adenomas, radioactivity within the aortopulmonary window was only slightly reduced.

Conclusion: High myocardial uptake of 99mTc-MIBI limits the feasibility of radioguided surgery in aortopulmonary parathyroid adenoma.

Citing Articles

Pitfalls of Intraoperative Parathyroid Hormone Monitoring in Achieving Complete Surgical Resection of Ectopic Mediastinal Parathyroid Adenoma: A Case Report and Literature Review.

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PMID: 40062044 PMC: 11890155. DOI: 10.7759/cureus.78638.

Prevalence of Thymic Parathyroids in Primary Hyperparathyroidism During Radioguided Parathyroidectomy.

Dream S, Lindeman B, Chen H Clin Med Insights Endocrinol Diabetes. 2019; 12:1179551419869917.

PMID: 31452607 PMC: 6696833. DOI: 10.1177/1179551419869917.

Aortopulmonary window parathyroid gland causing primary hyperparathyroidism in men type 1 syndrome.

Tonelli F, Biagini C, Giudici F, Cioppi F, Brandi M Fam Cancer. 2015; 15(1):133-8.

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References

Onoda N, Ishikawa T, Nishiyama N, Kawabe J, Takashima T, Hirakawa K . Focused approach to ectopic mediastinal parathyroid surgery assisted by radio-guided navigation. Surg Today. 2013; 44(3):533-9. DOI: 10.1007/s00595-013-0547-z. View

Beller G, WATSON D . Physiological basis of myocardial perfusion imaging with the technetium 99m agents. Semin Nucl Med. 1991; 21(3):173-81. DOI: 10.1016/s0001-2998(05)80038-8. View

Bach-Gansmo T, Schwarzlmuller T, Joraholmen V, Salbu J, Biermann M, Naum A . SPECT/CT hybrid imaging; with which CT?. Contrast Media Mol Imaging. 2010; 5(4):208-12. DOI: 10.1002/cmmi.375. View

Ismail M, Maza S, Swierzy M, Tsilimparis N, Rogalla P, Sandrock D . Resection of ectopic mediastinal parathyroid glands with the da Vinci robotic system. Br J Surg. 2010; 97(3):337-43. DOI: 10.1002/bjs.6905. View

Wiseman S, Levine D, Sexsmith G, Ling H . Aortopulmonary window parathyroid adenoma. J Am Coll Surg. 2009; 209(3):412. DOI: 10.1016/j.jamcollsurg.2008.11.022. View

Zerizer I, Parsai A, Win Z, Al-Nahhas A . Anatomical and functional localization of ectopic parathyroid adenomas: 6-year institutional experience. Nucl Med Commun. 2011; 32(6):496-502. DOI: 10.1097/MNM.0b013e32834557a3. View

Randone B, Costi R, Scatton O, Fulla Y, Bertagna X, Soubrane O . Thoracoscopic removal of mediastinal parathyroid glands: a critical appraisal of an emerging technique. Ann Surg. 2009; 251(4):717-21. DOI: 10.1097/SLA.0b013e3181c1cfb0. View

Dackiw A, Sussman J, Fritsche Jr H, Delpassand E, Stanford P, Hoff A . Relative contributions of technetium Tc 99m sestamibi scintigraphy, intraoperative gamma probe detection, and the rapid parathyroid hormone assay to the surgical management of hyperparathyroidism. Arch Surg. 2000; 135(5):550-5; discussion 555-7. DOI: 10.1001/archsurg.135.5.550. View

Murphy C, Norman J . The 20% rule: a simple, instantaneous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery. 1999; 126(6):1023-8; discussion 1028-9. DOI: 10.1067/msy.2099.101578. View

10.

Doppman J, Skarulis M, Chen C, Chang R, Pass H, Fraker D . Parathyroid adenomas in the aortopulmonary window. Radiology. 1996; 201(2):456-62. DOI: 10.1148/radiology.201.2.8888240. View

11.

Arnault V, Beaulieu A, Lifante J, Sitges Serra A, Sebag F, Mathonnet M . Multicenter study of 19 aortopulmonary window parathyroid tumors: the challenge of embryologic origin. World J Surg. 2010; 34(9):2211-6. DOI: 10.1007/s00268-010-0622-1. View

12.

Kurtay M, CRILE Jr G . Aberrant parathyroid glands in relationship to the thymus. Am J Surg. 1969; 117(5):705. DOI: 10.1016/0002-9610(69)90410-3. View

13.

Sfakianakis G, Irvin 3rd G, Foss J, Mallin W, Georgiou M, Deriso G . Efficient parathyroidectomy guided by SPECT-MIBI and hormonal measurements. J Nucl Med. 1996; 37(5):798-804. View

14.

Geissler B, Grober S, Zugel N, Lindemann F . [Radio-guided parathyroidectomy: successful intraoperative parathyroid localization diagnosis with 99mTc-sestamibi in primary and recurrent hyperparathyroidism]. Chirurg. 2001; 72(10):1179-85. DOI: 10.1007/s001040170057. View

15.

Profanter C, Schmid T, Prommegger R, Bale R, Sauper T, Bodner J . Robot-assisted mediastinal parathyroidectomy. Surg Endosc. 2004; 18(5):868-70. DOI: 10.1007/s00464-003-4272-3. View

16.

Onoda N, Ishikawa T, Yamada N, Okamura T, Tahara H, Inaba M . Radioisotope-navigated video-assisted thoracoscopic operation for ectopic mediastinal parathyroid. Surgery. 2002; 132(1):17-9. DOI: 10.1067/msy.2002.125172. View

17.

ODoherty M, Kettle A, Wells P, Collins R, Coakley A . Parathyroid imaging with technetium-99m-sestamibi: preoperative localization and tissue uptake studies. J Nucl Med. 1992; 33(3):313-8. View

18.

Rubello D, Pelizzo M, Boni G, Schiavo R, Vaggelli L, Villa G . Radioguided surgery of primary hyperparathyroidism using the low-dose 99mTc-sestamibi protocol: multiinstitutional experience from the Italian Study Group on Radioguided Surgery and Immunoscintigraphy (GISCRIS). J Nucl Med. 2005; 46(2):220-6. View

19.

Iihara M, Suzuki R, Kawamata A, Horiuchi K, Okamoto T . Thoracoscopic removal of mediastinal parathyroid lesions: selection of surgical approach and pitfalls of preoperative and intraoperative localization. World J Surg. 2011; 36(6):1327-34. DOI: 10.1007/s00268-011-1404-0. View

20.

Rubello D, Casara D, Giannini S, Piotto A, De Carlo E, Muzzio P . Importance of radio-guided minimally invasive parathyroidectomy using hand-held gamma probe and low (99m)Tc-MIBI dose. Technical considerations and long-term clinical results. Q J Nucl Med. 2003; 47(2):129-38. View