NUCLEAR MEDICINE IMAGING OF PARATHYROID

1
NUCLEAR MEDICINE IMAGING OF PARATHYROID

• LALITHA RAMANNA M.D.
• Little Company of Mary Hospital,Torrance , CA
• 34 th Annual Western Regional SNM mtg
• OCT29-NOV1, 2009, Monterey, CA

2
Parathyroid GlandsHistory

• 1852-first identified in rhinoceros.
• 1898- tetany first described in cats/dogs after
  removing parathyroid glands
• 1898-histology described
• 1903-relation between bone dis. parathy.
• 1914- discovery of parathyroid hyperplasia
• in response to low ca diet.
• 1921- Measure of serum calcium

3
ParathyroidHistory( contd)

• 1926-first parathyroid surgery humans(Mandl)
• 1958-isolation of purified PTH(Rasmussen Craig)
• 84 chain aminoacid polypeptide
• 1960s RIA for PTH

4
ANATOMY OF PARATHYROID GLANDS
-Wt30 mg (10-70 mg). -Size 5x3x1mm. -Develop
from 3rd and 4 th ------bronchial pouches at 6
wks gestation - Migrate to neck at 8
wks. -Blood supply Inferior thyroid artery -
Inferior glands are more variable postition
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
Hypercalcemia.

• Malignancy Multiple myeloma
• Lymphoma,
  Leukemia
• Bone metastases
• Production of
  PTH/Prostaglandins by other
• tumors.
• Drugs Thiazide diuretics
• Vitamin D
  toxicity
• Milk- alkali
  syndrome
• Endocrine Hyperparathyroidism
• Hyperthyroidism
• Acromegaly
• Adrenal
  insufficiency
• Miscellaneous Sarcoidosis
• Tuberculosis
• Immobilization

11
Anatomy of Parathyroid Glands.

• Autopsy study 503 Cases
• 4 glands ------84
• Supernuerary- 13
• 3 glands 3
• Symmetric 80
• Anatomic distribution fairly consistent.
• Surgery, Jan 1984

12
Renal Stones, painful bones and Abdominal
Groansto Vague Neuromuscular and behavioral
symptoms or even without any symptoms
13
Hyperparathyroidism Symptoms and signs

• Renal stones - 63.4
• Bone disease- 24.0
• Peptic ulcer - 7.8
• Asymptomatic- 5.4
• Fatigue 3.0
• Mental confusion2.4

• Pancreatitis 2.3
• Hypertension-1.4
• Palpable neck-1.3
• mass
• Multiple endocrine
• syndrome 1.1
• Pseudogout 0.6

14
Parathyroid adenoma

• Single adenoma (80-90)
• Double adenoma(5-10)
• 4 gland hyperplasia (10-15).
• Neck Surg.2005132359-372

15
Parathyroid adenoma LocalizationMehods

• Radionuclide Techniques
• High resolution Ultrasound
• CT/MRI
• Cine- Esophagography
• Mediastinography
• Arteriography
• Selective Venography( PTH assay)
• Thermography

16
Parathyroid Imaging Agents.
Se-75 Methionine TL-201 Tc-99m

sestamibi
TI/2 120 days
73 hrs
6hrs Photon Energy(kev) 136,265,280,560
69-83,135,169 140 Uptake
Incorporation Potassium analog
-non-specific Mechanism into protein
Intracellular -blood flow


-Mitochondria
17
Dosimetry of Parathyroid Imaging.
Radiopharmaceutica Activity
EDV(mSv) Tc-99m pertechnetate
75 1.0 1-123
20
3.0 Tc-99m Sestamibi
200 2.4(M)

3.0(F) Tl-201
75
25
18
Parathyroid Surgery( controversial)Consensus
Development Conference Panel(Annals of Internal
Medicine,Vol 114 no 7) April ,1991.

• Endocrinologists, surgeons, Radiologists,
• Epidemiologists and primary health care
  providers
• Symptomatic- surgery
• Asymptomatic- not always surgery
• If serum ca is elevated careful surveillance
• If renal and bone status is close to normal
• Preoperative localization without prior surgery
  is
• rarely indicated and not proven to be cost
  effective

19
Parathyroid adenoma localization Various
Protocols

• Tl-201/ Tc /i-123 subtraction.
• Dual phase TC-99m planar Sestamibi .
• Dual phase Tc-99m pin hole sestamibi
• Dual phase Tc-99m Sestamibi with Tc thyroid or
  123 thyroid( subtraction )
• Dual phase pin hole Tc-99 m Sestamibe with Tc-
  99m or 123 thyroid ( subtraction)
• SPECT
• SPECT with thyroid subtraction
• SPECT/CT

20
(No Transcript)
21
Tc-99m-Tl-201 Parathyroid ScanLiterature
ReviewRadiology 1987 162133-137

• Sensitivity82
• Accuracy78
• PPV 94
• FP 5

• No. of papers14
• No. of scans 396
• No. operated317

22
Disadvantages of Tl/Tc scan

• Limited dose of Tl-201
• Poor physical properties
• Proloned pt immobilization
• Pt motion
• Processing artifacts

23
J nucl Med 199233313-318
24
400mg 3.5 gm 300mg
J Nucl Med 1992331801-1807
25
Parathyroid Imaging Protocol.

• SNM procedure guide lines approved June 2004.(
  SPECT/CT not mentioned)
• 3 mci. Tc-99m pertechnetate i.v.
• Anterior 10 minute Neck/chest image
• 25 mci.Tc-99m Sestamibi i.v.
• Serial anterior neck/chest images
• 20, 30, 40, 60 min and 2-3 hr delay
• Computer assisted pertechnetate subtraction from
  sestamibi
• Additional delays, SPECT/CT and pinhole optional

26
10 min with subtraction
3 hrs
27
Tc-99m 10 min Mibi 10 min
Mibi 3hrs
28
SPECT/CT
29
59 yr old man with hypercalcemia and renal stone
on CT.
30
TcO MIBI
Subtraction
31
SPECT/CT
32
Thyroid Spect/ct Thyroid
US
Left thyroid lobe
33
TcO
10 min Mibi
30 min Mibi 3
hr Mibi
Pt on exogenous thyroid medic.
34
AXIAL CORONAL
SAGITAL
35
Tc-99 m Mibi 10 min
Mibi 3 hrs
10 min subtraction
36
SPECT/CT
37
Tc O MIBI 10 MIN
MIBI 3HRS
Transmission
38
PLANAR PINHOLE
39
Early
Delay
7GM ADENOMA
40
The Usefulness of Neck Pinhole SPECT as a
Complementary Tool to Planar Scintigraphy in
Primary and Secondary Hyperparathyroidism Angela
Spanu, MD1, Antonio Falchi, MD1, Alessandra
Manca, MD2, Pietro Marongiu, MD1, Antonio Cossu,
MD2, Nicola Pisu, MD1, Francesca Chessa, MD1,
Susanna Nuvoli, MD1 and Giuseppe Madeddu, MD1
Sen, of 98 vs88
J Nucl Med 20044540-48
41
Ectopic Parathyroid adenoma

• Mediastinal
• Retropharynx
• Carotid sheath
• thymus

42
(No Transcript)
43
Mediastinal Adenoma
coronal
sagital
SPECT
Planar

44
MULTIPLE ADENOMA
Early Delay
45
DIFFUSE HYPERPLASIA
23 yr old man with decreased renal function Serum
ca high Serum PTH 1800
46
Parathyroid ImagingAdvantages prior to surgery

• Reduces operative tim/anasthesia.
• Reduces need for ext. exploration.
• May reduce operative morbidity.
• Localization important in re-explorations.

47
(No Transcript)
48
(No Transcript)
49
Overall Results
plt0.05 versus ALL
Subt Subtraction T Threshold
Nichols, Radiology 2008248(1)221-32.
50
False Negative

• Small adenomas
• Small hyperplastic glands
• Technical
• Histology
• Multiple adenomas

51
FALSE POSITIVE

• Thyroid CA(nodules)
• Multinodular Goiter
• Chronic thyroiditis
• Thymus remnant
• Lymph nodes