Title: NUCLEAR MEDICINE IMAGING OF PARATHYROID
1NUCLEAR 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
2Parathyroid 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
3ParathyroidHistory( contd)
- 1926-first parathyroid surgery humans(Mandl)
- 1958-isolation of purified PTH(Rasmussen Craig)
- 84 chain aminoacid polypeptide
- 1960s RIA for PTH
4ANATOMY 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
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10Hypercalcemia.
- 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
-
11Anatomy 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
13Hyperparathyroidism 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
-
-
14Parathyroid adenoma
- Single adenoma (80-90)
- Double adenoma(5-10)
- 4 gland hyperplasia (10-15).
- Neck Surg.2005132359-372
15Parathyroid adenoma LocalizationMehods
- Radionuclide Techniques
- High resolution Ultrasound
- CT/MRI
- Cine- Esophagography
- Mediastinography
- Arteriography
- Selective Venography( PTH assay)
- Thermography
16Parathyroid 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
17Dosimetry 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
18Parathyroid 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
19Parathyroid 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
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21Tc-99m-Tl-201 Parathyroid ScanLiterature
ReviewRadiology 1987 162133-137
- Sensitivity82
- Accuracy78
- PPV 94
- FP 5
- No. of papers14
- No. of scans 396
- No. operated317
22Disadvantages of Tl/Tc scan
- Limited dose of Tl-201
- Poor physical properties
- Proloned pt immobilization
- Pt motion
- Processing artifacts
23J nucl Med 199233313-318
24400mg 3.5 gm 300mg
J Nucl Med 1992331801-1807
25Parathyroid 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
2610 min with subtraction
3 hrs
27Tc-99m 10 min Mibi 10 min
Mibi 3hrs
28SPECT/CT
2959 yr old man with hypercalcemia and renal stone
on CT.
30TcO MIBI
Subtraction
31SPECT/CT
32Thyroid Spect/ct Thyroid
US
Left thyroid lobe
33TcO
10 min Mibi
30 min Mibi 3
hr Mibi
Pt on exogenous thyroid medic.
34AXIAL CORONAL
SAGITAL
35Tc-99 m Mibi 10 min
Mibi 3 hrs
10 min subtraction
36SPECT/CT
37Tc O MIBI 10 MIN
MIBI 3HRS
Transmission
38PLANAR PINHOLE
39Early
Delay
7GM ADENOMA
40The 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
41Ectopic Parathyroid adenoma
- Mediastinal
- Retropharynx
- Carotid sheath
- thymus
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43Mediastinal Adenoma
coronal
sagital
SPECT
Planar
44MULTIPLE ADENOMA
Early Delay
45DIFFUSE HYPERPLASIA
23 yr old man with decreased renal function Serum
ca high Serum PTH 1800
46Parathyroid ImagingAdvantages prior to surgery
- Reduces operative tim/anasthesia.
- Reduces need for ext. exploration.
- May reduce operative morbidity.
- Localization important in re-explorations.
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49Overall Results
plt0.05 versus ALL
Subt Subtraction T Threshold
Nichols, Radiology 2008248(1)221-32.
50False Negative
- Small adenomas
- Small hyperplastic glands
- Technical
- Histology
- Multiple adenomas
51FALSE POSITIVE
- Thyroid CA(nodules)
- Multinodular Goiter
- Chronic thyroiditis
- Thymus remnant
- Lymph nodes