Preoperative imaging for focused parathyroidectomy: making a good strategy even better

Area of Science:

• Endocrinology
• Nuclear Medicine
• Surgical Oncology

Background:

• Surgical treatment for primary hyperparathyroidism (pHPT) has shifted from bilateral neck exploration to focused surgical approaches.
• Image-guided techniques are crucial for the success of focused surgery.

Purpose of the Study:

• To compare the diagnostic performance of parathyroid scintigraphy (PS), ultrasonography (US), and their combination for guiding focused parathyroid surgery.
• To evaluate modified interpretation criteria for these imaging modalities.

Main Methods:

• Retrospective analysis of data from 199 patients with sporadic pHPT.
• Evaluation of ultrasonography (US) and dual-isotope (123)I/(99m)Tc-sestamibi parathyroid scintigraphy (PS) with planar pinhole and SPECT imaging.
• Comparison of imaging results with surgical outcomes.

Main Results:

• Parathyroid scintigraphy (PS) demonstrated high sensitivity (93.3%) and accuracy (83.4%) in predicting uniglandular disease, outperforming US.
• SPECT imaging improved localization of posterior adenomas missed by US.
• The combined imaging protocol diagnosed multiglandular disease in 60.6% of cases.

Conclusions:

• Dual-tracer subtraction parathyroid scintigraphy (PS) is the most accurate modality for directing focused parathyroid surgery.
• PS can guide focused surgery even with a negative US, particularly for posterior adenomas or in patients with a history of thyroidectomy.