Double-phase Tc-99m sestamibi scintigraphy in the preoperative location of lesions causing hyperparathyroidism

Hyperparathyroidism (HPT) is one of the most prevalent endocrine diseases, for which the only effective treatment is surgery. The use of imaging techniques in the preoperative localization of the hyperfunctioning glands is the subject of controversy. The purpose of this paper is to assess the use of double-phase scintigraphy with Tc-99m sestamibi in the localization of lesions causing HPT. We used scintigraphy to preoperatively examine 41 patients, 31 of whom had primary HPT and 10 with secondary HPT. We acquired two anterior view planar images of the neck and chest 10 minutes and 3 hours after injection of Tc-99m sestamibi. Final diagnosis, determined with biopsy, was adenoma in 26 patients, 24 of whom had a positive scintigraphic study (sensitivity 92%), with only two false negative results. In the 14 cases of parathyroid hyperplasia, scintigraphy was also positive, and 62% (30/48) of the excised glands were identified by Tc-99m sestamibi. The radioisotope study was of particular interest in the six patients who previously had undergone surgery, since all the studies were positive; in two patients, additional diseased glands were located in the neck, and an ectopic adenoma was found in the remaining four patients. A fifth ectopic lesion was also sestamibi-positive and, in this case, the scintigraphic result was a direct indication for mediastinal surgery. There were no false positive results, even in patients with multinodular goiter. We conclude that, due to its high sensitivity and the ease with which it is performed, double-phase scintigraphy with Tc-99m sestamibi is the preferred technique for the preoperative localization of diseased glands in patients with HPT, especially in cases of parathyroid adenoma, including those with aberrant location. Its use is of particular interest in patients who previously have undergone surgery.