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NUCLEAR MEDICINE IMAGING OF PARATHYROID

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. Parathyroid Glands History. 1852-first identified in rhinoceros.

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NUCLEAR MEDICINE IMAGING OF PARATHYROID

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  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 • 1960’s RIA for PTH

  4. ANATOMY OF PARATHYROID GLANDS -Wt=30 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. 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

  6. 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

  7. “ Renal Stones, painful bones and Abdominal Groans”to “ Vague Neuromuscular and behavioral symptoms or even without any symptoms”

  8. 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% Hyperparathyroidism: Symptoms and signs

  9. Parathyroid adenoma • Single adenoma (80-90%) • Double adenoma(5-10%) • 4 gland hyperplasia (10-15%). Neck Surg.2005;132:359-372

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

  11. 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

  12. 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

  13. 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

  14. 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

  15. No. of papers=14 No. of scans= 396 No. operated=317 Sensitivity=82% Accuracy=78% PPV =94% FP =5% Tc-99m-Tl-201 Parathyroid ScanLiterature ReviewRadiology 1987: 162:133-137

  16. Disadvantages of Tl/Tc scan • Limited dose of Tl-201 • Poor physical properties • Proloned pt immobilization • Pt motion • Processing artifacts

  17. J nucl Med 1992;33:313-318

  18. 400mg 3.5 gm 300mg J Nucl Med 1992;33:1801-1807

  19. 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

  20. 10 min with subtraction 3 hrs

  21. Tc-99m 10 min Mibi 10 min Mibi 3hrs

  22. SPECT/CT

  23. 59 yr old man with hypercalcemia and renal stone on CT.

  24. TcO MIBI Subtraction

  25. SPECT/CT

  26. Thyroid Spect/ct: Thyroid US Left thyroid lobe

  27. TcO 10 min Mibi 30 min Mibi 3 hr Mibi Pt on exogenous thyroid medic.

  28. AXIAL CORONAL SAGITAL

  29. Tc-99 m Mibi 10 min Mibi 3 hrs 10 min subtraction

  30. SPECT/CT

  31. Tc O MIBI 10 MIN MIBI 3HRS Transmission

  32. PLANAR PINHOLE

  33. Early Delay 7GM ADENOMA

  34. 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 2004;45:40-48

  35. Ectopic Parathyroid adenoma • Mediastinal • Retropharynx • Carotid sheath • thymus

  36. Mediastinal Adenoma coronal sagital SPECT Planar

  37. MULTIPLE ADENOMA Early Delay

  38. DIFFUSE HYPERPLASIA 23 yr old man with decreased renal function Serum ca high Serum PTH 1800

  39. Parathyroid Imaging:Advantages prior to surgery • Reduces operative tim/anasthesia. • Reduces need for ext. exploration. • May reduce operative morbidity. • Localization important in re-explorations.

  40. Overall Results * p<0.05 versus ALL Subt: Subtraction; T: Threshold Nichols, Radiology 2008;248(1):221-32.

  41. False Negative • Small adenomas • Small hyperplastic glands • Technical • Histology • Multiple adenomas

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