Prospective evaluation of the efficacy of technetium 99m sestamibi and iodine 123 radionuclide imaging of abnormal parathyroid glands.

BACKGROUND: Technetium 99m sestamibi is an isonitrile radionuclide imaging agent that, when used with subtraction iodine 123 thyroid scans, has the potential for imaging abnormal parathyroid glands. METHODS: We prospectively evaluated 20 patients with hyperparathyroidism to study the efficacy of Tc 99m sestamibi and 123I subtraction radionuclide scanning for the imaging of abnormal parathyroid glands. All patients underwent neck exploration and histologic confirmation of all parathyroid glands identified. RESULTS: The solitary adenomas in 11 of 16 patients with primary hyperparathyroidism were localized with sestamibi scans. The scans in four of five patients with diffuse parathyroid hyperplasia showed bilateral localization consistent with enlarged glands. The fifth patient previously underwent a subtotal parathyroidectomy, and a fifth supernumerary gland was localized with the sestamibi scan. Four patients had hyperparathyroidism related to kidney disease. Three of these had bilateral localization of enlarged glands. The fourth patient had undergone two previous operations, and a fifth supernumerary gland was localized with the sestamibi scan. CONCLUSIONS: The preliminary data indicate that Tc 99m sestamibi in combination with 123I radionuclide scanning may be useful in the preoperative localization of abnormal parathyroid glands. This technique localized all of the solitary adenomas that were subsequently resected, and in two reoperative cases it identified the remaining solitary gland causing persistent hypercalcemia.

Investigations on the level of circulating eosinophils throughout a 24 hour period in parasitic disease.

Circulating absolute eosinophil levels were studied over a 24 hour period in a series of 10 patients with presumed parasitological disease. Seven of these ten had the distinct nocturnal increase and a percentage swing paralleling that found in normal subjects. Three patients had a reversed pattern. The latter were thought to have one or other form of filariasis. Two patients with loasis and a "physiological response" had suppression as anticipated to exogenous steroid. It is concluded that steroid administration will not separate parasitic from other causes of eosinophilia.

Analysis of savings in operative time for primary hyperparathyroidism using localization with technetium 99m sestamibi scan.

BACKGROUND: The cost effectiveness of preoperative localization in cases of primary hyperpara-thyroidism has not been established. We analyzed the potential savings in operative time after localization with technetium 99m (99mTc) sestamibi scan. METHODS: Thirty-three patients had localization of a solitary adenoma with 99mTc-sestamibi. Measurement was made of the time required for adenomectomy, unilateral neck exploration (UNE), unilateral neck exploration and confirmation of one contralateral parathyroid gland (UNEC), or bilateral neck exploration (BNE). RESULTS: The total operative time in minutes was 76.4 +/- 18.8 for adenomectomy; 87.5 +/- 20.4 for UNE; 105.6 +/- 25.0 for UNEC; and 117.9 +/- 26.7 for BNE. The time difference was significant between adenomectomy versus UNE, UNEC, and BNE. There were also significant time differences between UNE versus UNEC and BNE. CONCLUSIONS: The preoperative localization of a solitary parathyroid adenoma may optimize operative time with UNE, saving approximately 30 minutes.

Prospective comparison of technetium-99m-sestamibi/iodine-123 radionuclide scan versus high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands in patients with previously unoperated primary hyperparathyroidism.

Surgery for primary hyperparathyroidism is successful in 95% of patients, but ectopic glands and anatomic variations in location are causes of surgical failure. The radionuclide imaging agent, technetium (Tc)-99m-sestamibi, in conjunction with subtraction iodine-123 scanning, is a new method of preoperative localization of abnormal parathyroid glands. In a study approved by the Institutional Review Board, 22 patients with primary hyperparathyroidism underwent preoperative evaluation with high-resolution ultrasonography and Tc-99m-sestamibi/I-123 radionuclide scanning for attempted localization of abnormal parathyroid glands. Results of Tc-99m-sestamibi scanning and ultrasound were correlated with surgical and pathologic findings. Of 22 patients, 16 had a solitary parathyroid adenoma, 1 had a double adenoma, and 5 had diffuse parathyroid hyperplasia. The Tc-99m-sestamibi/I-123 radionuclide scan preoperatively identified a solitary adenoma in 14 of 16 patients (sensitivity: 88%). However, when the data were analyzed retrospectively along with surgical and pathologic findings, the Tc-99m-sestamibi scan correctly localized all parathyroid adenomas for a sensitivity of 100%. The one patient with a double adenoma had a localization image consistent with two enlarged glands. All patients with diffuse parathyroid hyperplasia had Tc-99m-sestamibi imaging consistent with diffuse hyperplasia, although delineation of individual enlarged glands was not possible. High-resolution ultrasound identified 11 of 16 parathyroid adenomas (sensitivity: 69%). The patient with a double adenoma had a negative ultrasound. Ultrasound was less accurate in five patients with diffuse hyperplasia: one scan was completely negative, two scans revealed only one enlarged gland, and two scans revealed two enlarged glands. The Tc-99m-sestamibi/I-123 subtraction radionuclide scan is more sensitive than high-resolution ultrasonography for the preoperative localization of abnormal parathyroid glands. Tc-99m-sestamibi/I-123 radionuclide scanning may be more useful than ultrasonography to the surgeon in the preoperative localization of abnormal parathyroid glands.

99m-Technetium sestamibi localized solitary parathyroid adenoma as an indication for limited unilateral surgical exploration.

BACKGROUND: Because of its successful localization of solitary adenomas, 99m-Technetium sestamibi (MIBI) may challenge the standard operation for primary hyperparathyroidism. METHODS: Thirty-five consecutive patients underwent preoperative MIBI localization to optimize a surgical approach. Single-site localization in 21 patients directed a limited unilateral neck exploration (UNE) with adenomectomy and ipsilateral gland biopsy. Fourteen patients who did not localize underwent bilateral neck exploration (BNE). Conversion to a bilateral operation was required in 1 UNE patient because no adenoma was found on that side. RESULTS: There were no significant differences in preoperative and postoperative serological markers between the two groups. However, the total operative time for UNE (49 +/- 21 minutes) was significantly less than for BNE (103 +/- 45 minutes; P <0.001). CONCLUSIONS: Preoperative MIBI scan-directed limited unilateral neck operation may be used reliably for primary hyperparathyroidism due to a single adenoma, and thereby reduce operative time, extent of surgical dissection, and risk.

Cost utility of routine imaging with Tc-99m-sestamibi in primary hyperparathyroidism before initial surgery.

Tc-99m-sestamibi has been shown to localize parathyroid adenomas effectively, but controversy continues as to the use of this scan before initial surgery for primary hyperparathyroidism. We analyzed the cost utility of obtaining this study before initial surgery for primary hyperparathyroidism. Twenty-two consecutive patients with primary hyperparathyroidism underwent dual-phase Tc-99m-sestamibi scan before initial bilateral neck exploration. Surgical findings were correlated with the results of sestamibi scan. There were 15 women and 7 men, with a mean age of 50.5 years (range, 22-76). Preoperative mean total calcium was 11.74 mg/dL (range, 10-15), ionized calcium was 6.19 mg/dL (range, 5.2-7.7), and intact parathyroid hormone was 153.5 pg/mL (range, 83.1-551). Postoperative mean ionized calcium was 4.56 mg/dL (range, 4.1-5.57). Twenty sestamibi scans had a positive localization, and 2 scans had no localization. At surgery, 18 solitary adenomas, 3 diffuse hyperplasias, and 1 patient with four normal parathyroid glands were found. Sixteen sestamibi scans were true positive (solitary adenoma), 4 scans were false positive (2 diffuse hyperplasia, 1 wrong side, and 1 lymph node), 1 negative scan was true negative (diffuse hyperplasia), and 1 negative scan was false negative (adenoma). One patient (four normal glands) at the second operation had a supernumerary fifth gland adenoma excised from the mediastinum. Preoperative Tc-99m-sestamibi scan did not offer any advantage when a complete bilateral neck exploration is performed. Sixteen of (84%) adenomas were correctly localized, but 18 of 19 adenomas were in the neck and were easily found. The 1 ectopic adenoma was not found by scanning or with initial surgery. The 4 of 22 (18%) false-positive localizations and the 2 of 22 (9%) negative scans contributed nothing to the surgery. Of the 22 localizing sestamibi scans, surgery was not altered to affect the outcome. At a cost of $550 per sestamibi scan and with the error inherent in the scan, it is not cost effective to obtain Tc-99m-sestamibi scan before initial surgery for primary hyperparathyroidism.

Impact of technetium-99m-sestamibi localization on operative time and success of operations for primary hyperparathyroidism.

Intraoperative identification of abnormal parathyroid glands during initial neck exploration for primary hyperparathyroidism is challenging and may require extensive dissection of the neck and mediastinum. We, therefore, evaluated the impact of preoperative localization with Technetium-99m-sestamibi (Tc-99m-sestamibi) and Iodine-123 radionuclide subtraction imaging on operative time and success of initial operation for primary hyperparathyroidism. From January 1989 to September 1992, 42 patients underwent neck exploration for primary hyperparathyroidism; 21 patients underwent neck exploration without preoperative radionuclide scanning, and 21 patients were operated upon following radionuclide Tc-99m-sestamibi localization. In the control group, pathologic exam revealed 15 patients had solitary adenomas, and six patients had diffuse hyperplasia. In the Tc-99m-sestamibi group, 16 patients had solitary adenomas, four had diffuse hyperplasia, and one had multiple adenomas. Analysis of patient demographic data revealed no differences between the control group and the Tc-99m-sestamibi group in mean age (56 vs 59 years), mean intact PTH levels (249 vs 234 pg/mL), mean total calcium (11.3 vs 12.0 mg/dL), and mean ionized calcium (6.19 vs 6.28 mg/dL). Comparison of operative data revealed no differences between groups in the mean number of parathyroid glands identified and biopsied per patient (3.1 vs 3.3), the mean largest diameter of the resected adenomas (19.6 vs 20.0 mm), and the number of patients requiring thymectomy, thyroid resection, retroesophageal exploration, mediastinal exploration, or carotid sheath exploration. The operative success rate was 90 per cent for the control group versus 100 per cent for the Tc-99m-sestamibi group.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo uptake of technetium-99M-sestamibi by parathyroid glands in comparison to surrounding tissues of the neck.

Technetium-99M-sestamibi (Tc-99M-sestamibi) has recently been proven to be a sensitive and specific agent for imaging of parathyroid disease; however, the selective nature of its uptake by different tissues has not been investigated. Fifteen consecutive patients undergoing neck exploration for hyperparathyroidism were given 3 to 15 mCi of Tc-99M-sestamibi at various times before surgery, and at the time of exploration, samples of parathyroid tissue, blood, fat, muscle, and thyroid were taken from the neck. All samples were carefully weighed and counts of radioactivity were measured. Activity was normalized to counts per gram of tissue and counts of radioactivity were compared using a multiple range analysis of variance test. Mean counts per gram (+/- SE) in abnormal parathyroid tissue (adenomas and hyperplastic glands; 1.1 x 10(6) +/- 2.7 x 10(6)) were significantly higher than in any of the other tissues measured (P < 0.05): thyroid, 7.0 x 10(4) +/- 1.6 x 10(4); muscle, 8.9 x 10(4) +/- 2.1 x 10(4); fat, 2.1 x 10(4) +/- 4.2 x 10(3); and blood, 9.8 x 10(3) +/- 2.3 x 10(3). Mean ratios of counts (+/- SE) of abnormal parathyroid tissue to other tissues were found to be as follows: thyroid, 35.3 +/- 12.6; muscle, 17.4 +/- 6.2; fat, 80.7 +/- 20.0; and blood, 161.0 +/- 31.6. From these data, Tc-99M-sestamibi clearly exhibits significantly higher uptake in abnormal parathyroid tissue relative to other tissues measured in the neck. This increased uptake in parathyroid gland tissue accounts for the utility of Tc-99M-sestamibi in localization studies for hyperparathyroidism. Quantification of in vivo uptake of Tc-99M-sestamibi may help refine techniques for improved localization of hyperfunctional parathyroid glands.

Early detection of Rasmussen's syndrome by brain SPECT imaging.

The authors describe a patient with Rasmussen's syndrome detected by grossly abnormal results of Tc-99m HMPAO SPECT brain imaging obtained with a single-headed camera. Results of magnetic resonance imaging and cerebrospinal fluid examinations were normal.

Ga-67 used to localize the tumor bed for radiation therapy after lumpectomy.

The authors present a new method to locate the tumor bed after lumpectomy. The method relies on accumulation of Ga-67 at the surgical site. This technique was useful in identifying the tumor bed in six candidates for breast conserving surgery and radiation therapy. This method may be applicable in other soft tissue malignancies that require postoperative radiation.

Pneumothorax complicating acute asthma.

The association of asthma and pneumothorax in hospital practice is examined. The association varies from 1:300 to 1:1 000 acute asthmatics admitted to either a specialized or general unit. The clinical details of 18 patients with further reference to associated parenchymal lung diseases are discussed.

Problems in distinguishing tuberculosis of bowel from Crohn's disease in Asians.

The cases of five immigrants with definite or almost certain intestinal tuberculosis are described. Because of the clinical, pathological, and radiological features all were thought as some time, often for long periods, to have Crohn's disease. Recommendations are made for medical and surgical treatment.

Characterization of the neoplastic potential of solitary solid thyroid lesions with Tc-99m-pertechnetate and Tc-99m-sestamibi scanning.

BACKGROUND: Radionuclide scans that use Tc-99m-pertechnetate or I-123 currently lack the specificity to assess the malignant potential of solitary solid lesions of the thyroid gland. Tc-99m-sestamibi scanning was used to determine the neoplastic potential of thyroid lesions. METHODS: Patients with lesions of the thyroid underwent Tc-99m-sestamibi imaging to assess the neoplastic potential of their thyroid lesions, identified as solitary and cold by radionuclide imaging with Tc-99m-pertechnetate. Tc-99m-sestamibi uptake was correlated with fine-needle aspiration cytology or surgical pathology. RESULTS: Twenty-seven patients were evaluated using Tc-99m-pertechnetate and Tc-99m-sestamibi scans: 14 had right thyroid lesions, and 13 had left thyroid lesions. Of 27 patients, 10 had a positive Tc-99m-sestamibi scan: one Hürthle cell adenoma, one papillary carcinoma, six follicular adenomas, and two nodular goiters. Of 27 patients, 17 had a negative Tc-99m-sestamibi scan: one follicular carcinoma, one papillary carcinoma, two follicular adenomas, one Hürthle cell adenoma, one metastatic adenocarcinoma, one medullary carcinoma, four nodular goiters, and six colloid nodules. Positive Tc-99m-sestamibi scan identified neoplasms with a sensitivity of 53%, a specificity of 83%, and a positive predictive value of 80%. CONCLUSIONS: Tc-99m-sestamibi scanning lacks sufficient sensitivity for diagnosis of solitary thyroid nodules. Future work may define a role for its use in recurrent or metastatic thyroid neoplasms.

Isoniazid-induced pellagra in a patient on vitamin B supplement.

A patient who was treated with isoniazid and who developed pellagra is presented. Vitamin B supplements did not help, but the patient's condition improved when isoniazid treatment was stopped.

Parathyroid scintigraphy with iodine-123 and 99mTc-sestamibi: imaging findings.

Subtraction scintigraphy with 99mTc-pertechnetate and 201Tl-chloride is widely used for localizing the parathyroid gland, but the sensitivity of this method averages only 55%. The sensitivity of scintigraphy is improved by using a combination of 99mTc-sestamibi and iodine-123. Parathyroid adenomas can also be localized with 99mTc-sestamibi alone by subtracting early images from late sequential images. The fast washout of 99mTc-sestamibi from the thyroid gland allows visualization of the parathyroid gland. The purpose of this essay is to illustrate the findings of abnormalities of the parathyroid glands when using a combination of 99mTc-sestamibi and iodine-123.