Correlation of Preoperative Imaging Findings and Parathyroidectomy Outcomes Support NICE 2019 Guidance.

CONTEXT: Preoperative localization studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalized disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. OBJECTIVE: This study aims to correlate parathyroidectomy outcomes with preoperative imaging in a single, high-volume institution. METHODS: Data from a prospectively maintained departmental database of operations performed from 2017 to 2019 were analyzed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, preoperative imaging, surgical strategy, and postoperative outcomes. RESULTS: A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localized patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalized group (those with negative US and sestamibi) (P = 0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double-positive imaging and 5.7% of patients with double-negative imaging (otherwise, bilateral parathyroid visualization was performed). There was no significant difference in postoperative complications between patients undergoing unilateral or bilateral neck exploration. CONCLUSIONS: Patients with negative preoperative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localized. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of preoperative imaging findings.

A cost-utility analysis of 18F-fluorocholine-positron emission tomography imaging for localizing primary hyperparathyroidism in the United States.

BACKGROUND: Primary hyperparathyroidism historically necessitated bilateral neck exploration to remove abnormal parathyroid tissue. Improved localization allows for focused parathyroidectomy with lower complication risks. Recently, positron emission tomography using radiolabeled 18F-fluorocholine demonstrated high accuracy in detecting these lesions, but its cost-effectiveness has not been studied in the United States. METHODS: A decision tree modeled patients who underwent parathyroidectomy for primary hyperparathyroidism using single preoperative localization modalities: (1) positron emission tomography using radiolabeled 18F-fluorocholine, (2) 4-dimensional computed tomography, (3) ultrasound, and (4) sestamibi single photon emission computed tomography (SPECT). All patients underwent either focused parathyroidectomy versus bilateral neck exploration, with associated cost ($) and clinical outcomes measured in quality-adjusted life-years gained. Model parameters were informed by literature review and Medicare costs. Incremental cost-utility ratios were calculated in US dollars/quality-adjusted life-years gained, with a willingness-to-pay threshold set at $100,000/quality-adjusted life-year. One-way, 2-way, and threshold sensitivity analyses were performed. RESULTS: Positron emission tomography using radiolabeled 18F-fluorocholine gained the most quality-adjusted life-years (23.9) and was the costliest ($2,096), with a total treatment cost of $11,245 or $470/quality-adjusted life-year gained. Sestamibi single photon emission computed tomography and ultrasound were dominated strategies. Compared with 4-dimentional computed tomography, the incremental cost-utility ratio for positron emission tomography using radiolabeled 18F-fluorocholine was $91,066/quality-adjusted life-year gained in our base case analysis, which was below the willingness-to-pay threshold. In 1-way sensitivity analysis, the incremental cost-utility ratio was sensitive to test accuracy, positron emission tomography using radiolabeled 18F-fluorocholine price, postoperative complication probabilities, proportion of bilateral neck exploration patients needing overnight hospitalization, and life expectancy. CONCLUSION: Our model elucidates scenarios in which positron emission tomography using radiolabeled 18F-fluorocholine can potentially be a cost-effective imaging option for primary hyperparathyroidism in the United States. Further investigation is needed to determine the maximal cost-effectiveness for positron emission tomography using radiolabeled 18F-fluorocholine in selected populations.

Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism.

BACKGROUND: Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. METHODS: Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. RESULTS: In 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). CONCLUSION: Long-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.

Feasibility and Utility of Adenosine Stress Echocardiography in Children Following Post-Arterial Switch Operation: A Comparison with Technetium 99m-Sestamibi Myocardial Perfusion SPECT (MPS).

There is a need for a sensitive, safe, and cost-effective tool for coronary assessment among asymptomatic post-operative children who have undergone arterial switch operation (ASO) for transposition of great arteries (TGA). Adenosine stress echocardiography may be useful in assessing major structures as well for coronary functional assessment. Twenty-six children [median age 6.0 years; IQR 4.9-7.1 years, (22 boys)], who had undergone ASO at a median age of 40 days (IQR 30-75 days), were prospectively included. Left ventricular ejection fraction (LVEF) was calculated in both rest and stress studies (140 µg/kg/min of adenosine IV over 4 min), along with assessment of regional myocardial wall motion. Coronary flow reserve (CFR) was also measured in the left anterior descending artery (LAD). Technetium 99m-MIBI [0.2mCi/kg] was injected after 2 min of adenosine infusion. Adenosine infusion had to be stopped in two children, due to transient atrioventricular (AV) block. The LVEF increased from 55.87 ± 7.27 to 61.20 ± 7.70% (p < 0.001) with adenosine stress. No significant regional wall motion abnormality was seen in rest or stress. Distal LAD could not be visualized in four patients. Basal and peak coronary flow velocities were 41.51 ± 14.12 and 74.18 ± 6.01 cm/s. Mean CFR was 1.91 ± 0.51. Myocardial perfusion scintigraphy (MPS) was normal in all the patients. Four patients were lost to follow-up and remaining children did not develop any adverse events in the follow-up period of 64.5 ± 7.19 months. Adenosine stress echocardiography is feasible as the initial screening test in the assessment of asymptomatic post-operative children with ASO, at minimal to no inconvenience to the patient. The findings concurred with stress MPS.

The changing face of reoperative parathyroidectomy: a single-centre comparison of 147 parathyroid reoperations.

INTRODUCTION: Reoperative parathyroidectomy for persistent and recurrent primary hyperparathyroidism is dependent on radiology. This study aimed to compare outcomes in reoperative parathyroidectomy at a single centre using a combination of traditional and newer imaging studies. MATERIALS AND METHODS: Retrospective case note review of all reoperative parathyroidectomies for persistent and recurrent primary hyperparathyroidism over five years (June 2014 to June 2019; group A). Imaging modalities used and their positive predictive value, complications and cure rates were compared with a published dataset spanning the preceding nine years (group B). RESULTS: From over 2000 parathyroidectomies, 147 were reoperations (101 in group A and 46 in group B). Age and sex ratios were similar (56 vs 62 years; 77% vs 72% female). Ultrasound use remains high and shows better positive predictive value (76% vs 57 %). 99mTc-sestamibi use has declined (79% vs 91%) but the positive predictive value has improved (74% vs 53%). 4DCT use has almost doubled (61% vs 37%) with better positive predictive value (88% vs 75%). 18F-fluorocholine positron emission tomography-computed tomography and ultrasound-guided fine-needle aspiration for parathyroid hormone are novel modalities only available for group A. Both carried a positive predictive value of 100%. Venous sampling with or without angiography use has decreased (35% vs 39%) but maintains a high positive predictive value (86% vs 91%). Cure rates were similar (96% vs 100%). Group A had 5% permanent hypoparathyroidism, 1% permanent vocal cord palsy and 1% haematoma requiring reoperation. No complications for group B. CONCLUSION: Optimal imaging is key to good cure rates in reoperative parathyroidectomy. High-quality, non-interventional imaging techniques have produced a shift in the preoperative algorithm without compromising outcomes.

Acute hyperparathyroid crisis: ectopic submandibular parathyroid gland the culprit.

Parathyroid exploration via a focused approach or bilateral neck exploration should be considered in the management of all types of hyperparathyroidism. Eutopic and ectopic, single or multiple glands can pose challenges to the surgeon and available preoperative imaging modalities may not be equally applicable or appropriate in all cases. We report an interesting case of parathyroid surgery where the patient presented with a rare ectopic adenoma in the form of a hyperparathyroid crisis.

The role of 99mTc-MIBI SPECT/CT in patients with secondary hyperparathyroidism: comparison with 99mTc-MIBI planar scintigraphy and ultrasonography.

BACKGROUND: This study aimed to compare the sensitivity of 99mTc-MIBI SPECT/CT, 99mTc-MIBI planar scintigraphy and ultrasonography (US) in patients with secondary hyperparathyroidism (SHPT), and to explore the factors that affect the sensitivity of 99mTc-MIBI SPECT/CT. METHODS: In this retrospective study, forty-six patients with SHPT who underwent 99mTc-MIBI planar scintigraphy, 99mTc-MIBI SPECT/CT and US were enrolled. They underwent surgery within 1 month. We compared the sensitivity of the different imaging methods based on the lesions according to the pathological results. The parathyroid lesions on 99mTc-MIBI SPECT/CT images were divided into missed diagnosis group (MDG) and non-missed diagnosis group (NMDG). We compared the lesion to background ratio (LBR), maximum diameter, volume, the mean CT Hounsfield unit values (CTmean) and location of lesions between MDG and NMDG. RESULTS: The sensitivity of 99mTc-MIBI SPECT/CT, 99mTc-MIBI planar scintigraphy and US were 70.30% versus 48.48% versus 61.82%, respectively. The sensitivity of 99mTc-MIBI SPECT/CT combined US was 79.39%, which was higher than 99mTc-MIBI SPECT/CT with significant difference (P = 0.000). On 99mTc-MIBI SPECT/CT images, the LBR, maximum diameter and volume of lesions in MDG was smaller than those in NMDG with significant difference (P < 0.001). The average LBR, maximum diameter and volume of lesions in MDG and NMDG were 3.42 ± 1.28, 9.32 ± 2.69 mm, 208.51 ± 163.22 mm3 versus 6.75 ± 5.08, 15.03 ± 4.94 mm and 863.85 ± 1216.0 mm3, respectively. CONCLUSIONS: 99mTc-MIBI SPECT/CT exhibited the highest sensitivity among the three methods. When 99mTc-MIBI SPECT/CT combined with US, the sensitivity can be further improved. Lesions with lower MIBI uptake and smaller lesions on 99mTc-MIBI SPECT/CT images were easily missed.

18F-fluorocholine PET/CT in MEN1 Patients with Primary Hyperparathyroidism.

BACKGROUND: Primary hyperparathyroidism (HPT1) is the most frequent endocrinopathy in multiple endocrine neoplasia type 1 (MEN1). Its surgical management is challenging. We aimed to describe and compare the imaging findings of parathyroid ultrasound (US), sestaMIBI scintigraphy (sestaMIBI), and 18F-fluorocholine (FCH) PET/CT in a series of MEN1 patients with HPT1. METHODS: Retrospective analysis of a cohort of MEN1 patients with HPT1 assessed by parathyroid US, sestaMIBI scintigraphy and SPECT/CT, and FCH-PET/CT for potential surgery between 2015 and 2019. RESULTS: Twenty-two patients with a confirmed diagnosis of MEN1 who presented with HPT1 and were assessed by the 3 imaging modalities were included. After imaging workups, 11 patients were operated on for the first time, 4 underwent a redo surgery, and 7 did not undergo an operation. The overall patient-based positivity rate of imaging was 91% (20 of 22) for parathyroid US and 96% (21 of 22) for both sestaMIBI and FCH-PET/CT. The 3 imaging modalities demonstrated negative findings in 1/22 patient who did not undergo surgery. Overall, 3 pathologic glands were not detected by any imaging technique. SestaMIBI and FCH-PET/CT both resulted in the same 3 false-positive results in ectopic areas with a significant uptake on two thymic carcinoid tumors and one inflammatory lymph node. FCH-PET/CT provided more surgically relevant data than sestaMIBI in 4/11 patients with initial surgery and in 1/4 patient who underwent redo surgery. CONCLUSIONS: Compared to sestaMIBI scintigraphy, FCH-PET/CT provides additional information regarding the number of pathologic parathyroid glands and their localization in MEN1 patients with HPT1.

Surgical options in treating patients with primary hyperparathyroidism.

Background Primary hyperparathyroidism is the third most common endocrine disorder for which surgical procedure called parathyroidectomy is the most effective treatment. Since the early 20th century, parathyroid surgery has improved extensively. With the advances in preoperative imaging and with understanding the causes of disease, new and minimally invasive surgical approaches overrode the standard bilateral exploratory operations. Directed parathyroidectomy is currently the standard technique for treatment of primary hyperparathyroidism worldwide. Conclusions Surgery is the only definitive treatment of primary hyperparathyroidism. The most appropriate type of surgical procedure depends on the number and localization of the hyperactive parathyroid glands, availability of modern imaging techniques, limitation of each type of procedure and expertise.

Added value of 18F-fluorocholine positron emission tomography-computed tomography in presurgical localization of hyperfunctioning parathyroid glands after dual tracer subtraction scintigraphy failure: A retrospective study of 47 patients.

Hyperparathyroidism is a common endocrine disorder. The precise localization of causal parathyroid gland is crucial to guide surgical treatment. Several studies report the added value of 18F-fluorocholine (FCH) positron emission tomography-computed tomography (PET/CT) as second line imaging but rely on suboptimal first-line imaging using 99mTc-sestaMIBI dual phase scintigraphy. The aim of this study is to evaluate the percentage of successful parathyroid localization with FCH PET/CT after failure of a more sensitive first-line detection protocol associating neck ultrasonography and 99mTc-Pertechnetate/99mTc-sestaMIBI dual tracer subtraction scintigraphy.We included retrospectively 47 patients who underwent a FCH PET/CT as second line imaging for biologically proven primary hyperparathyroidism from November 2016 to October 2018 in Godinot Institute (Reims, France). 99mTc-Pertechnetate/99mTc-sestaMIBI dual tracer subtraction scintigraphy and neck ultrasonography were used as first-line imaging and failed to localize the causal parathyroid lesion in all cases.FCH PET/CT demonstrated at least 1 parathyroid target lesion in 29 patients (62%). 21/29 patients underwent surgery. Target lesions corresponded histologically to hyperfunctioning parathyroid glands for all 21 patients and surgery was followed by hyperparathyroidism biological resolution. Calcium serum levels were associated to FCH PET/CT positivity (P = .002) and a trend toward significance was seen for Parathyroid hormone (PTH) levels (P = .09).FCH PET/CT is a promising tool in second-line parathyroid imaging. Large prospective studies and cost-effectiveness analyses are needed to precise its role.

Does acid reflux precipitate ischaemia in subjects with acute coronary syndrome?

AIM: It has been postulated that gastro-oesophageal reflux disease (GORD) may trigger coronary ischaemia through viscerocardiac reflex vasoconstriction in subjects with ischaemic heart disease (IHD). Our aim was to estimate the prevalence of GORD in subjects with IHD who present with acute coronary syndrome (ACS) and to determine whether GORD may serve as a trigger for ischaemic events. METHODS: Twenty patients with isolated reflux oesophagitis and 39 with acute coronary syndrome (ACS with concomitant GORD) were studied. Twenty-two subjects comprising normal volunteers and those who were admitted for minor surgical trauma were used as normal controls. All subjects underwent oesophago-gastroduodenal endoscopy (EGD) and acid instillation with hydrochloric acid (0.1 M), as well as nuclear imaging (sestaMIBI) with technetium99. Ischaemia was detected by ST depression using ECG monitoring for one hour during and immediately after EGD. RESULTS: Of the 111 subjects with ACS, 39 (35.1%) had erosive GORD and comprised the study group. Subjects with ACS had more incidence of diabetes (p = 0.001), hypertension (p = 0.002), a history of smoking (p = 0.006) and elevated serum triglyceride levels (p = 0.008) compared to the GORD group. Risk-factor clustering in the form of the metabolic syndrome was more common in ACS subjects (44 vs 5%; p = 0.008). ST depression was documented in 8/39 (20.5%) patients in the ACS group and 5/20 (25%) in the GORD group (p = 0.958). Reversible perfusion defects on sestaMIBI scan were seen in 35.6% of the ACS subjects. CONCLUSIONS: Although GORD is common in subjects with ACS, we have not been able to show that GORD may serve as a trigger for ischaemia in these subjects.

18Fluorocholine PET/CT scanning with arterial phase-enhanced CT is useful for persistent/recurrent primary hyperparathyroidism: first UK case series results.

INTRODUCTION: Redo parathyroidectomy for persistent/recurrent primary hyperparathyroidism is associated with a higher risk of complications and should be planned only with convincing localisation. We assessed whether 18fluorocholine positron emission tomography/computed tomography could identify parathyroid adenoma(s) in patients with persistent/recurrent primary hyperparathyroidism and negative conventional scans. MATERIALS AND METHODS: A departmental database was used to identify patients with failed localisation attempts (sestamibi single photon emission computed tomography/computed tomography and/or computed tomography/magnetic resonance imaging and/or selective parathyroid hormone sampling) after previous unsuccessful surgery for primary hyperparathyroidism. 18Fluorocholine positron emission tomography was performed in all patients and redo surgery offered to those with positive findings. RESULTS: 18Fluorocholine positron emission tomography incorporating arterial and portal phase enhanced computed tomography was performed in 12 patients with persistent/recurrent primary hyperparathyroidism (four men and eight women). Seven patients (58%) were cured after excision of adenomas located in ectopic positions (n = 3) or in anatomical position (n = 4). Five patients (42%) had persistent hypercalcaemia and repeat 18fluorocholine scan confirmed that the area highlighted on preoperative scans was excised. The arterial phase enhancement of the computed tomography was significantly different between cured and not-cured patients (P = 0.007). All seven cured patients had either a strong or weak enhancing pattern on computed tomography. Standardised uptake value at 60 minutes in patients with successful surgery (range 2.7-15.7, median 4.05) was higher than in patients with failed surgery (range 1.8-5.8, median 3.2) but was not statistically significant (P = 0.300). DISCUSSION: 18fluorocholine scanning can identify elusive parathyroid adenomas, including those that are ectopic, and is useful in the management of patients with persistent/recurrent primary hyperparathyroidism when first-line scans are negative. The grading of the arterial phase of computed tomography can help to differentiate between true adenomas and false positive targets (lymph nodes).

Impact of short-term low-dose tamoxifen on molecular breast imaging background parenchymal uptake: a pilot study.

BACKGROUND: High background parenchymal uptake (BPU) on molecular breast imaging (MBI) has been identified as a breast cancer risk factor. We explored the feasibility of offering a short-term intervention of low-dose oral tamoxifen to women with high BPU and examined whether this intervention would reduce BPU. METHODS: Women with a history of high BPU and no breast cancer history were invited to the study. Participants had an MBI exam, followed by 30 days of low-dose oral tamoxifen at either 5 mg or 10 mg/day, and a post-tamoxifen MBI exam. BPU on pre- and post-tamoxifen MBI exams was quantitatively assessed as the ratio of average counts in breast fibroglandular tissue vs. average counts in subcutaneous fat. Pre-tamoxifen and post-tamoxifen BPU were compared with paired t tests. RESULTS: Of 47 women invited, 22 enrolled and 21 completed the study (10 taking 5 mg tamoxifen, 11 taking 10 mg tamoxifen). Mean age was 47.7 years (range 41-56 years). After 30 days low-dose tamoxifen, 8 of 21 women (38%) showed a decline in BPU, defined as a decrease from the pre-tamoxifen MBI of at least 15%; 11 of 21 (52%) had no change in BPU (within ± 15%); 2 of 21 (10%) had an increase in BPU of greater than 15%. Overall, the average post-tamoxifen BPU was not significantly different from pre-tamoxifen BPU (1.34 post vs. 1.43 pre, p = 0.11). However, among women taking 10 mg tamoxifen, 5 of 11 (45%) showed a decline in BPU; average BPU was 1.19 post-tamoxifen vs. 1.34 pre-tamoxifen (p = 0.005). In women taking 5 mg tamoxifen, 2 of 10 (20%) showed a decline in BPU; average BPU was 1.51 post-tamoxifen vs.1.53 pre-tamoxifen (p = 0.99). CONCLUSIONS: Short-term intervention with low-dose tamoxifen may reduce high BPU on MBI for some patients. Our preliminary findings suggest that 10 mg tamoxifen per day may be more effective than 5 mg for inducing declines in BPU within 30 days. Given the variability in BPU response to tamoxifen observed among study participants, future study is warranted to determine if BPU response could predict the effectiveness of tamoxifen for breast cancer risk reduction within an individual. TRIAL REGISTRATION: ClinicalTrials.gov NCT02979301 . Registered 01 December 2016.

Ectopic Parathyroid Adenoma: Surgical Correction and its Complication Management.

Ectopic parathyroid are most frequently found in the anterior mediastinum, in association with the thymus or the thyroid gland. Ectopic parathyroid glands are a major cause of persistent and recurrent Hyperparathyroidism. We report a case of 65-year-old female was referred from Surgical Endocrine department to the department of Cardiac Surgery on 20 September, 2017 in Bangabandhu Sheikh Mujib Medical University with parathyroid crisis due to an ectopic mediastinal parathyroid adenoma with her serum calcium and PTH markedly increased in short time. Computed tomography of the chest and lower neck showed an ovoid soft tissue density area measuring about 25×20×15mm in the anterior mediastinum. Technetium-99m-sestamibi (MIBI) scintigraphy scan showed positive and detected localized parathyroid adenoma/hyperplasia in superior mediastinum. Ectopic parathyroid adenoma resection was performed via median sternotomy approach. But after 4 hours patient developed the color change of the left arm due to acute left upper limb ischemia of unknown cause for which the patient was rushed to operation theatre suspecting it to be embolic occlusion and managed by both surgical and medical therapy.

Dwarfs and Giants of Parathyroid Adenomas-No Difference in Outcome After Parathyroidectomy.

BACKGROUD: This study compares the outcome of parathyroidectomy for primary hyperparathyroidism (PHPT) in patients whose adenomas' weights were at the extremes of the distribution curve. As the size of parathyroid adenomas influences the success rate of localization studies for PHPT, it is possible that a difference in cure rate could be observed between subgroups of patients. MATERIALS AND METHODS: Data were retrieved from a prospective database maintained in a large university hospital. RESULTS: From a cohort of 519 patients who underwent parathyroidectomy for PHPT, two subgroups of patients were identified based on the extreme 10% of the distribution curve for adenomas' weight: adenomas <300 mg ("dwarfs", n = 100, median 200 mg) and >3000 mg ("giants", n = 56, median 4300 mg). In comparison with giant adenomas, dwarf adenomas were associated with less severe hypercalcemia (median 2.84 versus 3.00 mmol/L, P < 0.001) and lower PTH (median 11.7 versus 25.6 pmol/L, P < 0.001). The occurrence of dwarf adenomas showed no trend during the study period (23/173 [13%] in 2000-2004 versus 36/217 [17%] in 2007-2011). Scan-directed parathyroidectomy was feasible in more patients with giant adenomas (59% versus 38%). Persistent disease was diagnosed in three patients with dwarf adenomas. Patients with giant adenomas had no recurrence during a follow-up of 40 mo even though eight patients had histological features suggestive of atypical/malignant tumors. CONCLUSIONS: Preoperative biochemistry is a poor predictor of adenomas' size even at the extremes of the distribution curve. Cure can be achieved in all patients with "dwarf" adenomas. Even in the presence of suspicious histological features, "giant" adenomas did not show malignant behavior.

Combined use of a nanocarbon suspension and 99mTc-MIBI for the intra-operative localization of the parathyroid glands.

OBJECTIVE: To investigate the combined use of a nanocarbon (NC) suspension and low-dose 99mTc-MIBI for parathyroid localization during surgery in patients with secondary hyperparathyroidism (sHPT). METHODS: Between March 2010 and September 2015, 40 patients with sHPT were enrolled in this study and were randomized to receive either low-dose 99mTc-MIBI+NC (group I) or low-dose 99mTc-MIBI (group II). Pre- and post-operative serum levels of intact PTH (iPTH), calcium and phosphorus between groups were compared and the intra-operative radioactive counts of the parathyroid glands were measured. RESULTS: The post-operative iPTH level was significantly lower in patients of group I (24.2±31ng/L) than in those of group II (106±155ng/L) (P=0.03) while there were no significant differences in intra-operative parathyroid gland radioactive counts between the groups. The duration of the surgical procedure was shorter for patients of group I than patients of group II. There were no serious intra-operative or post-operative complications. CONCLUSION: The combined use of an NC suspension and 99mTc-MIBI for patients with sHPT is strongly recommended for the localization of parathyroid glands during surgery and is likely to improve clinical outcomes for patients.

Cardiac death in patients with left ventricular aneurysm, remodeling and myocardial viability by gated 99mTc-MIBI SPECT and gated 18F-FDG PET.

(1) To evaluate the prognostic value of LV remodeling parameters in patients with LV aneurysm by gated SPECT (GSPECT), gated PET (GPET) and CMR; (2) to evaluate the impact of myocardial viability and LV remodeling on the long-term cardiac survival in patients with LV aneurysm. One hundred and twenty-six consecutive patients underwent GPET, GSPECT and CMR within two weeks, with a mean follow-up of 3.9 ± 1.5 years. End-diastolic volume (EDV, mL) and end-systolic volume (ESV, mL) measured by GPET, GSPECT and CMR and corrected for BSA; EDVI and ESVI were calculated. Patients were divided into three groups by aneurysmal viability [mismatch score (MMS) of aneurysm ≥2.0] and LV remodeling (ESVI by GPET > 60 mL/m2). Group 1 (Viability -, LV remodeling -); Group 2 (Viability -, LV remodeling +) and Group 3 (Viability +, LV remodeling -/+). ESVI by GPET, MMS of aneurysm and summed rest score of aneurysm by multivariate regression analysis; as well as ESVI by GPET (HR 1.024, 95% CI 1.011-1.037, p = .0004), MMS of aneurysm (HR 1.284, 95% CI 1.051-1.577, p = .015) by interaction analysis were approved being independent predictors for cardiac death (p < .05). The long-term cardiac survival was significantly improved by revascularization in comparison with medical therapy in Group3 (p < .01), but did not significantly differ between Groups 1 and 2. ESVI by GPET showed a significant positive predictive value for cardiac death. Patients with viable myocardial aneurysm were most likely at increased risk for cardiac death and coronary revascularization was significantly associated with improved long-term cardiac survival. In contrast, the long-term cardiac survival of patients without LV remodeling and without aneurysmal viability was promising and, thus, could be treated by medical therapy.

Is Technetium-99m Sestamibi Imaging Able to Predict Pathologic Nonresponse to Neoadjuvant Chemotherapy in Breast Cancer? A Meta-analysis Evaluating Current Use and Shortcomings.

BACKGROUND: Interest in technetium-99m (99mTc)-sestamibi imaging for neoadjuvant chemotherapy (NAC) response monitoring in locally advanced breast cancer (LABC) is increasing but remains matter of discussion. The present study conducted a meta-analysis of the diagnostic performance of 99mTc-sestamibi to predict pathologic nonresponse to NAC for primary LABC. MATERIALS AND METHODS: A systematic data search was performed. Studies with a minimum of 10 LABC patients that had evaluated 99mTc-sestamibi imaging for NAC nonresponse using conventional planar scintimammography, breast-specific γ-imaging, and/or single photon emission computed tomography/computed tomography (SPECT/CT) were included. The histopathologic findings were the reference standard. The meta-analysis was performed using a mixed logistic regression model. RESULTS: The search revealed 14 eligible studies with 529 patients. Of the 14 studies, 11 had evaluated scintimammography and 3 breast-specific γ-imaging. No studies examining SPECT or SPECT/CT were found. The overall estimated pooled sensitivity, specificity, and positive and negative likelihood ratios of 99mTc-sestamibi imaging to predict nonresponsiveness to NAC were 70.3% (95% confidence interval [CI], 56.5%-81.3%%), 90.1% (95% CI, 77.5%-96.0%), 7.13 (95% CI, 3.08-16.53), and 0.33 (95% CI, 0.22-0.49), respectively. Only 3 studies (107 patients) evaluated 99mTc-sestamibi imaging during NAC, reported an estimated pooled sensitivity of 87% (95% CI, 72%-100%) and specificity of 93% (95% CI, 85%-100%). CONCLUSION: Only planar 99mTc-sestamibi imaging has been investigated for NAC nonresponse in LABC but showed low sensitivity to predict pathologic nonresponse. However, most studies focused on the prediction of pathologic complete response after NAC. Although experience is limited, 99mTc-sestamibi uptake during NAC seems highly sensitivity for the prediction of nonresponsiveness. Features such as SPECT/CT imaging, standardized quantification, relation to tumor subtypes, and proper timing have been insufficiently evaluated and require further investigation.

Focal Pulmonary Uptake on 99mTc-Sestamibi Parathyroid Scintigraphy Due to Iatrogenic Microembolism.

A middle-aged woman underwent Tc-sestamibi parathyroid scintigraphy because of parathyroid disease, and a focal pulmonary uptake of Tc-sestamibi was incidentally found on both planar and SPECT/CT images without corresponding pulmonary abnormality on the CT images. After 10 days, a subsequent parathyroid scintigraphy revealed no pulmonary accumulation. Therefore, the pulmonary intense Tc-sestamibi focus that once appeared in the first scan might be an artifact of iatrogenic microembolism from injection site.