NUCLEAR MEDICINE
IMAGING OF PARATHYROID
LALITHA RAMANNA M.D.
Little Company of Mary Hospital,Torrance , CA
34 th Annual We...
Parathyroid Glands
History
• 1852-first identified in rhinoceros.
• 1898- tetany first described in cats/dogs
after removi...
Parathyroid
History( contd)
• 1926-first parathyroid surgery
humans(Mandl)
• 1958-isolation of purified
PTH(Rasmussen& Cra...
ANATOMY OF PARATHYROID GLANDS
-Wt=30 mg (10-70 mg).
-Size = 5x3x1mm.
-Develop from 3rd and 4 th
------bronchial pouches at...
Hypercalcemia.
• Malignancy: Multiple myeloma
Lymphoma, Leukemia
Bone metastases
Production of PTH/Prostaglandins by other...
Anatomy of Parathyroid Glands.
• Autopsy study 503 Cases
– 4 glands –------84%
– Supernuerary- 13%
– 3 glands 3%
– Symmetr...
“ Renal Stones, painful bones
and
Abdominal Groans”
to
“ Vague Neuromuscular and
behavioral symptoms or even
without any s...
Hyperparathyroidism:
Symptoms and signs
• Renal stones - 63.4%
• Bone disease- 24.0%
• Peptic ulcer - 7.8%
• Asymptomatic-...
Parathyroid adenoma
• Single adenoma (80-90%)
• Double adenoma(5-10%)
• 4 gland hyperplasia (10-15%).
Neck Surg.2005;132:3...
Parathyroid adenoma Localization
Mehods
• Radionuclide Techniques
• High resolution Ultrasound
• CT/MRI
• Cine- Esophagogr...
Parathyroid Imaging Agents.
Se-75 Methionine TL-201 Tc-99m
sestamibi
TI/2 120 days 73 hrs 6hrs
Photon
Energy(kev) 136,265,...
Dosimetry of Parathyroid Imaging.
Radiopharmaceutica Activity EDV(mSv)
Tc-99m pertechnetate 75 1.0
1-123 20 3.0
Tc-99m Ses...
Parathyroid Surgery( controversial)
Consensus Development Conference Panel
(Annals of Internal Medicine,Vol 114 no 7) Apri...
Parathyroid adenoma localization :
Various Protocols
• Tl-201/ Tc /i-123 subtraction.
• Dual phase TC-99m planar Sestamibi...
Tc-99m-Tl-201 Parathyroid Scan
Literature Review
Radiology 1987: 162:133-137
• No. of papers=14
• No. of scans= 396
• No. ...
Disadvantages of Tl/Tc scan
• Limited dose of Tl-201
• Poor physical properties
• Proloned pt immobilization
• Pt motion
•...
J nucl Med 1992;33:313-318
J Nucl Med 1992;33:1801-1807
400mg
3.5 gm
300mg
Parathyroid Imaging Protocol.
• SNM procedure guide lines approved June
2004.( SPECT/CT not mentioned)
• 3 mci. Tc-99m per...
10 min with subtraction
3 hrs
Tc-99m 10 min Mibi 10 min Mibi 3hrs
SPECT/CT
59 yr old man with hypercalcemia and renal stone on CT.
TcO MIBI Subtraction
SPECT/CT
Thyroid Spect/ct: Thyroid
US
Left thyroid lobe
TcO 10 min
Mibi
30 min Mibi 3 hr Mibi
Pt on exogenous thyroid medic.
AXIAL CORONAL
SAGITAL
Tc-99 m Mibi 10 min Mibi 3 hrs
10 min subtraction
SPECT/CT
Tc O MIBI 10 MIN MIBI 3HRS
Transmission
PLANAR PINHOLE
7GM ADENOMA
Early Delay
The Usefulness of Neck Pinhole SPECT as a Complementary Tool
to Planar Scintigraphy in Primary and Secondary
Hyperparathyr...
Ectopic Parathyroid adenoma
• Mediastinal
• Retropharynx
• Carotid sheath
• thymus
Mediastinal Adenoma
Planar
coronal
sagital
SPECT
Early
Delay
MULTIPLE ADENOMA
DIFFUSE HYPERPLASIA
23 yr old man with decreased
renal function
Serum ca high
Serum PTH 1800
Parathyroid Imaging:
Advantages prior to surgery
• Reduces operative tim/anasthesia.
• Reduces need for ext. exploration.
...
Overall Results
EARLY LATE SUBT SPECT Early +
Late
PLANAR ALL
Sens
66%* 78%* 81%* 83%* 84%* 88% 90%
Spec
93% 91% 93% 84%* ...
False Negative
• Small adenomas
• Small hyperplastic glands
• Technical
• Histology
• Multiple adenomas
FALSE POSITIVE
• Thyroid CA(nodules)
• Multinodular Goiter
• Chronic thyroiditis
• Thymus remnant
• Lymph nodes
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
Ramanna, Saturday, Session VIII
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  • AKIYAMA WENDY
  • Mary lou Cohen
  • Mary Lou Cohen
  • VOLKERT, JACOB 1/15/2009 Thy ca and parathyroid adenoma
  • VOLKERT, JACOB
  • VOLKERT, JACOB
  • JERNG,LINDA ,7/15/2009 PT ON EXOGENOUS THY MEDICATION
  • JERING LINDA
  • BURNS,CHARLOTTE, 7/27/2009
  • BURNS CHARLOTTE
  • Stephens Gordon 9/15/2008
  • Ramanna, Saturday, Session VIII

    1. 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. 2. Parathyroid Glands History • 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. 3. Parathyroid History( contd) • 1926-first parathyroid surgery humans(Mandl) • 1958-isolation of purified PTH(Rasmussen& Craig) 84 chain aminoacid polypeptide • 1960’s RIA for PTH
    4. 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. 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. 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. 7. “ Renal Stones, painful bones and Abdominal Groans” to “ Vague Neuromuscular and behavioral symptoms or even without any symptoms”
    8. 8. Hyperparathyroidism: Symptoms and signs • 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%
    9. 9. Parathyroid adenoma • Single adenoma (80-90%) • Double adenoma(5-10%) • 4 gland hyperplasia (10-15%). Neck Surg.2005;132:359-372
    10. 10. Parathyroid adenoma Localization Mehods • Radionuclide Techniques • High resolution Ultrasound • CT/MRI • Cine- Esophagography • Mediastinography • Arteriography • Selective Venography( PTH assay) • Thermography
    11. 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. 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. 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. 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. 15. Tc-99m-Tl-201 Parathyroid Scan Literature Review Radiology 1987: 162:133-137 • No. of papers=14 • No. of scans= 396 • No. operated=317 • Sensitivity=82% • Accuracy=78% • PPV =94% • FP =5%
    16. 16. Disadvantages of Tl/Tc scan • Limited dose of Tl-201 • Poor physical properties • Proloned pt immobilization • Pt motion • Processing artifacts
    17. 17. J nucl Med 1992;33:313-318
    18. 18. J Nucl Med 1992;33:1801-1807 400mg 3.5 gm 300mg
    19. 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. 20. 10 min with subtraction 3 hrs
    21. 21. Tc-99m 10 min Mibi 10 min Mibi 3hrs
    22. 22. SPECT/CT
    23. 23. 59 yr old man with hypercalcemia and renal stone on CT.
    24. 24. TcO MIBI Subtraction
    25. 25. SPECT/CT
    26. 26. Thyroid Spect/ct: Thyroid US Left thyroid lobe
    27. 27. TcO 10 min Mibi 30 min Mibi 3 hr Mibi Pt on exogenous thyroid medic.
    28. 28. AXIAL CORONAL SAGITAL
    29. 29. Tc-99 m Mibi 10 min Mibi 3 hrs 10 min subtraction
    30. 30. SPECT/CT
    31. 31. Tc O MIBI 10 MIN MIBI 3HRS Transmission
    32. 32. PLANAR PINHOLE
    33. 33. 7GM ADENOMA Early Delay
    34. 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 J Nucl Med 2004;45:40-48 Sen, of 98% vs88%
    35. 35. Ectopic Parathyroid adenoma • Mediastinal • Retropharynx • Carotid sheath • thymus
    36. 36. Mediastinal Adenoma Planar coronal sagital SPECT
    37. 37. Early Delay MULTIPLE ADENOMA
    38. 38. DIFFUSE HYPERPLASIA 23 yr old man with decreased renal function Serum ca high Serum PTH 1800
    39. 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. 40. Overall Results EARLY LATE SUBT SPECT Early + Late PLANAR ALL Sens 66%* 78%* 81%* 83%* 84%* 88% 90% Spec 93% 91% 93% 84%* 90% 87% 89% Acc 79%* 85%* 87%* 83%* 87%* 88% 89% PPV 91% 91% 93% 85%* 90% 88% 90% NPV 71%* 79%* 81%* 82%* 83%* 87% 89% T >1 >2 >2 >2 >2 >2 >2 * p<0.05 versus ALLSubt: Subtraction; T: Threshold Nichols, Radiology 2008;248(1):221-32.
    41. 41. False Negative • Small adenomas • Small hyperplastic glands • Technical • Histology • Multiple adenomas
    42. 42. FALSE POSITIVE • Thyroid CA(nodules) • Multinodular Goiter • Chronic thyroiditis • Thymus remnant • Lymph nodes

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