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ORIGINAL ARTICLE
Year : 2022  |  Volume : 21  |  Issue : 2  |  Page : 161-164  

Primary hyperparathyroidism: Correlation between cervical ultrasound and MIBI scan


1 Department of Endocrinology, Diabetology and Nutrition, Hospital University Hassan II.Fez; Faculty of Medicine and Pharmacy, Sidi Mohamed Benabdellah University; Laboratory of Epidemiology and Research in Health Sciences, Fez, Morocco
2 Department of Endocrinology, Diabetology and Nutrition; Department of Radiology, Hospital University Hassan II.Fez, Fez, Morocco
3 Department of Radiology, Hospital University Hassan II.Fez; Faculty of Medicine and Pharmacy, Sidi Mohamed Benabdellah University, Fez, Morocco
4 Department of Radiology, Hospital University Hassan II.Fez; Laboratory of Epidemiology and Research in Health Sciences, Fez, Morocco
5 Department of Endocrinology, Diabetology and Nutrition; Department of Radiology; Department of Nuclear Medicine, Hospital University Hassan II.Fez, Fez, Morocco

Date of Submission18-Jul-2020
Date of Acceptance29-Apr-2021
Date of Web Publication6-Jul-2022

Correspondence Address:
Houda Salhi
Department of Endocrinology, Diabetology and Nutrition, University Hospital Hassan II, Fez 30000
Morocco
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_73_20

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   Abstract 


Introduction: The standard gold treatment of primary hyperparathyroidism (PHP) is parathyroidectomy. Imaging in particular, cervical ultrasound (US) and technetium-99 m- méthoxyisobutylisonitrileparathyroid scintigraphy using the single-photon emission computed tomography (TC-99 m-MIBI-SPECT) are always indicated prior to parathyroid surgery, allowing the location of parathyroid adenomas. The objective of our study is to evaluate the contribution of TC-99 m-MIBI-SPECT and US in the preoperative topographic diagnosis of PHP. Materials and Methods: this is a descriptive and analytical retrospective study, conducted in our department of Endocrinology, Diabetology and Metabolic Diseases in Hassan II University Hospital of Fez between 2009 and 2018. All patients who received a para-thyroidectomy for PHP were recruited. All patients had received a cervical US and a TC-99 m-MIBI-SPECT. We compared imaging data before surgery with data from intraoperative exploration and anatomopathological findings of surgical samples. Results: Forty-eight patients were collected. US correctly identified parathyroid adenoma in 85.40% of patients with PHP versus 89.50% in TC-99 m-MIBI-SPECT. US correctly predicted surgical outecomes in 97.60% of patients and TC-99 m-MIBI-SPECT in 97.72% of cases. Their combination had better results in sensitivity and positive predictive value. Conclusion: TC-99 m-MIBI-parathyroid scintigraphy SPECT had a higher probability for solitary parathyroid adenoma compared to cervical US. Its use coupled with the TC-99 m-MIBI-parathyroid scintigraphy SPECT allows reliable preoperative tracking.

   Abstract in French 

Résumé
Introduction: Le gold standard du traitement de l'hyperparathyroïdie primaire (HPTP) est la parathyroïdectomie. Afin de localiser l'adénome parathyroïdien avant la chirurgie, Le bilan topographique fait appel à l'échographie cervicale et à la scintigraphie parathyroïdienne au technetium-99 m-méthoxyisobutylisonitrile(TC-99m-MIBI-SPECT).L'objectif de notre étude est d'évaluer la contribution du TC-99 m-MIBI-SPECT et de l'échographie au diagnostic topographique préopératoire de HPTP. Matériels et méthodes: Il s'agit d'une étude rétrospective descriptive et analytique, menée dans notre département d'Endocrinologie, Diabétologie et Maladies métaboliques au CHU Hassan II de Fès entre 2009 et 2018. Tous les patients ayant subi une para-thyroïdectomie pour des HPTP ont été recrutés. Tous les patients avaient bénéficié d'une échographie cervicale et une scintigraphie au TC - 99 m - MIBI - SPECT. Nous avons comparé les données d'imagerie avant la chirurgie avec les données issues de l'exploration peropératoire et les résultats de l'étude anatomopathologique des échantillons chirurgicaux. Résultats: on a inclus quarante-huit patients. l'adénome parathyroïdien était correctement identifié chez 85,40% des patients à l'échographie cervicale contre 89,50% à la scintigraphie au TC - 99 m - MIBI - SPECT. l'échographie cervicale avait prédit correctement les résultats chirurgicaux chez 97,60% des patients contre 97,72% à la scintigraphie au TC - 99 m - MIBI - SPECT. Leur combinaison avait une meilleure sensibilité et une meilleure valeur prédictive positive. Conclusion: la scintigraphie parathyroïde auTC - 99 m - MIBI - SPECT avait une probabilité plus élevée les adénomes parathyroïdiens solitaires par rapport à l'échographie cervicale. Son utilisation couplée à la scintigraphie parathyroïde TC-99 m-MIBI- SPECT permettait une localisation préopératoire plus fiable.
Mots-clés: échographie cervicale, valeur prédictive positive, hyperparathyroïdie primaire, scintigraphie parathyroidienne au technétium-99m - méthoxyisobutylisonitrileparathyroïde à l'aide de la tomodensitométrie par émission de photons uniques

Keywords: Cervical ultrasound, positive predictive value, primary hyperparathyroidism, technetium-99 m-méthoxyisobutylisonitrileparathyroid scintigraphy using the single-photon emission computed tomography


How to cite this article:
Salhi H, Bouziane T, Maaroufi M, Alaoui NI, El Ouahabi H. Primary hyperparathyroidism: Correlation between cervical ultrasound and MIBI scan. Ann Afr Med 2022;21:161-4

How to cite this URL:
Salhi H, Bouziane T, Maaroufi M, Alaoui NI, El Ouahabi H. Primary hyperparathyroidism: Correlation between cervical ultrasound and MIBI scan. Ann Afr Med [serial online] 2022 [cited 2022 Aug 18];21:161-4. Available from: https://www.annalsafrmed.org/text.asp?2022/21/2/161/349965




   Introduction Top


It was long considered a rare disease; primary hyperparathyroidism (PHP) is now a common disease.[1] The most common cause of PHP is an adenoma of one of the four parathyroid glands. Rarely, PHP is part of one of three forms of family PHP.[2] Parathyroid surgery has evolved significantly over the last 25 years. Most surgeons have rapidly accepted the use of minimally invasive surgery (MIP) instead of traditional parathyroidectomy. Indeed, MIP has a lot of advantages such as reducing operating time, length of hospitalization, and postoperative complications.[3] The location of the skin incision is usually dictated by preoperative tracking data. Imaging in particular ultrasound (US) and technetium-99 m-méthoxyisobutylisonitrileparathyroid (TC-99 m-MIBI)-parathyroid scintigraphy are indicated prior to parathyroid surgery, thus locating parathyroid adenomas. In recent years, single-photon emission computed tomography (SPECT)/CT has been added to parathyroid scintigraphy protocols to provide a valuable three-dimensional localization.[4] Their diagnostic accuracy was similar, if not superior, to those of second-line localization methods such as CT scans or magnetic resonance imaging.[5] While the cervical US provides more anatomical details; TC-99 m-MIBI-SPECT gives functional details. The purpose of our study is to assess the contribution of TC-99 m-MIBI-SPECT and cervical US for presurgical localization of abnormal parathyroid glands in patients with PHP while comparing imaging data with data from intraoperative exploration and anatomopathological findings.


   Materials and Methods Top


Patient selection

This retrospective study enrolled all patients who underwent a parathyroidectomy for PHP between 2009 and 2018 in the Department of Endocrinology, Diabetology and Metabolic Diseases of hospital university Hassan II de Fez. We included all symptomatic patients (bone pain or fracture, renal lithiases). Patients with asymptomatic PHP under surveillance only, PHP discovered during pregnancy were excluded. All of our patients had a biological assessment of calcemia, albuminemia, phosphoremia, daily urinary calcium excretion, parathyroid hormone (PTH), and 25 hydroxyl vitamin D. The PHP was diagnosed on the basis of the finding of high levels of total and/or ionized calcium and high or inappropriate PTH levels. All of our patients had a cervical US and TC-99 m-MIBI-parathyroid scintigraphy-SPECT.

The cervical US was performed at the radiology department by an expert radiologist in the parathyroid gland. The report provided specifies the following: seat, size, echogenicity, and vascularization.

The TC-99 m-MIBI-parathyroid scintigraphy was performed in the Nuclear medicine Department of Hospital University Hassan II Fez. Hybrid wash-out protocol (double tracer): acquisition of images on hybrid camera SPECT/CT Symbia T6.

Thyroid tracking scan

realization of a planar recording in previous incidence 10 min after injection of 49 MBq of Pertechnetate.

Parathyroidal scintigraphy

realization of a planar recording with an anterior incidence 10 min and then 2, 4, and 6 h after injection of 550 MBq of 99 mTc MIBI. Followed by a single-photon emission computed tomography (SPECT)/CT.

The scintigraphic and US results before surgery were compared with the results of intraoperative exploration and anatomopathological findings of surgical samples. The reference standard for correct localization was the location of the gland or glands on the basis of surgical reports, with pathologic confirmation of resected glands as parathyroid adenoma or hyperplasia.

Informed consent

All patients gave their verbal consent for use of their anonymized data for scientific purposes.

Statistical analysis

The statistical analysis was conducted using Microsoft Excel 2004 (XML) and EPI info 7(7.2.2. Février 2018). Quantitative values are expressed on average-standard deviation and qualitative values as a percentage. For all analyses, a P = 0.05 was considered to be significant.


   Results Top


Forty-eight patients were enrolled. The average age was 55.6 years with a female predominance. Demographic and biological characteristics are summarized in [Table 1].
Table 1: Demographic and biological characteristics of our population

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[Table 2] shows the following information.
Table 2: Positive and negative results by ultrasound and TC 99m MIBI SPECT

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Among the 48 patients, cervical US correctly identified 41/48 adenomas (85.40%) and TC-99 m-MIBI-SPECTidentified43/48 adenomas (89.50%). Furthermore, when both modalities were applied together, 45/48 (93.70%) adenomas were correctly detected.

Of the 48 suspected adenomas, the overall sensitivity of cervical US, TC-99 m-MIBI-SPECT, and the combined US and TC-99 m-MIBI-SPECT with respect to anatomopathological findings were 91.10%, 95.50s%, and 95.70% respectively. While the overall specificity was 66.6%, 66.6%, 100%, respectively. Positive predictive values (PPVs) of US and TC-99 m-MIBI-SPECT and the Combined US and TC-99 m-MIBI-SPECT were 97.60%, 97.72% and 100% respectively for parathyroid adenomas [Figure 1] and [Figure 2].
Figure 1: Cervical ultrasound showing a mass under and retro thyroid left lobar; measuring 2.30 cm in longitudinal section. In Color Doppler: central and peripheral hypervascularization of the parathyroid nodule

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Figure 2: Cervical ultrasound showing a mass under and retro thyroid left lobar; measuring 2.30 cm in longitudinal section. In Color Doppler: central and peripheral hypervascularization of the parathyroid nodule

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   Discussion Top


Prior to the advent of imaging, previous studies had objected that exploratory cervicotomia was curative in 92%–95% of cases.[5] Preoperative topographical imaging to locate the pathological gland in a preoperative setting is highly recommended. It will avoid surgical failures.[6] A variety of imaging techniques have been used in the past to provide presurgical localization for parathyroid surgery. Currently favored approaches use US and Tc-99 m-MIBI. They have benefited from technological advances. In addition; they provide the resolution and specificity that achieve the required PPVs.[5] The two techniques are complementary. This preoperative localization is essential if we are considering a MIP with a unilateral surgical approach under local anesthesia, which have tended to develop since the 1990s.[7] MIP can be done either through the standard Kocher incision, a smaller midline incision, with video assistance or through an ectopically placed, extracervical incision. Indeed, this technique compared to conventional surgery reduces the duration of surgery, the limitation of fibrosis-the area operated-if indication of a new re-intervention as well as the stay at the hospital.[8] In their study, Cakal et al.[9] had shown that cervical US had a sensitivity of 89.7% and the TC-99 m-MIBI of 71.8%, and their combined use had a sensitivity of 92.3%. On the other hand, EAG Ibrahim et al.[10] reported an estimated 97.2% sensitivity of cervical US and 92% TC-99 m-MIBI and that their combinations increase the sensitivity to 100%. They explained his findings, by the fact that they had few cases of parathyroid hyperplasia in their series and they excluded ectopic parathyroid adenomas, secondary hyperparathyroidism. In our study, cervical US had a sensitivity of 91.10% and TC-99 m-MIBI-SPECTof 95.50%, and that their combinations increase the sensitivity to 95.70%. We can explain that by the use of MIBI scan coupled with the SPECT/CT which provides a valuable three-dimensional localization. Tokman et al. concluded through their study that there is significant value in adding SPECT-CT to initial diagnostic imaging algorithms to localize a parathyroid adenoma preoperatively.[4] In a number of cases (10%–15%),[11] 4.16% in our study, TC-99 m-MIBI-SPECT shows no fixation on parathyroid adenoma, even when it is in a nonectopic and good-size position. This finding, while unusual should not lead to questioning the diagnosis of location made by the v, if it is sufficiently safe. Conversely, TC-99 m-MIBI-SPECT may show an obvious fixation image that does not correspond to US to any precise image of parathyroid. In our study, cervical US was negative in 8.33%. Therefore, the presence of a concomitant multinodular goiter can distract this research. In this case, repeat the US, focusing it on the suspect region; this often allows to find an anomaly that had gone unnoticed at the first US.[10] In their study, Cakal et al. reported that the diagnosis of a parathyroid adenoma was missed by cervical US in 25% of patients with thyroid pathology.[9] Most diagnostic studies reported the PPV of the test instead of specificity due to false-negative cases. In their meta-analysis, comparing 12 studies, Moghadam et al. concluded that there were no significant differences between the two methods in terms of sensitivity and specificity. There were overlaps in 99% confidence intervals. The characteristics of the two methods are also similar.[12] Zang et al. had objected that cervical US and MIBI scans are two complementary techniques that overcome the limitations inherent in each technique.[13] In our study, the PPVs of US and TC-99 m-MIBI-SPECT and the Combined US and TC-99 m-MIBI-SPECT were 97.60%, 97.72% and 100% respectively for parathyroid adenomas.


   Conclusion Top


In our study, Tc-99 m-MIBI-SPECT had a higher sensitivity, accuracy, and PPV for solitary parathyroid adenoma compared to the cervical US. Its use coupled with the Tc-99 m-MIBI-SPECT allows reliable preoperative identification in case of agreement of the two methods on the uniqueness of the adenoma.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Heath H 3rd, Hodgson SF, Kennedy MA. Primary hyperparathyroidism. Incidence, morbidity, and potential economic impact in a community. N Engl J Med 1980;302:189-93.  Back to cited text no. 1
    
2.
Köhler Ballan B, Philippe J. Primary hyperparathyroidism asymptomatic in 2014. Swiss Med J 2015; 11: 58-61.  Back to cited text no. 2
    
3.
Berngelfelz A, Kanngiesser V, Zielcke A, Nies C, Rothmund M. Conventional bilateral cervical exploration versus open minimally invasive parathyroidectomy under local anaesthesia for primary hyperparathyroidism. Br J Surg 2005;92:190-7.  Back to cited text no. 3
    
4.
Tokmak H, Demirkol MO, Alagöl F, Tezelman S, Terzioglu T. Clinical impact of SPECT-CT in the diagnosis and surgical management of hyper-parathyroidism. Int J Clin Exp Med 2014;7:1028-34.  Back to cited text no. 4
    
5.
Scheiner JD, Dupuy DE, Monchik JM, Noto RB, Cronan JJ. Pre-operative localization of parathyroid adenoma: A comparison of power and colour Doppler ultrasonography with nuclear medicine scintigraphy. Clin Radiol 2001;56:984-8.  Back to cited text no. 5
    
6.
ScottM. Wilhelm ; Tracy S.Wang ; Daniel T. Ruan ; James A. Lee ; Sylvia L. Asa ;Quan-Yang et al. The American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary Hyperparathyroidism.JAMA Surg. 2016;151(10):959-968.  Back to cited text no. 6
    
7.
Chapuis Y, Fulla Y, Bonnichon P, Tarla E, Abboud B, Pitre J, et al. Values of ultrasonography, sestamibi scintigraphy, and intraoperative measurement of 1-84 PTH for unilateral neck exploration of primary hyperparathyroidism. World J Surg 1996;20:835-9.  Back to cited text no. 7
    
8.
van Dalen A, Smit CP, van Vroonhoven TJ, Burger H, de Lange EE. Minimally invasive surgery for solitary parathyroid adenomas in patients with primary hyperparathyroidism: Role of US with supplemental CT. Radiology 2001;220:631-9.  Back to cited text no. 8
    
9.
Cakal E, Cakir E, Dilli A, Colak N, Unsal I, Aslan MS, et al. Parathyroid adenoma screening efficacies of different imaging tools and factors affecting the success rates. Clin Imaging 2012;36:688-94.  Back to cited text no. 9
    
10.
Ibrahim EA, Elsadawy ME. Combined Tc-99m sesta MIBI scintigraphy and ultrasonography. Egypt J Radiol Nucl Med 2015;46:937-41.  Back to cited text no. 10
    
11.
Xue J, Liu Y, Ji T, Zhao A, Liang Y, Deng H, et al. Comparison between technetium-99m methoxyisobutylisonitrile scintigraphy and ultrasound in the diagnosis of parathyroid adenoma and parathyroid hyperplasia. Nucl Med Commun 2018;39:1129-37.  Back to cited text no. 11
    
12.
Nafisi Moghadam R, Amlelshahbaz AP, Namiranian N, Sobhan-Ardekani M, Emami-Meybodi M, Dehghan A, et al. Comparative diagnostic performance of ultrasonography and 99mtc-sestamibi scintigraphy for parathyroid adenoma in primary hyperparathyroidism; systematic review and meta- analysis. Asian Pac J Cancer Prev 2017;18:3195-200.  Back to cited text no. 12
    
13.
Yang Z, Li AY, Alexander G, Chadha M. Complementary sestamibi scintigraphy and ultrasound for primary hyperparathyroidism. Nucl Med Biomed Imaging 2017;2:1-6.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2]



 

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