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THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING
Rivista di Medicina Nucleare e Imaging Molecolare
A Journal on Nuclear Medicine and Molecular Imaging
Affiliated to the and to the International Research Group of Immunoscintigraphy
Indexed/Abstracted in: Current Contents/Clinical Medicine, EMBASE, PubMed/MEDLINE, Science Citation Index (SciSearch), Scopus
Impact Factor 2,413
The Quarterly Journal of Nuclear Medicine 2003 Giugno;47(2):129-38
Importance of radio-guided minimally invasive parathyroidectomy using hand-held γ probe and low 99mTc-MIBI dose. Technical considerations and long-term clinical results
Rubello D. 1, Casara D. 1, Giannini S. 2, Piotto A. 3, De Carlo E. 4, Muzzio P. C. 5, Pelizzo M. R. 2
1 2nd Nuclear Medicine Service, General Hospital of Padova, Padova, Italy
2 1st Clinical Medicine Institute, University of Padova, Padova, Italy
3 3rd Clinical Surgery Institute, University of Padova, Padova, Italy
4 3rd Clinical Medicine Institute, University of Padova, Padova, Italy
5 Oncological Radiology, University of Padova, Padova, Italy
Aim. 99mTc-MIBI radio-guided surgery results, obtained in a group of 141 patients with primary hyperparathyroidism (HPT), are reported.
Methods. All patients were preoperatively evaluated by a single day protocol based on double-tracer parathyroid scintigraphy and neck ultrasound, and then operated by the same surgical team. In 102 patients (72.3%) with a high scan/ultrasound probability of solitary parathyroid adenoma and normal thyroid gland, a minimally invasive radio-guided surgery was planned. In the other 39 patients (27.7%) with scan/ultrasound evidence of multi-glandular disease (n=8) or concomitant nodular goiter (n=31), the intraoperative γ probe was used during a standard bilateral neck exploration. Intraoperative quick parathyroid hormone (PTH) levels were routinely measured. The minimally invasive radio-guided surgery technique we developed, consisted of: a) injection of a low 37 MBq 99mTc-MIBI dose in the operative theatre during anaesthesia induction, b) patient’s neck scan with a hand-held γ probe just before the surgical cut to localize the cutaneous projection of the parathyroid adenoma, c) intraoperative probe detection of the parathyroid adenoma and its removal through a small 2-2.5 cm skin incision.
Results. Minimally invasive radio-guided surgery was successfully performed in 99/102 patients (97.0%). The γ probe was particularly useful in patients with an ectopic parathyroid adenoma in the upper mediastinum (n=11) or to the carotid bifurcation (n=1) or located deep in the neck (n=8). Minimally invasive radio-guided surgery was also obtained in 18/23 patients who had previously undergone thyroid/parathyroid surgery. The mean operative time for minimally invasive radio-guided surgery was 38 min. No major surgical complication was recorded. Conversion to bilateral neck exploration was required in only 3 cases because of intra-operative diagnosis of parathyroid carcinoma (n=2), and persistence of elevated quick PTH levels after removal of the preoperatively visualized parathyroid adenoma (n=1). Among patients treated by standard bilateral neck exploration, the γ probe was useful in localizing a thymical enlarged parathyroid gland in 1 patient with multi-glandular disease, a parathyroid adenoma located deep in the neck in 4 patients with concomitant nodular goiter and an ectopic parathyroid adenoma to the carotid bifurcation in another. However, in some other patients with a parathyroid adenoma located near to the thyroid, it was difficult to intraoperatively distinguish the parathyroid adenoma from a MIBI avid thyroid nodule.
Conclusion. It can be concluded that: (a) in primary HPT patients with high scan/ultrasound probability of solitary parathyroid adenoma and normal thyroid gland, the γ probe appears to be an effective, rapid and safe technique to perform minimally invasive radio-guided surgery; b) a 99mTc-MIBI dose as low as 37 MBq appears to be adequate to successfully perform radio-guided surgery; c) the measurement of quick PTH is recommended during minimally invasive radio-guided surgery; d) minimally invasive radio-guided surgery can be performed also in HPT patients with previous parathyroid/thyroid surgery thus limiting surgical trauma; e) with the possible exception of parathyroid adenoma located in ectopic sites or deep in the neck, the γ probe technique does not seem recommendable in HPT patients with concomitant nodular goiter.