Rubello D, Saladini G, Casara D
Servizio di Medicina Nucleare II, Unità Operativa di Radioterapia e Medicina Nucleare, Azienda Ospedaliera, Padua, Italy.
Minerva Endocrinol. 2001 Mar;26(1):13-21.
The diagnostic value of scintigraphy using a dual tracer and high-resolution neck ecotomography in the preoperative localisation of parathyroid enlargements was evaluated in a group of consecutive patients suffering from primary hyperparathyroidism (HPT) who were uniformly studied and subsequently operated by the same surgical team.
Scintigraphic imaging and high-resolution neck ecotomography were carried out in a single session on 143 patients. Scintigraphic imaging was performed using a dual tracer, 99mTc-pertechnetate/99mTc-MIBI), modified by the addition of potassium perchlorate (KCL04) to achieve a rapid washout of 99mTc04 from the thyroid and, consequently, to achieve good quality and rapid MIBI images. In a limited number of patients (21 cases) SPECT was also performed. Limited surgery was planned in patients with evidence of single parathyroid lesions and with normal thyroid parameters, in the form of either unilateral or with mini-invasive surgery (91 cases). Patients with eco-scintigraphic evidence of multiglandular parathyroid pathology or the coexistence of a nodular thyroid goitre, or in patients suffering from MEN or familial HPT, or lastly those with negative eco-scintigraphic results under-went more extensive surgery with bilateral exploration of the neck (52 cases). A single parathyroid lesion was diagnosed during surgery in 90 out of 91 patients undergoing planned unilateral or mini-invasive exploration of the neck. Therefore, in our experience, the predictive value of preoperative imaging as a mean of identifying single parathyroid lesions was 98.9% with a clear impact on the choice of conservative surgery. After the removal of the parathyroid to which preoperative imaging referred, it was only necessary in one patient to extend surgical exploration to the other side of the neck to remove another enlarged parathyroid owing to persistent high PTH.
The sensitivity of scintigraphy and high-resolution neck ecotomography in pa-tients with a single adenoma was 94% and 83.7% respectively, whereas it was 76.9% and 64.5% respectively in the group of patients with multiglandular pathology. It is worth underlining that in all 31 patients with associated nodular thyroid pathology, the evaluation of thyroid scintigraphic imaging using 99mTc04 and high-resolution neck ecotomography enabled the preoperative diagnosis of thyroid pathology, therefore guiding the surgeon towards more extensive surgery. SPECT enabled the parathyroid adenoma to be correctly localised in a deep site in 5 patients, in the neck in 3 cases and at the mediastinum in 2 patients, providing additional data that helped the surgeon to plan surgery.
In conclusion, in our experience: a) an integrated diagnostic approach based on scintigraphy 99mTc04 & KCLO4/MIBI and high-resolution neck ecotomography was an extremely accurate mean of identifying patients with single parathyroid lesions before surgery, enabling them to undergo limited surgery, b) scintigraphy with a dual tracer might be the elective methods for studying patients with HPT because it allows the contemporary diagnosis of possible thyroid diseases. This aspect is extremely important in geographical areas with a high predominance of nodular thyroid pathology, c) SPECT scintigraphic analysis may be useful in some patients with suspected parathyroid adenoma localised in a deep seat, allowing a more precise identification of the latter and better surgical planning.
在一组连续的原发性甲状旁腺功能亢进症（HPT）患者中，评估了使用双示踪剂闪烁扫描和高分辨率颈部断层扫描在甲状旁腺增大术前定位中的诊断价值。这些患者均接受了相同手术团队的统一研究并随后进行手术。
对143例患者在同一时段进行了闪烁扫描成像和高分辨率颈部断层扫描。闪烁扫描成像使用双示踪剂（99mTc - 高锝酸盐/99mTc - MIBI），通过添加高氯酸钾（KCL04）进行改良，以实现99mTc04从甲状腺的快速洗脱，从而获得高质量且快速的MIBI图像。在少数患者（21例）中还进行了SPECT检查。对于有单发性甲状旁腺病变且甲状腺参数正常的患者，计划进行有限手术，采用单侧或微创形式（91例）。对于有生态闪烁扫描证据显示多腺体甲状旁腺病变、并存结节性甲状腺肿、患有MEN或家族性HPT的患者，或者最后那些生态闪烁扫描结果为阴性的患者，进行更广泛的手术，双侧探查颈部（52例）。在91例计划进行单侧或微创颈部探查的患者中，90例在手术中诊断出单发性甲状旁腺病变。因此，根据我们的经验，术前成像作为识别单发性甲状旁腺病变手段的预测价值为98.9%，对保守手术的选择有明显影响。在切除术前成像所指的甲状旁腺后，仅1例患者因甲状旁腺激素（PTH）持续升高而需要将手术探查扩展至颈部另一侧以切除另一个增大的甲状旁腺。
单发性腺瘤患者中，闪烁扫描和高分辨率颈部断层扫描的敏感性分别为94%和83.7%，而在多腺体病变患者组中分别为76.9%和64.5%。值得强调的是，在所有31例伴有结节性甲状腺病变的患者中，使用99mTc04进行甲状腺闪烁扫描成像评估和高分辨率颈部断层扫描能够在术前诊断甲状腺病变，从而指导外科医生进行更广泛的手术。SPECT能够在5例患者中将甲状旁腺腺瘤正确定位在深部，3例在颈部，2例在纵隔，提供了有助于外科医生规划手术的额外数据。
总之，根据我们的经验：a）基于99mTc04&KCLO4/MIBI闪烁扫描和高分辨率颈部断层扫描的综合诊断方法是术前识别单发性甲状旁腺病变患者的极其准确的手段，使他们能够接受有限手术；b）双示踪剂闪烁扫描可能是研究HPT患者的首选方法，因为它能够同时诊断可能的甲状腺疾病。在结节性甲状腺病变高度流行的地区，这一方面极其重要；c）SPECT闪烁扫描分析可能对一些疑似甲状旁腺腺瘤位于深部的患者有用，能够更精确地识别腺瘤并更好地规划手术。
