Wei J P, Burke G J
Section of Endocrine and Oncologic Surgery, Medical College of Georgia, Augusta 30912, USA.
Am Surg. 1997 Dec;63(12):1097-100; discussion 1100-1.
Tc-99m-sestamibi has been shown to localize parathyroid adenomas effectively, but controversy continues as to the use of this scan before initial surgery for primary hyperparathyroidism. We analyzed the cost utility of obtaining this study before initial surgery for primary hyperparathyroidism. Twenty-two consecutive patients with primary hyperparathyroidism underwent dual-phase Tc-99m-sestamibi scan before initial bilateral neck exploration. Surgical findings were correlated with the results of sestamibi scan. There were 15 women and 7 men, with a mean age of 50.5 years (range, 22-76). Preoperative mean total calcium was 11.74 mg/dL (range, 10-15), ionized calcium was 6.19 mg/dL (range, 5.2-7.7), and intact parathyroid hormone was 153.5 pg/mL (range, 83.1-551). Postoperative mean ionized calcium was 4.56 mg/dL (range, 4.1-5.57). Twenty sestamibi scans had a positive localization, and 2 scans had no localization. At surgery, 18 solitary adenomas, 3 diffuse hyperplasias, and 1 patient with four normal parathyroid glands were found. Sixteen sestamibi scans were true positive (solitary adenoma), 4 scans were false positive (2 diffuse hyperplasia, 1 wrong side, and 1 lymph node), 1 negative scan was true negative (diffuse hyperplasia), and 1 negative scan was false negative (adenoma). One patient (four normal glands) at the second operation had a supernumerary fifth gland adenoma excised from the mediastinum. Preoperative Tc-99m-sestamibi scan did not offer any advantage when a complete bilateral neck exploration is performed. Sixteen of (84%) adenomas were correctly localized, but 18 of 19 adenomas were in the neck and were easily found. The 1 ectopic adenoma was not found by scanning or with initial surgery. The 4 of 22 (18%) false-positive localizations and the 2 of 22 (9%) negative scans contributed nothing to the surgery. Of the 22 localizing sestamibi scans, surgery was not altered to affect the outcome. At a cost of $550 per sestamibi scan and with the error inherent in the scan, it is not cost effective to obtain Tc-99m-sestamibi scan before initial surgery for primary hyperparathyroidism.
已证实锝-99m-甲氧基异丁基异腈（Tc-99m-sestamibi）能有效定位甲状旁腺腺瘤，但对于在原发性甲状旁腺功能亢进症初次手术前进行该项扫描的应用仍存在争议。我们分析了在原发性甲状旁腺功能亢进症初次手术前进行此项检查的成本效益。22例连续的原发性甲状旁腺功能亢进症患者在初次双侧颈部探查术前接受了双期Tc-99m-甲氧基异丁基异腈扫描。手术结果与甲氧基异丁基异腈扫描结果相关。其中有15名女性和7名男性，平均年龄为50.5岁（范围22 - 76岁）。术前平均总钙为11.74mg/dL（范围10 - 15），离子钙为6.19mg/dL（范围5.2 - 7.7），完整甲状旁腺激素为153.5pg/mL（范围83.1 - 551）。术后平均离子钙为4.56mg/dL（范围4.1 - 5.57）。20次甲氧基异丁基异腈扫描显示定位阳性，2次扫描未显示定位。手术中，发现18个孤立性腺瘤、3个弥漫性增生以及1例甲状旁腺均正常的患者。16次甲氧基异丁基异腈扫描为真阳性（孤立性腺瘤），4次扫描为假阳性（2例弥漫性增生、1例定位错误和1例淋巴结），1次阴性扫描为真阴性（弥漫性增生），1次阴性扫描为假阴性（腺瘤）。1例患者（甲状旁腺均正常）在第二次手术时从纵隔切除了一个额外的第五个甲状旁腺腺瘤。当进行完整的双侧颈部探查时，术前Tc-99m-甲氧基异丁基异腈扫描未显示出任何优势。16个（84%）腺瘤被正确定位，但19个腺瘤中有18个位于颈部且很容易被发现。1个异位腺瘤通过扫描或初次手术均未被发现。22例中有4例（18%）假阳性定位和22例中有2例（9%）阴性扫描对手术没有任何帮助。在22次有定位的甲氧基异丁基异腈扫描中，手术未因扫描结果而改变，从而影响手术结果。每次甲氧基异丁基异腈扫描费用为550美元，且扫描存在固有误差，因此在原发性甲状旁腺功能亢进症初次手术前进行Tc-99m-甲氧基异丁基异腈扫描不具有成本效益。
