Hyperparathyroidism is an affliction associated with increased parathyroid hormones in the blood and can be primary, secondary or tertiary. Primary hyperparathyroidism commonly presents with bone pain, recurrent renal stone formation, weakness, and irritability. It is clinically diagnosed based on elevated serum Parathyroid hormone, calcium, and reduced phosphate levels. The most common cause of Primary hyperparathyroidism is a small benign tumor called parathyroid adenoma and common treatment being surgical removal. However, localisation of tumor is often difficult as any one of the four glands may harbor this tumor. Further complicating it is a rare occurrence of ectopic locations in neck and mediastinum. 99mTc SestaMIBI scans have been extremely useful in this localisation and allow an operating surgeon to choose an optimal strategy and plan even a small incision low morbidity focused surgery.
99mTc Sesta MIBI Parathyroid Scan in Imaging based pre-surgical localisation of hyperparathyroidism
This case study highlights the utility of SestaMIBI Parathyroid inaccurate non-invasive and presurgical localisation of a parathyroid adenoma in a patient presenting with Primary hyperparathyroidism with bone pain, abdominal discomfort and recurrent kidney stones.
27 years old Male was referred for localisation of a suspected parathyroid adenoma with clinically diagnosed Primary hyperparathyroidism (Serum PTH 172 ng/ml) and hypercalcemia (Serum calcium 11.7). USG and CT performed previously did not reveal any obvious abnormality.
A SestaMIBI Parathyroid scan was performed with acquisition of 10 minutes, 30 minutes and 02 hours images following administration of a standard dose of 99mTc SestaMIBI. A 99mTc pertechnate thyroid scan was performed separately as a part of the recommended sestaMIBI – pertechnate subtraction protocol.
SestaMIBI Parathyroid scan images revealed the homogenous distribution of the tracer in the thyroid gland (Fig 1a. Arrowhead) showing progressive washout of tracer activity in delayed 30 minutes and 02 hours images. A well-defined focus of tracer retention was visualized at the level of the upper pole of the thyroid gland at 30 minutes and 02 hours (Fig 1b & 1c. Broken Arrows) consistent with Right upper parathyroid adenoma.
Pertechnate scan performed on next day showed no obvious Hot or cold nodule in the above-described region (Fig 1d. Arrowhead) suggesting an extrathyroidal right posterior upper parathyroid adenoma.
A low dose CT scan performed for localisation confirmed above findings showing a subcentimetric adenoma (Fig 2. White Arrow), otherwise missed on previous USG and CT evaluations.
The patient underwent surgery using a micro-incision keyhole Focused parathyroidectomy and PTH levels dropped to normal range postoperatively.
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