A Multimodal Imaging Protocol, 123I/99Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization

Grace S. Lee, Travis J. McKenzie, Brian P. Mullan, David R. Farley, Geoffrey B. Thompson, Melanie L. Richards

Research output: Contribution to journalArticle

6 Citations (Scopus)

Abstract

Introduction: Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown. Method: Patients with 1°HPT, who underwent parathyroidectomy in 2012-2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of 123I/99Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed. Results: Of 360 patients who were identified, a curative operation was performed in 96 %, using pre-operative imaging and IOPTH. Imaging analysis showed that 123I/99Tc-sestamibi had a sensitivity of 86 % (95 % CI 82-90 %), positive predictive value (PPV) 93 %, and accuracy 81 %, based on correct lateralization. SPECT had a sensitivity of 77 % (95 % CI 72-82 %), PPV 92 % and accuracy 72 %. SPECT/CT had a sensitivity of 75 % (95 % CI 70-80 %), PPV of 94 %, and accuracy 71 %. There were 3 of 45 (7 %) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 %) with positive uptake on sestamibi (93 % true positive, 7 % false positive), concordant findings were present in 86 % SPECT and 84 % SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, 123I/99Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p <0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold. Conclusion: 123I/99Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with 123I/99Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.

Original languageEnglish (US)
Pages (from-to)589-594
Number of pages6
JournalWorld Journal of Surgery
Volume40
Issue number3
DOIs
StatePublished - Mar 1 2016

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Multimodal Imaging
Primary Hyperparathyroidism
Single-Photon Emission-Computed Tomography
Intraoperative Monitoring
Parathyroidectomy
Single Photon Emission Computed Tomography Computed Tomography
Radionuclide Imaging
Cost-Benefit Analysis
Costs and Cost Analysis

ASJC Scopus subject areas

  • Surgery

Cite this

A Multimodal Imaging Protocol, 123I/99Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization. / Lee, Grace S.; McKenzie, Travis J.; Mullan, Brian P.; Farley, David R.; Thompson, Geoffrey B.; Richards, Melanie L.

In: World Journal of Surgery, Vol. 40, No. 3, 01.03.2016, p. 589-594.

Research output: Contribution to journalArticle

Lee, Grace S. ; McKenzie, Travis J. ; Mullan, Brian P. ; Farley, David R. ; Thompson, Geoffrey B. ; Richards, Melanie L. / A Multimodal Imaging Protocol, 123I/99Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization. In: World Journal of Surgery. 2016 ; Vol. 40, No. 3. pp. 589-594.
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title = "A Multimodal Imaging Protocol, 123I/99Tc-Sestamibi, SPECT, and SPECT/CT, in Primary Hyperparathyroidism Adds Limited Benefit for Preoperative Localization",
abstract = "Introduction: Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown. Method: Patients with 1°HPT, who underwent parathyroidectomy in 2012-2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of 123I/99Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed. Results: Of 360 patients who were identified, a curative operation was performed in 96 {\%}, using pre-operative imaging and IOPTH. Imaging analysis showed that 123I/99Tc-sestamibi had a sensitivity of 86 {\%} (95 {\%} CI 82-90 {\%}), positive predictive value (PPV) 93 {\%}, and accuracy 81 {\%}, based on correct lateralization. SPECT had a sensitivity of 77 {\%} (95 {\%} CI 72-82 {\%}), PPV 92 {\%} and accuracy 72 {\%}. SPECT/CT had a sensitivity of 75 {\%} (95 {\%} CI 70-80 {\%}), PPV of 94 {\%}, and accuracy 71 {\%}. There were 3 of 45 (7 {\%}) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 {\%}) with positive uptake on sestamibi (93 {\%} true positive, 7 {\%} false positive), concordant findings were present in 86 {\%} SPECT and 84 {\%} SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, 123I/99Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p <0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold. Conclusion: 123I/99Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with 123I/99Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.",
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AU - Lee, Grace S.

AU - McKenzie, Travis J.

AU - Mullan, Brian P.

AU - Farley, David R.

AU - Thompson, Geoffrey B.

AU - Richards, Melanie L.

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N2 - Introduction: Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown. Method: Patients with 1°HPT, who underwent parathyroidectomy in 2012-2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of 123I/99Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed. Results: Of 360 patients who were identified, a curative operation was performed in 96 %, using pre-operative imaging and IOPTH. Imaging analysis showed that 123I/99Tc-sestamibi had a sensitivity of 86 % (95 % CI 82-90 %), positive predictive value (PPV) 93 %, and accuracy 81 %, based on correct lateralization. SPECT had a sensitivity of 77 % (95 % CI 72-82 %), PPV 92 % and accuracy 72 %. SPECT/CT had a sensitivity of 75 % (95 % CI 70-80 %), PPV of 94 %, and accuracy 71 %. There were 3 of 45 (7 %) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 %) with positive uptake on sestamibi (93 % true positive, 7 % false positive), concordant findings were present in 86 % SPECT and 84 % SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, 123I/99Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p <0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold. Conclusion: 123I/99Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with 123I/99Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.

AB - Introduction: Focused parathyroidectomy in primary hyperparathyroidism (1°HPT) is possible with accurate preoperative localization and intraoperative PTH monitoring (IOPTH). The added benefit of multimodal imaging techniques for operative success is unknown. Method: Patients with 1°HPT, who underwent parathyroidectomy in 2012-2014 at a single institution, were retrospectively reviewed. Only the patients who underwent the standardized multimodal imaging workup consisting of 123I/99Tc-sestamibi subtraction scintigraphy, SPECT, and SPECT/CT were assessed. Results: Of 360 patients who were identified, a curative operation was performed in 96 %, using pre-operative imaging and IOPTH. Imaging analysis showed that 123I/99Tc-sestamibi had a sensitivity of 86 % (95 % CI 82-90 %), positive predictive value (PPV) 93 %, and accuracy 81 %, based on correct lateralization. SPECT had a sensitivity of 77 % (95 % CI 72-82 %), PPV 92 % and accuracy 72 %. SPECT/CT had a sensitivity of 75 % (95 % CI 70-80 %), PPV of 94 %, and accuracy 71 %. There were 3 of 45 (7 %) patients with negative sestamibi imaging that had an accurate SPECT and SPECT/CT. Of 312 patients (87 %) with positive uptake on sestamibi (93 % true positive, 7 % false positive), concordant findings were present in 86 % SPECT and 84 % SPECT/CT. In cases where imaging modalities were discordant, but at least one method was true-positive, 123I/99Tc-sestamibi was significantly better than both SPECT and SPECT/CT (p <0.001). The inclusion of SPECT and SPECT/CT in 1°HPT imaging protocol increases patient cost up to 2.4-fold. Conclusion: 123I/99Tc-sestamibi subtraction imaging is highly sensitive for preoperative localization in 1°HPT. SPECT and SPECT/CT are commonly concordant with 123I/99Tc-sestamibi and rarely increase the sensitivity. Routine inclusion of multimodality imaging technique adds minimal clinical benefit but increases cost to patient in high-volume setting.

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