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"Technetium Tc 99m Sestamibi"
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Low-dose radio-guided parathyroidectomy: A non-inferiority systematic review and meta-analysis
Performing MIRP procedure with a 20-fold less MIBI isotope dose allows lower radiation exposure risk for both patient and staff and reduce the overall cost of the procedure. The main goal of this systemic review and meta-analysis is to prove the non-inferiority of the very low dose MIRP compared to the standard dose.
We performed a systemic review and meta-analysis of three different electronic databases - PubMed, Web of Science and google scholar. Meta-extraction was conducted in accordance with PRISMA guidelines.
Among 4750 studies imported for screening, only 13 studies were selected for the meta-analysis. Analyzed data from the 13 selected studies performed with low dose MIRP demonstrated a detection rate greater than 97 % and a success rate greater than 95 %, which is comparable to the cure rate required by current guidelines, as well as to data published by studies using the original high dose protocol.
Very low dose MIRP is not inferior to the high dose original MIRP and may be used in separate day protocol routinely.
•Minimally invasive radioguided parathyroidectomy (MIRP) can be used with low dose MIBI injection (<10mci).•In this systemic review and meta-analysis, we analyzed all studies examining the efficiency of low dose MIBI (<10mci).•Our analysis demonstrated no significant decline in detection and success rate when MIBI dose was less than <10 mci.•There was no significant decline in detection success rate compared with all other doses equal to or less than 10mci.•Our results indicate that MIRP can be efficiently done with MIBI doses that are 20 times less than the original dose.
Journal Article
Effect of Proton Pump Inhibitors and H2 Antagonists on the Stomach Wall in 99mTc-Sestamibi Cardiac Imaging
On the basis of previously unpublished observations, we hypothesized that prolonged use of proton pump inhibitors (PPIs) causes an increase in (99m)Tc-sestamibi uptake in the stomach wall, manifested as curvilinear activity surrounding the photopenic fundus of the stomach cavity. We prospectively evaluated the frequency of stomach wall uptake in patients undergoing myocardial perfusion SPECT who were taking PPIs or H(2) antagonists.
Patients (n = 138) who were scheduled for single-day rest/stress (99m)Tc-sestamibi SPECT were randomly selected. Poststress SPECT was performed 30 min after treadmill exercise or 45 min after dipyridamole infusion. The rest scan was obtained 45 min after tracer injection. All patients drank 473 mL of water 5-10 min after both the rest and the stress radiotracer injections. Patients were questioned regarding their use of PPIs and H(2) antagonists. The significant use of either was defined as more than 2 wk of continuous therapy before cardiac SPECT. Masked observers assessed poststress planar projection images in endless-loop cinematic format for the following 3 patterns: stomach cavity uptake, attributable to duodenogastric reflux of tracer; stomach wall uptake; and no stomach uptake. A 2-tailed chi(2) test with Yates correction was used to calculate statistically significant associations among variables.
Only patients with observed patterns of stomach wall uptake (n = 30) and no stomach wall uptake (n = 91) were included. Patients with stomach cavity uptake (n = 17) were excluded because the assessment of the adjacent stomach wall uptake was not possible. Of the patients included (n = 121), 30 were men and 91 were women. Sixty-seven patients were older than 60 y; 26 patients were taking PPIs. Of the 95 patients not taking PPIs, 14 were taking H(2) antagonists. No patients were taking both medications. Stomach wall uptake was strongly associated with prolonged use of PPIs (chi(2) = 51.9, P < 0.0001). No statistically significant association was noted among age, sex, or use of H(2) antagonists (P = NS).
Prolonged PPI therapy, but not H(2) antagonist therapy, contributes to a significant increase in stomach wall activity, potentially resulting in Compton scatter or ramp filter artifacts affecting the inferior wall of the left ventricle. Stomach wall activity, unlike the stomach cavity activity, cannot be prevented by the ingestion of water before imaging. Therefore, it is important to elicit a history of prolonged PPI use to better anticipate the possibility of increased stomach wall activity, which can confound the image quality and interpretation.
Journal Article
A comparison of three radionuclide myocardial perfusion tracers in clinical practice: the ROBUST study
There are no large studies available to guide the selection of thallium (Tl), methoxyisobutylisonitrile (MIBI) or tetrofosmin (Tf) for myocardial perfusion imaging. Our objective was to compare the technical and clinical performance of the three in routine clinical practice. We randomised 2,560 patients to receive Tl, MIBI or Tf. A 1-day stress/rest protocol was used for MIBI and Tf. Tracer uptake was scored using a 17-segment model, quality and artefact scores were assigned, and ratios of heart (H), liver (L), subdiaphragmatic (S) and lung activity were measured. Mean quality scores (stress/rest) were Tl 2.13/2.16, MIBI 2.18/2.39, Tf 2.18/2.42 ( P=ns stress and <0.00001 rest). For attenuation artefact, Tl>MIBI=Tf ( P<0.05) and for low-count artefact Tl>MIBI>Tf ( P<0.001). For H/S, Tl>MIBI=Tf, for H/L Tl>MIBI=Tf, and for H/lung Tl
Journal Article
Upfront F18-choline PET/CT versus Tc99m-sestaMIBI SPECT/CT guided surgery in primary hyperparathyroidism: the randomized phase III diagnostic trial APACH2
Background
The common endocrine disorder primary hyperparathyroidism (PHPT) can be cured by surgery. Preoperative localization of parathyroid adenoma (PTA) by imaging is a prerequisite for outpatient minimally invasive parathyroidectomy (MIP). Compared to inpatient bilateral cervical exploration (BCE) which is performed if imaging is inconclusive, MIP is superior in terms of cure and complication rates and less costly. The imaging procedure F18-choline (FCH) PET/CT outperforms Tc99m-sestaMIBI (MIBI) SPECT/CT for PTA localization, but it is much costlier. The aim of this study is to identify the most efficient first-line imaging modality for optimal patient care in PHPT without added cost to society.
Methods
We will conduct a multicenter open diagnostic intervention randomized phase III trial comparing two diagnostic strategies in patients with PHPT: upfront FCH PET/CT versus MIBI SPECT/CT. The primary endpoint is the proportion of patients in whom the first-line imaging method results in successful MIP and cure. Follow-up including biological tests will be performed 1 and 6 months after surgery. The main secondary endpoint is the social cost of both strategies. Other secondary endpoints are as follows: FCH PET/CT and MIBI SPECT/CT diagnostic performance, performance of surgical procedure and complication rate, FCH PET/CT inter- and intra-observer variability and optimization of FCH PET/CT procedure. Fifty-eight patients will be enrolled and randomized 1:1.
Discussion
FCH PET/CT is a highly efficient but expensive imaging test for preoperative PTA localization and costs three to four times more than MIBI SPECT/CT. Whether FCH PET/CT improves patient outcomes compared to the reference standard MIBI SPECT/CT is unknown. To justify its added cost, FCH PET/CT-guided parathyroid surgery should lead to improved patient management, resulting in higher cure rates and fewer BCEs and surgical complications.
In the previous phase II APACH1 study, we showed that second-line FCH PET/CT led to a cure in 88% of patients with negative or inconclusive MIBI SPECT/CT. BCE could be avoided in 75% of patients and surgical complication rates were low. We therefore hypothesize that upfront FCH PET/CT would improve patient care in PHPT and that the reduction in clinical costs would offset the increase in imaging costs.
Trial registration
NCT04040946
, registered August 1, 2019.
Protocol version
Version 2.1 dated from 2020/04/23.
Journal Article
Usefulness of feature analysis of breast-specific gamma imaging for predicting malignancy
ObjectivesThe purpose of this study was to investigate which feature of the breast-specific gamma imaging (BSGI) uptake in women who were recently diagnosed with breast cancer was associated with malignancy.MethodsData on 231 newly diagnosed breast cancer patients who underwent preoperative BSGI were retrospectively reviewed. Feature analysis was done by classifying BSGI uptake into mass, non-mass, or focus/foci. Descriptors for mass, non-mass, or focus/foci were shape, distribution, number, and intensity. BSGI features of known malignancies and lesions that were additionally found by BSGI were correlated with mammographic breast density, histology, hormonal status, and clinical follow-up data obtained over at least 2 years.ResultsAmong 372 breast lesions from 231 patients, 241 malignancies had been pathologically confirmed prior to BSGI and 131 additional lesions were found on BSGI. Irregular shape was more predictive of malignancy than oval shape (p=0.004) in mass uptake. Linear/ductal distribution was more predictive of malignancy than focal, regional, and segmental distribution (p<0.05) in non-mass uptake. Mammographic breast density was not associated with BSGI features. The lesion to normal ratio (LNR) was higher in the postmenopausal patients than that in the premenopausal patients (p=0.003).ConclusionsThe feature analysis of radiotracer uptake in BSGI is useful in predicting whether breast lesions are malignant or benign.Key Points• The feature analysis of BSGI uptake is useful in predicting malignancy.• Irregular shape was predictive of malignancy in mass uptake.• Linear/ductal distribution was predictive of malignancy in non-mass uptake.
Journal Article
Effect of ursodeoxycholic acid in facilitating early hepatic clearance of radiotracer among patients undergoing 99mTc-sestamibi myocardial perfusion scintigraphy: A randomized double blind placebo controlled parallel trial
BackgroundInfra-cardiac tracer activity due to persistent hepatic activity interferes in inferior and infero-septal wall assessment during 99mTc-MIBI SPECT/CT myocardial perfusion scintigraphy (MPS) in evaluation of patients with coronary artery disease. It affects image interpretation with increased study duration. Ursodeoxycholic acid (UDCA) is known to enhance hepatic excretion of bilirubin and bile salts, though its role in enhancing the hepatic tracer clearance in facilitating cardiac imaging is not known.MethodsThis prospective, randomized double-blind, placebo controlled clinical trial of 120 patients, referred for adenosine stress or viability MPS studies were randomized 1:1 to receive either UDCA or placebo. Outcome was quantitative & qualitative improvement in imaging for better interpretation and to reduce the waiting time for scan.Results118 participants (59 ± 11.9 years; 84 men) underwent adenosine stress MPS or viability MPS. Sixty participants had UDCA while 58 had placebo intervention. The study showed significant decrease in liver counts with improved myocardial to liver ratio at 30 and 60 minutes in adenosine stress MPS group, and marginally significant alteration in liver counts at 60 minutes in viability MPS group receiving UDCA, resulting in better images.ConclusionUDCA intervention in MPS provides early and better image due to faster hepatic tracer clearance.
Journal Article
Prevalence of silent myocardial ischemia in asymptomatic individuals with subclinical atherosclerosis detected by electron beam tomography
Electron beam tomography coronary calcium imaging is an evolving technique for the early detection of coronary atherosclerosis, and recent studies have established its prognostic value in asymptomatic individuals. The relationship of coronary artery calcium scores (CAC) to obstructive coronary artery disease (CAD) has been poorly studied but is clinically relevant because it determines which individuals are likely to benefit from revascularization procedures. Hence, we prospectively evaluated the prevalence of myocardial ischemia in asymptomatic patients with cardiovascular risk factors and subclinical atherosclerosis.
We studied 864 asymptomatic patients with no previous CAD but with cardiovascular risk factors, referred for electron beam tomography coronary calcium imaging to our institution over an 18-month period. From this group, 220 consecutive patients (85% men; mean age, 61 ± 9 years; age range, 31-84 years) with moderate to severe atherosclerotic disease (coronary calcium score ≥100 Agatston units) were prospectively evaluated by technetium 99m sestamibi single photon emission computed tomography (SPECT). Patients were followed up (mean follow-up, 14 months) and data regarding their subsequent clinical management recorded. Of the 220 patients, 119 had moderate atherosclerosis (CAC score of 100-400 Agatston units) and 101 had severe atherosclerosis (CAC score ≥400 Agatston units). Abnormal SPECT findings were seen in 18% of patients with moderate atherosclerosis (n = 21) and 45% of patients with severe atherosclerosis (n = 45). Increasing severity of atherosclerosis was related to increasing ischemic burden (summed difference score = 1 ± 0.2 for CAC score of 100-400 Agatston units and 3.2 ± 0.5 for CAC score ≥400 Agatston units). In a multivariate linear regression model incorporating risk factors, CAC was the only predictor of silent ischemia.
In comparison to previously published data, we detected a higher prevalence of silent ischemia even in patients with moderate coronary atherosclerosis (18%). This may reflect the differing risk factor profile of our patient population. When coronary calcium screening is used to preselect asymptomatic patients with cardiovascular risk factors for myocardial perfusion imaging, the optimum coronary calcium score threshold will depend on the population prevalence of risk factors and asymptomatic obstructive CAD.
Journal Article
Factors affecting the myocardial activity acquired during exercise SPECT with a high-sensitivity cardiac CZT camera as compared with conventional Anger camera
Purpose
Injected doses are difficult to optimize for exercise SPECT since they depend on the myocardial fraction of injected activity (MFI) that is detected by the camera. The aim of this study was to analyse the factors affecting MFI determined using a cardiac CZT camera as compared with those determined using conventional Anger cameras.
Methods
Factors affecting MFI were determined and compared in patients who had consecutive exercise SPECT acquisitions with
201
Tl (84 patients) or
99m
Tc-sestamibi (87 patients) with an Anger or a CZT camera. A predictive model was validated in a group of patients routinely referred for
201
Tl (78 patients) or
99m
Tc-sestamibi (80 patients) exercise CZT SPECT.
Results
The predictive model involved: (1) camera type, adjusted mean MFI being ninefold higher for CZT than for Anger SPECT, (2) tracer type, adjusted mean MFI being twofold higher for
201
Tl than for
99m
Tc-sestamibi, and (3) logarithm of body weight. The CZT SPECT model led to a +1 ± 26 % error in the prediction of the actual MFI from the validation group. The mean MFI values estimated for CZT SPECT were more than twofold higher in patients with a body weight of 60 kg than in patients with a body weight of 120 kg (15.9 and 6.8 ppm for
99m
Tc-sestamibi and 30.5 and 13.1ppm for
201
Tl, respectively), and for a 14-min acquisition of up to one million myocardial counts, the corresponding injected activities were only 80 and 186 MBq for
99m
Tc-sestamibi and 39 and 91 MBq for
201
Tl, respectively.
Conclusion
Myocardial activities acquired during exercise CZT SPECT are strongly influenced by body weight and tracer type, and are dramatically higher than those obtained using an Anger camera, allowing very low-dose protocols to be planned, especially for
99m
Tc-sestamibi and in non-obese subjects.
Journal Article
Tc-99m methoxyisobutylisonitrile bone marrow imaging for predicting the levels of myeloma cells in bone marrow in multiple myeloma: correlation with CD38/CD138 expressing myeloma cells
The percentage of myeloma cells in bone marrow is subsequently an important index of disease in patients with multiple myeloma (MM). Bone marrow myeloma cells can be detected by strong CD38/CD138 positivity and light scatter characteristics using flow cytometry. The aim of the study was to evaluate the relationship between the degree of Tc-99m methoxyisobutylisonitrile (MIBI) uptake and the percentage of CD38/CD138 expressing myeloma cells in the bone marrow of patients with MM. A total of 15 patients with MM (mean age: 61.7+/-2.4 years; 7 F and 8 M) were included in the study. Tc-99m MIBI imaging was obtained 20 min after injection of 740 MBq Tc-99m MIBI. Planar spot images of the pelvis and thorax were acquired. The uptake of Tc-99m MIBI in the bone marrow was evaluated using a qualitative and also a semiquantitative scoring system for the bone marrow in areas that included the proximal femurs, anterior iliac crest, and sternum. In all patients, flow cytometry was performed for assessing the percentage of CD38/CD138 expressing myeloma cells in the bone marrow samples. There was a statistically significant positive correlation between the percentage of CD38/CD138 expressing plasma cells in bone marrow and both mean qualitative (r=0.689, p=0.005) and semiquantitative (r=0.669, p=0.006) results of Tc-99m MIBI uptake. In conclusion, our results indicate that increased Tc-99m MIBI uptake of bone marrow is related to the percentage of plasma cell infiltration of bone marrow. Tc-99m MIBI bone marrow imaging may be a useful tool for predicting the levels of myeloma cells in bone marrow of patients with MM.
Journal Article
Thoracoscopic surgical case of an ectopic mediastinal parathyroid adenoma detected by chance: a case report
Background
Ectopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection.
Case presentation
A 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT.
Conclusions
The VATS approach was effective for the resection of EMPT.
Journal Article