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Parathyroid Imaging with Tc-99m Sestamibi Planar and SPECT Scintigraphy¹

¹ From the Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd, Scottsdale, AZ 85259. Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received June 17, 1998; revision requested July 13 and received September 11; accepted September 14. Address reprint requests to the author.

View larger version (108K): [in a new window]   Figure 1.  Healthy subject. Top: Ten-minute scintigrams show normal uptake of Tc-99m sestamibi in the thyroid, submandibular glands, heart, and liver. Bottom: Two-hour scintigrams show normal clearance of sestamibi from the thyroid. There is no focus of radiotracer retention to suggest parathyroid disease. p.i. = post injection.

View larger version (140K): [in a new window]   Figure 2a.  Differential washout between thyroid gland and parathyroid adenoma. (a) Early-phase scintigram shows a focus of increased activity in the middle of the left thyroid lobe (arrow). (b) Two-hour scintigram shows persistence of the focus (arrow), a finding consistent with parathyroid adenoma.

View larger version (123K): [in a new window]   Figure 2b.  Differential washout between thyroid gland and parathyroid adenoma. (a) Early-phase scintigram shows a focus of increased activity in the middle of the left thyroid lobe (arrow). (b) Two-hour scintigram shows persistence of the focus (arrow), a finding consistent with parathyroid adenoma.

View larger version (125K): [in a new window]   Figure 3a.  Parathyroid adenoma in the tracheoesophageal groove. Twenty-minute (a) and 2-hour (b) scintigrams show a focus of activity in the middle of the mediastinum (arrow). The focus appeared to be posterior on the SPECT reprojection image.

View larger version (104K): [in a new window]   Figure 3b.  Parathyroid adenoma in the tracheoesophageal groove. Twenty-minute (a) and 2-hour (b) scintigrams show a focus of activity in the middle of the mediastinum (arrow). The focus appeared to be posterior on the SPECT reprojection image.

View larger version (110K): [in a new window]   Figure 4.  Parathyroid adenoma in the right carotid sheath. Delayed scintigram of the neck and chest shows a focus of activity inferior to the right thyroid lobe (arrow).

View larger version (94K): [in a new window]   Figure 5a.  Intrathyroid parathyroid adenoma. Twenty-minute (a) and 2-hour (b) scintigrams show a focus of uptake in the inferior aspect of the left thyroid lobe (arrow in b).

View larger version (94K): [in a new window]   Figure 5b.  Intrathyroid parathyroid adenoma. Twenty-minute (a) and 2-hour (b) scintigrams show a focus of uptake in the inferior aspect of the left thyroid lobe (arrow in b).

View larger version (145K): [in a new window]   Figure 6a.  Retroesophageal parathyroid adenoma. (a) Delayed scintigram shows a focus of uptake just superior and to the left of the suprasternal notch (arrow). (b) Left lateral SPECT image shows that the focus has a middle to posterior location (arrow).

View larger version (97K): [in a new window]   Figure 6b.  Retroesophageal parathyroid adenoma. (a) Delayed scintigram shows a focus of uptake just superior and to the left of the suprasternal notch (arrow). (b) Left lateral SPECT image shows that the focus has a middle to posterior location (arrow).

View larger version (109K): [in a new window]   Figure 7a.  Intrathymic parathyroid adenoma. (a) Delayed-phase scintigram shows an elongated focus of uptake in the left substernal region (arrow). (b) Left lateral SPECT image of another patient shows an abnormal focus of activity in the right mediastinum (arrow).

View larger version (98K): [in a new window]   Figure 7b.  Intrathymic parathyroid adenoma. (a) Delayed-phase scintigram shows an elongated focus of uptake in the left substernal region (arrow). (b) Left lateral SPECT image of another patient shows an abnormal focus of activity in the right mediastinum (arrow).

View larger version (108K): [in a new window]   Figure 8a.  Parathyroid adenoma within the thyrothymic ligament. (a) Delayed scintigram shows a questionable focus of activity inferior to the inferior pole of the left thyroid lobe (arrow). (b) Left lateral SPECT image shows the lesion (arrow).

View larger version (86K): [in a new window]   Figure 8b.  Parathyroid adenoma within the thyrothymic ligament. (a) Delayed scintigram shows a questionable focus of activity inferior to the inferior pole of the left thyroid lobe (arrow). (b) Left lateral SPECT image shows the lesion (arrow).

View larger version (158K): [in a new window]   Figure 9.  Mediastinal parathyroid adenoma attached to the upper aspect of the pericardium. Early-phase scintigram shows a left mediastinal lesion (arrow), which was nearly overlooked due to the restricted field of view.

View larger version (101K): [in a new window]   Figure 10.  Double parathyroid adenoma. Delayed-phase scintigram shows two inferior parathyroid adenomas. A left inferior parathyroid lipoadenoma (arrow) was found at surgery.

View larger version (121K): [in a new window]   Figure 11.  Multisite parathyroid disease. Delayed-phase scintigram shows mediastinal parathyroid hyperplasia (arrow). In addition to this lesion, four eutopic sites of parathyroid hyperplasia not seen with Tc-99m sestamibi scintigraphy were found at surgery.

View larger version (128K): [in a new window]   Figure 12.  Cystic parathyroid adenoma in a patient with multinodular goiter. Delayed-phase scintigram shows a focal defect (arrow) in the inferior aspect of an enlarged right thyroid lobe. The focal defect represented cystic degeneration of a right inferior parathyroid adenoma.

View larger version (100K): [in a new window]   Figure 13a.  Type 1 MEN. (a) Delayed-phase scintigram shows a right inferior parathyroid adenoma (arrow). (b) Fast spin-echo T2-weighted MR image (4,000/117) shows an islet cell tumor of the pancreas (arrow).

View larger version (154K): [in a new window]   Figure 13b.  Type 1 MEN. (a) Delayed-phase scintigram shows a right inferior parathyroid adenoma (arrow). (b) Fast spin-echo T2-weighted MR image (4,000/117) shows an islet cell tumor of the pancreas (arrow).

View larger version (151K): [in a new window]   Figure 14a.  Type 1 MEN. (a) Delayed-phase scintigram shows multiple sites of parathyroid disease with mediastinal involvement (arrow). (b) In-111 pentetreotide anterior reprojection SPECT image shows an islet cell tumor of the pancreas (open arrow) and a carcinoid tumor of the duodenum (solid arrow).

View larger version (87K): [in a new window]   Figure 14b.  Type 1 MEN. (a) Delayed-phase scintigram shows multiple sites of parathyroid disease with mediastinal involvement (arrow). (b) In-111 pentetreotide anterior reprojection SPECT image shows an islet cell tumor of the pancreas (open arrow) and a carcinoid tumor of the duodenum (solid arrow).

View larger version (92K): [in a new window]   Figure 15.  Hyperfunctioning parathyroid autograft in a patient with recurrent hyperparathyroidism. Scintigram of the right forearm shows hypervascularity as activity within the vessels of the extremity (arrow). The radiotracer was injected into the opposite upper extremity.

View larger version (149K): [in a new window]   Figure 16a.  Parathyroid adenoma with rapid clearance of Tc-99m sestamibi. (a) Early-phase scintigram shows a possible lesion within the inferior region of the left thyroid lobe (arrow). (b) Delayed-phase scintigram shows no focus of persistent activity.

View larger version (156K): [in a new window]   Figure 16b.  Parathyroid adenoma with rapid clearance of Tc-99m sestamibi. (a) Early-phase scintigram shows a possible lesion within the inferior region of the left thyroid lobe (arrow). (b) Delayed-phase scintigram shows no focus of persistent activity.

View larger version (142K): [in a new window]   Figure 17.  Multinodular goiter. Delayed-phase scintigram shows persistent activity in both thyroid lobes.

View larger version (86K): [in a new window]   Figure 18.  Hashimoto thyroiditis. Delayed-phase scintigram shows diffuse retention of the radiotracer. The focus of increased activity in the medial aspect of the right thyroid lobe is a parathyroid adenoma (solid arrow). The focal defect in the lateral aspect of the left thyroid lobe is a papillary thyroid carcinoma (open arrow).

View larger version (150K): [in a new window]   Figure 19a.  Parathyroid adenoma in a patient with multinodular goiter. (a) Early-phase scintigram shows a probable lesion of the right superior parathyroid (arrow). (b) Extended delayed-phase scintigram shows clearance of Tc-99m sestamibi from the thyroid and persistent activity in the right superior parathyroid (arrow).

View larger version (131K): [in a new window]   Figure 19b.  Parathyroid adenoma in a patient with multinodular goiter. (a) Early-phase scintigram shows a probable lesion of the right superior parathyroid (arrow). (b) Extended delayed-phase scintigram shows clearance of Tc-99m sestamibi from the thyroid and persistent activity in the right superior parathyroid (arrow).

View larger version (154K): [in a new window]   Figure 20.  Hyperplastic thymus. Delayed-phase scintigram shows a left inferior parathyroid adenoma (solid arrow) and a mediastinal focus of increased activity (open arrow), which was shown to represent thymic hyperplasia at surgery.