Radionuclide Imaging in the Surgical Management of Primary Hyperparathyroidism

Targeted CE per ARRT’s Discipline, Category, and Subcategory classification:
[Note: Discipline-specific Targeted CE credits may be less than the total Category A credits approved for this course.]

Nuclear Medicine Technology: 2.00
Procedures: 2.00
Endocrine and Oncology Procedures: 2.00

Outline

1. Introduction
2. Usefulness of Preoperative Imaging Before Conventional Bilateral Surgery
   1. Positive Parathyroid Scans
   2. Negative Parathyroid Scans
3. Advantages and Disadvantages of Targeted Surgery
4. Performance of Different Scintigraphic Protocols to Guide Targeted Surgery
   1. Importance of Simultaneous Dual-Tracer Imaging
   2. The Role of Dual-Isotope SPECT/CT
   3. Multiphase 4-Dimensional (4D) CT Scanner
5. Imaging Strategy Before Reoperation for Persistent or Recurrent Hyperparathyroidism
6. Parathyroid Imaging with Novel PET Tracers
7. Conclusion

Objectives

Upon completion of this course, students will:

1. be familiar with the signs and symptoms of PHPT
2. be familiar with the conditions found at PHPT diagnosis or during follow up that warrant surgical intervention in an asymptomatic patient
3. know the type of PHPT with the most frequent occurrence
4. know the number of parathyroid glands found in healthy patients
5. identify the technological developments that have driven the shift towards targeted operations for PHPT
6. know the role of ultrasound imaging in PHPT and how its effectiveness can be limited
7. be familiar with the gene associated with menin production
8. know the functions associated with the RET gene
9. understand why preoperative imaging for PHPT is recommended even though bilateral cervical exploration is 92–95% curative
10. know the location of ectopic parathyroid glands outside of the cervical area for a small percentage of PHPT patients
11. be familiar with aspects of good preoperative imaging practice for PHPT patients
12. be familiar with the benefits of PHPT preoperative imaging
13. be familiar with the differences between superior (P4) and lower (P3) parathyroid gland ectopias
14. understand the significance of negative parathyroid imaging results
15. know the advantages of targeted parathyroidectomy
16. know the details of the Miami criterion for intraoperative PTH monitoring
17. be familiar with the disadvantages of intraoperative PTH monitoring
18. be familiar with the four currently utilized criterion for intraoperative PTH monitoring
19. know the qualities of a valuable presurgical imaging technique for PHPT
20. understand the shortcomings of dual-phase, single-isotope ^99mTc Sestamibi parathyroid imaging
21. understand the reasoning for narrow energy window settings for dual-tracer, simultaneous acquisition parathyroid scintigraphy
22. understand the advantages of dual-isotope subtraction simultaneous acquisition parathyroid studies
23. be familiar with the patient preparation for dual-isotope parathyroid scintigraphy
24. understand the roles of SPECT and pinhole imaging for the parathyroid glands
25. be familiar with some of the disadvantages of 4D CT imaging of parathyroid
26. be familiar with parathyroid adenoma contrast enhancement pattern
27. know the first-line and confirmation imaging techniques before reoperation for persistent or recurrent hyperparathyroidism
28. be familiar with the sensitivities of the modalities used to image persistent or recurrent hyperparathyroidism
29. be familiar with the various PET isotope options for parathyroid imaging
30. know the advantages and disadvantages of ¹⁸F-fluorocholine PET imaging for parathyroid