More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research

More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research

More results...

Generic selectors
Exact matches only
Search in title
Search in content
Post Type Selectors
Filter by Categories
Abdominal Radiology, Original Research
Abdominal Radiology, Pictorial Essay
Anthropology and Dental Radiology, Original Research
Breast Imaging, Case Report
Breast Imaging, Original Research
Breast Imaging, Pictorial Essay
Breast Imaging, Review Article
Cardiopulmonary Imaging, Case Report
Cardiopulmonary Imaging, Case Series
Cardiopulmonary Imaging, Education
Cardiopulmonary Imaging, Original Research
Cardiopulmonary Imaging, Pictorial Essay
Cardiopulmonary Imaging, Review Article
Case Report
Case Report, Breast Imaging
Case Report, Cardiopulmonary Imaging
Case Report, Diagnostic Radiology
Case Report, Vascular and Interventional Radiology
Case Series
Case Series, Diagnostic Radiology
Case Series, Vascular and Interventional Radiology
DENTAL ARTICLE
Dental Radiology, Case Report
Dental Radiology, Case Series
Dental Radiology, Original Research
Diagnostic Radiology, Case Report
Diagnostic Radiology, Case Series
Diagnostic Radiology, Original Research
Diagnostic Radiology, Pictorial Essay
Diagnostic Radiology, Review Article
Editorial
Education, Original Research
Emergency, Original Research
Erratum
Gastrointestinal Imaging, Case Report
Gastrointestinal Imaging, Case Series
Gastrointestinal Imaging, Original Research
Gastrointestinal Imaging, Pictorial Essay
General and Emergency Radiology, Original Research
General and Emergency Radiology, Review Article
Genitourinary and Gynecologic Imaging, Case Report
Genitourinary and Gynecologic Imaging, Original Research
Imaging Science, Original Research
Interventional Radiology, Original Research
Letter to Editor
Musculoskeletal Imaging, Case Report
Musculoskeletal Imaging, Original Article
Musculoskeletal Imaging, Original Research
Musculoskeletal Imaging, Pictorial Essay
Musculoskeletal Imaging, Review Article
Neuroradiology , Review Article
Neuroradiology Head and Neck Imaging, Pictorial Essay
Neuroradiology, Case Report
Neuroradiology, Pictorial Essay
Neuroradiology/Head and Neck Imaging, Case Report
Neuroradiology/Head and Neck Imaging, Case Series
Neuroradiology/Head and Neck Imaging, Original Research
Neuroradiology/Head and Neck Imaging, Review Article
Neuroradiology/Spine Imaging, Original Research
Nuclear Medicine, Case Report
Nuclear Medicine, Original Research
Nuclear Medicine, Pictorial Essay
Original Article
Original Article, Neuroradiology
Original Research
Original Research Article
Original Research, Descriptive Study
Original Research, Diagnostic Radiology
Original Research, Gastrointestinal Imaging
Original Research, Genitourinary and Gynecologic Imaging
Original Research, Musculoskeletal Imaging
Original Research, Neuroradiology/Head and Neck Imaging
Original Research, Nuclear Medicine
Original Research, Vascular and Interventional Radiology
Pediatric Imaging, Case Report
Pediatric Imaging, Pictorial Essay
PICTORIAL ESSAY
PICTORIAL REVIEW
Radiologic-Pathologic Correlation
RADIOLOGICAL-PATHOLOGICAL CORRELATION
Radiology Business, Original Research
Research Article
Review Article
Review Article, Diagnostic Radiology
Review Article, Gastrointestinal imaging
Review Article, Musculoskeletal
Review Article, Vascular and Interventional Radiology
Technical Innovation
Technical Innovation, Gastrointestinal Imaging
Ultrasound, Case Report
Ultrasound, Original Research
Ultrasound, Review Article
Vascular and International Radiology, Case Report
Vascular and Interventional Radiology, Case Report
Vascular and Interventional Radiology, Case Series
Vascular and Interventional Radiology, Original Research
Vascular and Interventional Radiology, Pictorial Essay
Vascular and Interventional Radiology, Review Article
Vascular and Interventional Radiology, Short Communication
Vascular and Interventional, Original Research
View/Download PDF

Translate this page into:

Nuclear Medicine
Case Report
2020
:10;
61
doi:
10.25259/JCIS_125_2020

Ectopic Submandibular Parathyroid Adenoma by Tc-99m Sestamibi SPECT/CT Localization

Department of Radiology, Princess Margaret Hospital, Hong Kong
Corresponding author: Fung Him Ng, Department of Radiology, Princess Margaret Hospital, 2-10 Princess Margaret Hospital Road, Hong Kong. ngphonehim@gmail.com
Licence
This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.

How to cite this article: Ng FH, Yung KS, Luk WH. Ectopic submandibular parathyroid adenoma by Tc-99m sestamibi SPECT/CT localization. J Clin Imaging Sci 2020;10:61.

Abstract

We present a 74-year-old woman with primary hyperparathyroidism, with elevated parathyroid hormone and calcium. Tc-99m-methoxyisobutyl isonitrile (sestamibi) planar imaging showed a focus of uptake over the inferior aspect of the right submandibular gland that was localized on the single-photon emission computed tomography with CT.

Keywords

Ectopic parathyroid adenoma
Tc-99m
Sestamibi
Primary hyperparathyroidism
SPECT/CT

INTRODUCTION

Localization of parathyroid adenomas before surgery requires a multimodality approach to aid operative planning. Ectopic parathyroid adenomas are rare and are reported to account for 5–10% of cases of primary hyperparathyroidism (PHPT),[1] which is often a diagnostic challenge for localization.

CASE REPORT

A 74-year-old woman with a diagnosis of PHPT was sent to nuclear medicine with persistently raised serum calcium and parathyroid hormone (PTH) levels. The calcium was elevated to 2.7 mmol/L (2.15–2.55). The ionized calcium was elevated to 1.54 mmol/L (1.13–1.32). The PTH measures 9.03 pmol/L (1.6–6.9).

20 mCi Tc-99m sestamibi planar imaging [Figure 1] showed a solitary focus of uptake over right submandibular gland. The location for uptake in the right submandibular gland is uncommon for a parathyroid adenoma. Differential washout of tracer is seen from the immediate to the 3 h image with a clearer delineation of the lesion on delayed imaging. Single-photon emission computed tomography with CT (SPECT/CT) [Figure 2] demonstrated increased uptake over the inferior aspect of the right submandibular gland, suggestive of a parathyroid adenoma.

Figure 1:
A 74-year-old woman with primary hyperparathyroidism. Anterior static sestamibi images performed at 20 min (a) and 3 h (b) show a focal lesion over the inferior aspect of the right submandibular gland.
Figure 2:
A 74-year-old woman with primary hyperparathyroidism. SPECT/CT in tomographic, CT, and fused images in the axial, sagittal, and coronal plane shows a focal increased uptake over the right submandibular gland.

DISCUSSION

Ectopic parathyroid adenomas are rare and are reported to account for 5–10% of cases of PHPT.[1] Pre-operative localization of hyperfunctioning parathyroid tissue is an essential component if minimally invasive surgery is scheduled. Parathyroid localization has improved with numerous imaging techniques, including sestamibi scintigraphy, ultrasonography, and four-dimensional CT.[2]

Parathyroid scintigraphy using 99 mTc-MIBI has been proven to be greatly effective for the diagnosis of adenomas, however, despite the relatively high accuracy of planar parathyroid imaging, intrathyroidal adenomas with low 99 mTc-MIBI uptake and ectopic adenomas may be overlooked. Another limitation for planar 99 mTc-MIBI scintigraphy is a nodular goiter because thyroid nodules are frequently 99 mTc-MIBI avid and can cause false-positive scintigraphic results.

SPECT/CT fusion imaging is increasing used, due to the three-dimensional information, it provides and the improved sensitivity for the detection and localization of hyperfunctioning parathyroid lesions.[2] SPECT/CT can further enhance localization by providing better resolution of surrounding structures and has the added benefit of a more precise localization of ectopic and mediastinal parathyroid lesions.[2]

We routinely do SPECT/CT imaging at 20 min post-tracer injection for more accurate anatomical localization the lesion. If it is posteriorly located, we can confirm a parathyroid lesion, however, if it is located anteriorly, it may be due to an intrathyroidal parathyroid lesion or a false-positive finding of a thyroid nodule. In this instance, Tc-99m pertechnetate thyroid imaging will be helpful in deciding if a lesion is due to an intrathyroidal lesion versus a thyroid nodule. If the lesion is in an ectopic location, more accurate anatomical localization is obtained. SPECT/CT is more reproducible as compared to ultrasound, which is operator dependent.

The single isotope, dual-phase technique is simple and easy to perform.[1,3] It requires a single injection of sestamibi followed by early and delayed imaging. It takes advantage of the differential washout rates of sestamibi from the thyroid and the parathyroid glands. On delayed images, parathyroid lesions are easily visualized. This principle is based on the observation that sestamibi washes out more rapidly from the thyroid than from abnormal parathyroid tissue, where it is retained for a longer period of time. The retention in parathyroid lesions is assumed to be related to the presence of oxyphil cells, which are rich in mitochondria, and is the site of intracellular sestamibi sequestration.[4]

CONCLUSION

Localization of parathyroid adenomas before surgery requires a multimodality approach to aid operative planning. This is particularly important in cases of ectopic parathyroid adenomas, in which the surgical approach has to be modified. The hybrid SPECT-CT imaging used in our patient has helped not only in diagnosis with confidence but also provided good information regarding location and anatomical details for operation.

Declaration of patient consent

Patient’s consent not required as patients identity is not disclosed or compromised.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

  1. , , , . Anatomical and functional localization of ectopic parathyroid adenomas: 6-year institutional experience. Nucl Med Commun. 2011;32:496-502.
    [CrossRef] [PubMed] [Google Scholar]
  2. , , . Role of SPECT and SPECT/ CT in the surgical treatment of primary hyperparathyroidism. Int J Mol Imaging. 2011;2011:141593.
    [CrossRef] [PubMed] [Google Scholar]
  3. , . Detection of ectopic parathyroid adenoma by early Tc-99m sestamibi imaging. Ann Nucl Med. 2005;19:157-9.
    [CrossRef] [PubMed] [Google Scholar]
  4. , , , . Clinical utility of ultrasound and 99mTc sestamibi SPECT/CT for preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism. Clin Radiol. 2010;65:278-87.
    [CrossRef] [PubMed] [Google Scholar]

Fulltext Views
5,302

PDF downloads
4,331
View/Download PDF
Download Citations
BibTeX
RIS
Show Sections