|Year : 2016 | Volume
| Issue : 1 | Page : 49-51
11 C-Methionine positron emission tomography-computed tomography in localization of methoxyisobutyl isonitrile negative ectopic parathyroid adenoma
Nikhil Seniaray1, Harshul Sharma1, Arpana Arbind1, Abhinav Jaimini1, Maria D'souza1, Sanjeev Saw1, Puja Panwar Hazari2, AK Mishra2, Rajnish Sharma1, Anupam Mondal1
1 Department of PET Imaging, INMAS, New Delhi, India
2 Division of Cyclotron and Radiopharmaceutical Sciences, INMAS, New Delhi, India
|Date of Web Publication||21-Dec-2015|
Department of PET Imaging, INMAS, Brig SK Mazumdar Marg, New Delhi - 110 054
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Primary hyperparathyroidism is caused by parathyroid adenomas in 85% of the cases. Since parathyroid adenomas are known for their ectopic location, presurgical localization of the suspected site of adenoma is desirable. However, current imaging modalities are not always successful in localizing ectopic parathyroid adenomas. The aim of this case report is to show that 11 C-methionine positron emission tomography could accurately localize ectopic parathyroid adenomas in patients in whom conventional imaging had failed or is inconclusive.
Keywords: 11 C-methionine, parathyroid gland, positron emission tomography, primary hyperparathyroidism
|How to cite this article:|
Seniaray N, Sharma H, Arbind A, Jaimini A, D'souza M, Saw S, Hazari PP, Mishra A K, Sharma R, Mondal A. 11 C-Methionine positron emission tomography-computed tomography in localization of methoxyisobutyl isonitrile negative ectopic parathyroid adenoma. Indian J Nucl Med 2016;31:49-51
|How to cite this URL:|
Seniaray N, Sharma H, Arbind A, Jaimini A, D'souza M, Saw S, Hazari PP, Mishra A K, Sharma R, Mondal A. 11 C-Methionine positron emission tomography-computed tomography in localization of methoxyisobutyl isonitrile negative ectopic parathyroid adenoma. Indian J Nucl Med [serial online] 2016 [cited 2020 Jul 14];31:49-51. Available from: http://www.ijnm.in/text.asp?2016/31/1/49/172362
| Introduction|| |
Presurgical localization of adenoma in symptomatic primary hyperparathyroidism is desirable. However, all widely available techniques may have difficulty in localizing the site of adenomas since they are known for their ectopic nature. Ectopic parathyroid adenomas have been reported earlier, and mediastinum is one of the most common locations for ectopic parathyroid adenomas.  Various imaging modalities have been used to localize ectopic parathyroid adenomas responsible for primary hyperparathyroidism. Ultrasonography (USG), computed tomography (CT), magnetic resonance imaging (MRI), and 99m Tc-methoxyisobutyl isonitrile (MIBI) scintigraphy are the commonly used imaging modalities for this purpose. 
In cases where commonly used imaging techniques are inconclusive 11 C-methionine positron emission tomography-CT ( 11 C-Met PET-CT) can be used as complementary imaging technique for detection and localization of these adenomas. 
| Method|| |
Dual phase MIBI scintigraphy was first performed with injecting around 370 MBq of 99m Tc MIBI intravenously and high-count planar images were obtained of the neck and thorax at approximately at approximately 20 min and at 2 h using a gamma camera fitted with low energy high resolution parallel-hole collimator. In view of inconclusive MIBI scintigraphy 11 C-Met PET-CT which was done, by injecting around 740 MBq of 11 C-methionine intravenously and approximately 20 min later 11 C-Met PET-CT scan of neck and thorax region was acquired in a whole-body full ring PET-CT scanner (General Electric, Fairfield Connecticut,United States) (GE Discovery STE16). A low dose CT was obtained on the same area for attenuation correction and co-registration. Images were reconstructed using a three-dimensional VUE algorithm and slices were reformatted into transaxial, coronal, and sagittal views.
| Case report|| |
A 30-year-old female presented with the complaints of pain in bilateral lower limb and with difficulty in walking for more than 1-month. She had no previous history of trauma. She had a past history of nephrolithiasis. Her routine investigation revealed serum calcium levels of 12.4 mg/dl (normal 8.8-10.5 mg/dl), serum phosphate 1.8 mg/dl (normal 3.0-4.5 mg/dl), serum alkaline phosphatase > 750 IU/L (normal 30-120 IU/l) and serum parathyroid hormone (PTH) was 1258 pg/ml (normal 10-65 pg/ml). Other investigations revealed normal complete blood count and renal parameters. Since primary hyperparathyroidism is mostly caused due to adenomas, USG of neck and MIBI scintigraphy was performed both of these modalities did not show evidence of parathyroid adenoma. Hence, the patient was referred for an 11 C-Met PET-CT scan for detection and localization of parathyroid adenoma. The 11 C-Met PET-CT scan showed focal area of abnormal tracer uptake in the anterior mediastinum (anterior to aortic arch) with 11 C-methionine avid multiple lytic expansible lesion involving ribs, bilateral clavicle, bilateral scapulae, and bilateral humerus.
| Discussion|| |
Primary hyperparathyroidism is a common endocrine condition caused by the overproduction of PTH by either a single adenomatous gland (85%) or, less commonly, by multiple adenomatous or hyperplastic glands (15%). , Diagnosis of primary hyperparathyroidism in a clinically suspected case is suggested by hypercalcemia, hypophosphatemia, raised levels of bone-specific alkaline phosphatase and raised intact PTH levels. Excess PTH leads to the involvement of skeletal system and the kidneys in the majority of cases. Skeletal involvement is mainly as a result of increased bone resorption leading to characteristic manifestations such as osteitis fibrosa cystica, subperiosteal resorption of distal phalanges, bone cysts, and "brown tumors." Renal involvement is seen in many cases of primary hyperparathyroidism and is mainly due to hypercalciuria leading to nephrocalcinosis and nephrolithiasis. In our case-patient did not have hypercalciuria but had a past history of nephrolithiasis. The anterior neck mass may occasionally be palpable in a case of parathyroid adenoma, however, in our case no neck mass was palpable.
Surgical resection of the abnormal parathyroid adenoma is the standard treatment, and the goal of initial parathyroidectomy is a durable biochemical cure. Since ectopic parathyroid adenomas can be high cervical, intrathymic, intrathyroidal, retro-oesophageal, in the carotid sheath, interthyrotracheal, and in the mediastinum [Figure 1], , preoperative localization is necessary. Various imaging modalities like CT, MRI, and 99m Tc MIBI scintigraphy have been used to localize these glands preoperatively. , Presently, 99m Tc MIBI scintigraphy is the most commonly used investigation for this purpose.  However, In this case, MIBI scintigraphy did not show any radiotracer retention [Figure 2], but 11 C-Met PET scan showed ectopic parathyroid adenoma anterior to the arch of the aorta [Figure 3].
|Figure 2: 99mTc-methoxybutyl isonitrate scintigraphy showing no tracer retention on delayed images|
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|Figure 3: 11C-methionine positron emission tomography-computed tomography showing location of ectopic parathyroid gland near the arch of aorta|
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11 C-methionine uptake mechanism is not yet fully understood; it is presumed to be involved in the synthesis of pre-pro-PTH, a PTH precursor which results in intense and specific uptake in hyper functioning parathyroid glands. , Conversely, uptake of MIBI depends on the size, cellularity of the glands and PTH level, adenomas weighing more than one gram have greater than 95% sensitivity.  However, some parathyroid adenomas may show rapid washout or do not have any MIBI uptake in such cases 11 C-Met PET-CT scanning was found to have a sensitivity of 83%, a specificity of 100% and an accuracy of 88% in successfully locating parathyroid adenomas. ,,
| Conclusion|| |
11 C-Met PET-CT is a reliable and highly accurate technique for localizing ectopic parathyroid adenomas in patients especially where conventional imaging techniques have failed or are inconclusive.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Okuda I, Nakajima Y, Miura D, Maruno H, Kohno T, Hirata K. Diagnostic localization of ectopic parathyroid lesions: Developmental consideration. Jpn J Radiol 2010;28:707-13.
Johnson NA, Tublin ME, Ogilvie JB. Parathyroid imaging: Technique and role in the preoperative evaluation of primary hyperparathyroidism. AJR Am J Roentgenol 2007;188:1706-15.
Traub-Weidinger T, Mayerhoefer ME, Koperek O, Mitterhauser M, Duan H, Karanikas G, et al.
11C-methionine PET/CT imaging of 99mTc-MIBI-SPECT/CT-negative patients with primary hyperparathyroidism and previous neck surgery. J Clin Endocrinol Metab 2014;99:4199-205.
Marcocci C, Cetani F, Rubin MR, Silverberg SJ, Pinchera A, Bilezikian JP. Parathyroid carcinoma. J Bone Miner Res 2008;23:1869-80.
Wynne AG, van Heerden J, Carney JA, Fitzpatrick LA. Parathyroid carcinoma: Clinical and pathologic features in 43 patients. Medicine (Baltimore) 1992;71:197-205.
Mariette C, Pellissier L, Combemale F, Quievreux JL, Carnaille B, Proye C. Reoperation for persistent or recurrent primary hyperparathyroidism. Langenbecks Arch Surg 1998;383:174-9.
Mariani G, Gulec SA, Rubello D, Boni G, Puccini M, Pelizzo MR, et al.
Preoperative localization and radioguided parathyroid surgery. J Nucl Med 2003;44:1443-58.
Bernà L, Caixàs A, Piera J, Gómez G, Matías-Guiu X, Estorch M, et al.
Technetium-99m-methoxyisobutylisonitrile in localization of ectopic parathyroid adenoma. J Nucl Med 1996;37:631-3.
Otto D, Boerner AR, Hofmann M, Brunkhorst T, Meyer GJ, Petrich T, et al.
Pre-operative localisation of hyperfunctional parathyroid tissue with 11C-methionine PET. Eur J Nucl Med Mol Imaging 2004;31:1405-12.
Habener JF, Maunus R, Dee PC, Potts JT Jr. Early events in the cellular formation of proparathyroid hormone. J Cell Biol 1980;85:292-8.
Vijayakumar V, Anderson ME. Detection of ectopic parathyroid adenoma by early Tc-99m sestamibi imaging. Ann Nucl Med 2005;19:157-9.
Caldarella C, Treglia G, Isgrò MA, Giordano A. Diagnostic performance of positron emission tomography using 11C-methionine in patients with suspected parathyroid adenoma: A meta-analysis. Endocrine 2013;43:78-83.
Hayakawa N, Nakamoto Y, Kurihara K, Yasoda A, Kanamoto N, Miura M, et al.
A comparison between 11C-methionine PET/CT and MIBI SPECT/CT for localization of parathyroid adenomas/hyperplasia. Nucl Med Commun 2015;36:53-9.
[Figure 1], [Figure 2], [Figure 3]