PARATHYROID STUDY – SPECT/CT Radiology Associates of Clearwater Overview The Parathyroid Study depicts hypertrophied parathyroid tissue, probably because of uptake of Tc-99m-sestamibi in the mitochondria of hyperactive cells. Indications Detect and localize parathyroid adenomas (1-3). *Exams ordered for indications which are not listed above need to be discussed with the Nuclear Medicine Physician. Examination Time Initially: 60 minutes. Delayed imaging at 2 hours: 30 minutes. *Patients who are getting a pre-op injection will only require a single image at 15 minutes. Patient Instructions None Lab / Image Correlation Any imaging studies if the neck should be included for comparison. Patient Preparation Remove all jewelry from the head and neck. Equipment & Energy Windows Gamma camera: Small or large field of view with 1.5 zoom (1) for planar. Symbia SPECT/CT camera for SPECT. Collimator: Low energy high resolution Energy windows: 20% window centered at 140 keV.

Matrix 128x128 for planar and 256 x 256 for SPECT/CT Radiopharmaceutical, Dose, & Technique of Administration Radiopharmaceutical: Tc-99m-sestamibi (1,4). Dose: 25 mCi (925 MBq). Technique of administration: Standard intravenous injection. Patient Position & Imaging Field Patient position: Supine with head and neck extended (1). Imaging field: Neck and upper two thirds of the mediastinum. Acquisition Protocol (1) Acquire images of the neck and mediastinum for 300 seconds each as follows: 1. Immediate ant. w/mkr on SSN and 4 cm distance mkrs on right side of neck. 2. Ant. at 5 min. 3. RAO at 10 min. at 34º 4. LAO at 15 min. at 34º 5. Chest at 20 min. – salivary glands to diaphragm. 6. 2 hr after injection, do planar images using 1,2,3,4 above. *If this is a pre-op study only an anterior image is required. Do not Inject the radiotracer until called by Surgery to confirm the time of injection. After injection, document the time and date and send copies of the previous and current image with the patient to surgery. SPECT/CT at 90 minutes (5,6): 1. Degrees of rotation: 360 2. Number of images: 32 per head 3. Time per image: 30 seconds 4. CT at 2.5mA, 140kV, 256 x 256 Show images to the physician prior to the patient leaving. Data Processing SPECT PRocessing -­‐

In  category  drop  down  select  parathyroid  

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Double  click  SPECT  PROC  icon   Next  click  Tomo  Reconstruction  tab   Verify  Iterative  Reconstruction  OSEM  2D  is  being  used   Verify  4  subsets  are  being  used   Verify  10  iterations  are  being  used   Verify  Gausian  filter  at  8.0  is  being  used   Changs  Attenuation  Coefficient    0.15   Auto  contours  ON   Projection  Angles  2   Edge  Strength  0.5   Background  Threshold  5   In  3D  Orientation  tab  verify  image  is  centered  and  adjust  if  necessary   In  Flexible  Display  tab  adjust  slices  in  transverse  tab,  coronal  tab,  and  sagittal  tabs  across   the  top  of  screen   Send  to  Dr.  reading  station  and  PACS  

SPECT/CT Processing -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐

Select  Patient   In  categories  drop  down  select  SPECT/CT   In  the  first  Tomo  Reconstruction  tab  verify  Filtered  Back  Projection  is  being  used   Butterworth  filter  order  5  cuttoff  0.5   Changes  Attenuation  Coefficient  0.15   Auto  Contours   Projection  angle  2   Edge  Strength  0.5   Background  Threshold  5   Gausian  Slice  Averaging  #  of  slices  1   In  the  second  Tomo  Reconstruction  tab  verify   Flash  3D  is  being  used   8  subsets   10  itterations   Gausian  Filter  at  8.4   In  Image  Registration  tab  verify  SPECT  and  CT  images  are  aligned  properly.    Adjust  if   necessary.   In  Flexible  Display  tab  verify  image  quality  on  cine   In  Hard  Copy  tab  send  to  Dr.  reading  station  and  PACS   Click  complete  

Principle Radiation Emission Data - Tc-99m (11) Physical half-life = 6.01 hours. Radiation Mean % per disintegration Gamma-2 89.07 Dosimetry - Tc-99m-Sestamibi (12) Organ rads/25 mCi Upper large intestine 3.88 Lower large intestine 2.68 Gallbladder wall 2.41 Small intestine 2.32 Kidneys 1.39 Urinary bladder wall 1.29 Ovaries 1.02 Thyroid 0.68 Red marrow 0.60 Whole body 0.38 Liver 0.36 Testes 0.24

Mean energy (keV) 140.5 mGy/925 MBq 38.8 26.8 24.1 23.2 13.9 12.9 10.2 6.8 6.0 3.8 3.6 2.4

References 1.

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Taillefer R, Boucher Y, Potvin C, et al: Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med 33:1801-1807, 1992. McBiles M, Lamber AT, Cote MG, et al: Sestamibi parathyroid imaging. Sem Nucl Med 25:221-234, 1995. Geatti O, Shapiro B, Orsolon PG, et al: Localization of parathyroid enlargement: Experience with technetium-99m-methoxyisobutylisonitrile and thallium-201 scintigraphy, ultrasonography and computed tomography. Eur J Nucl Med 21:17-22, 1994. Aigner RM, Fueger GF, Micoletti R: Parathyroid scintigraphy: Comparison of technetium-99m methoxyisobutylisonitrile and technetium-99m tetrofosmin studies. Eur J Nucl Med 23:693-696, 1996. Billotey C, Sarfati E, Aurengo A, et al: Advantages of SPECT in technetium-99m-sestamibi parathyroid scintigraphy. J Nucl Med 37:1773-1778, 1996.

6. 7. 8. 9. 10. 10. 11.

Perez-monte JE, Brown ML, Shah AN, et al: Parathyroid adenomas: Accurate detection and localization with T-99m sestamibi SPECT. Radiology 201:85-91, 1996. Conte FA, Orzel JA, Weiland FL, et al: Prevention of motion artifacts on dual isotope subtraction parathyroid scintigraphy. J Nucl Med 28:1335-1337, 1987. Apple MG, Rosenberg RJ, Spencer RP: Hyperplastic parathyroid detection by use of Tc-99m-sestamibi/I-123 Na. Clin Nucl Med 19:1124, 1994. Chen CC, Skarulis MC, Graker DL, et al: Technetium-99m-sestamibi imaging before reoperation for primary hyperparathyroidism. J Nucl Med 36:2186-2191, 1995. Chen CC, Premkumar A, Hill SC, et al: Tc-99m sestamibi imaging of a hyperfunctioning parathyroid autograft with doppler ultrasound and MRI correlation.Clin Nucl Med 20:222-225, 1995. 43-Tc-99m: In MIRD: Radionuclide Data and Decay Schemes, DA Weber, KF Eckerman, AT Dillman, JC Ryman, eds, Society of Nuclear Medicine, New York, 1989, pp 178-179. Wackers FJT, Berman DS, Maddahi J, et al: Technetium-99m hexakis 2-methoxyisobutyl isonitrile: Human biodistribution, dosimetry, safety, and preliminary comparison to thallium-201 for myocardial perfusion imaging. J Nucl Med 30:301-311, 1989.

Normal Findings Taillefer R, Boucher Y, Potvin C, et al: Detection and localization of parathyroid adenomas in patients with hyperparathyroidism using a single radionuclide imaging procedure with technetium-99m-sestamibi (double-phase study). J Nucl Med 33:1801-1807, 1992. JSM PROTOCOL\04-4 10/14/14

Note: This protocol is in agreement with the Society of Nuclear Medicine Procedure Guidelines Manual, 1999.