High cardiac background activity limits Tc-MIBI radioguided surgery in aortopulmonary window parathyroid adenomas

Background: Radioguided surgery using 99m-Technetium-methoxyisobutylisonitrile (Tc-MIBI) has been recommended for the surgical treatment of mediastinal parathyroid adenomas. However, high myocardial Tc-MIBI uptake may limit the feasibility of radioguided surgery in aortopulmonary window parathyroid adenoma. Case presentation: Two female patients aged 72 (#1) and 79 years (#2) with primary hyperparathyroidism caused by parathyroid adenomas in the aortopulmonary window were operated by transsternal radioguided surgery. After intravenous injection of 370 MBq Tc-MIBI at start of surgery, the maximum radioactive intensity (as counts per second) was measured over several body regions using a gamma probe before and after removal of the parathyroid adenoma. Relative radioactivity was calculated in relation to the measured ex vivo radioactivity of the adenoma, which was set to 1.0. Both patients were cured by uneventful removal of aortopulmonary window parathyroid adenomas of 4400 (#1) and 985 mg (#2). Biochemical cure was documented by intraoperative measurement of parathyroid hormone as well as follow-up examination. Ex vivo radioactivity over the parathyroid adenomas was 196 (#1) and 855 counts per second (#2). Before parathyroidectomy, relative radioactivity over the aortopulmonary window versus the heart was found at 1.3 versus 2.6 (#1) and 1.8 versus 4.8 (#2). After removal of the adenomas, radioactivity within the aortopulmonary window was only slightly reduced. Conclusion: High myocardial uptake of Tc-MIBI limits the feasibility of radioguided surgery in aortopulmonary parathyroid adenoma.