Sequential improvement in parathyroid adenoma localisation: optimising the 99mTc-sestamibi washout study

Objectives In primary hyperparathyroidism, preoperative localisation of a parathyroid adenoma enables focussed excision rather than full neck exploration, with reduced complication rates, recovery time and cost. In this study, we sought to improve parathyroid adenoma localisation on 99m Tc-sestamibi so more patients can benefit from focussed excision. Methods We performed a baseline audit of our 99m Tc-sestamibi service, followed by three sequential changes: cycle 1: acquisition of new single-photon emission computed tomography/computed tomography (SPECT/CT) scanners, cycle 2: optimisation of image acquisition and reconstruction, cycle 3: addition of arterial phase iodinated contrast to SPECT/CT. We classified reporter confidence using a 5-point Likert scale. We correlated adenoma location on imaging with ‘gold standard’ location based on surgical and pathology results. We calculated the sensitivity, specificity, and receiver operator characteristics following each change cycle. Results Results comparing each cycle to the baseline audit: Baseline: 44% confidently located, 31% failed to identify an adenoma. Sensitivity: 69.8%, specificity: 95.7%, area under the curve (AUC): 0.92. Cycle 1: 54% confidently located, 24% failed to identify an adenoma. Sensitivity: 77.6%, specificity: 93.3%, AUC: 0.95. Cycle 2: 48% confidently located, 18% failed to identify an adenoma. Sensitivity: 84.3%, specificity: 95.9%, AUC: 0.98. Cycle 3: 67% confidently located, 6% failed to identify an adenoma. Sensitivity: 94.7%, specificity: 90%, AUC: 0.99 ( P < 0.001). Conclusion Our study demonstrated that sequential improvements in 99m Tc-sestamibi SPECT/CT significantly improved test performance by reducing the number of localisation failures, increasing test sensitivity, and reducing the number of false negatives. As a result, more patients can benefit from focussed excision parathyroidectomy.