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99mTc-MIBI针孔准直器双时相显像与平行孔准直器SPECT/CT断层融合显像术前定位诊断原发性甲状旁腺功能亢进症的临床价值比较
doi: 10.12290/xhyxzz.2023-0164
Clinical Values of 99mTc-MIBI Pinhole Dual-phase and Parallel-hole SPECT/CT for Preoperative Localization in Patients with Primary Hyperparathyroidism
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摘要:
目的 比较术前99mTc-甲氧基异丁基异腈(methoxyisobutylisonitrile, MIBI)针孔准直器双时相显像与平行孔准直器单光子发射计算机断层显像(single photon emission computed tomography, SPECT)/CT断层融合显像在原发性甲状旁腺功能亢进症(primary hyperparathyroidism，PHPT)术前定位诊断中的临床价值。 方法 回顾性收集2021年7月—2022年2月北京协和医院疑诊PHPT患者的术前99mTc-MIBI甲状旁腺显像资料。以术后组织病理为金标准，计算99mTc-MIBI针孔准直器双时相显像与平行孔准直器SPECT/CT断层融合显像检出PHPT病灶的灵敏度、准确度、阳性预测值，并分析甲状旁腺激素(parathyroid hormone，PTH)对上述两种显像方法检出PHPT病灶的影响。 结果 共入选135例行99mTc-MIBI甲状旁腺显像的疑诊PHPT患者。99mTc-MIBI针孔准直器双时相显像共检出病灶149个(包括1个异位病灶)、平行孔准直器SPECT/CT断层融合显像共检出病灶148个(包括11个异位病灶; 1个真阳性病灶为2个病灶融合而成，该方法无法分辨)，二者检出PHPT病灶的灵敏度(79.9%比74.8%，P=0.326)、准确度(79.2%比75.7%，P=0.490)、阳性预测值(98.3%比100%，P=0.499)均无显著差异。在PTH≤150 ng/L、PTH＞150 ng/L亚组中，99mTc-MIBI针孔准直器双时相显像检出PHPT病灶的灵敏度(79.1%比80.5%，P=0.838)、准确度(77.5%比80.8%，P=0.688)、阳性预测值(96.4%比100%，P=0.219)均无显著差异; SPECT/CT断层融合显像的灵敏度(71.6%比77.6%，P=0.445)、准确度(73.2%比77.9%，P=0.567)、阳性预测值(100%比100%，P＞0.999)亦均无显著差异。 结论 99mTc-MIBI针孔准直器甲状旁腺双时相显像及平行孔准直器SPECT/CT断层融合显像对PHPT均具有较好的诊断能力且受PTH水平变化的影响不显著，由于99mTc-MIBI针孔准直器甲状旁腺双时相显像分辨率高，其仍是目前PHPT术前定位诊断的重要依据，而平行孔准直器SPECT/CT断层融合显像对于异位PHPT的诊断具有明显优势，在一些特殊情况下值得被推荐。 -
关键词:
- 原发性甲状旁腺功能亢进症 /
- 针孔准直器 /
- 单光子发射计算机断层显像 /
- 99mTc-MIBI
Abstract:Objective To evaluate the clinical values of preoperative 99mTc-methoxyisobutylisonitrile (MIBI) pinhole collimator duplex imaging versus parallel-hole collimator single photon emission computed tomography (SPECT)/CT tomography fusion imaging in the preoperative localization of primary hyperparathyroidism (PHPT). Methods In this diagnostic test, the patients with suspected PHPT in Peking Union Medical College Hospital from July 2021 to February 2022 were retrospectively analyzed. With postoperative histopathology as the gold standard, the sensitivity, accuracy, and positive predictive value of 99mTc-MIBI pinhole collimator duplex imaging and parallel-hole collimator SPECT/CT tomographic fusion imaging for the detection of PHPT lesions were calculated, and the effect of parathyroid hormone (PTH) on the detection of PHPT lesions by these two diagnostic methods was analyzed. Results A total of 135 patients with suspected PHPT on 99mTc-MIBI parathyroid imaging were enrolled. A total of 149 lesions were detected on 99mTc-MIBI pinhole collimator diachronic imaging (including 1 ectopic lesion) and 148 lesions were detected on parallel-hole collimator SPECT/CT tomographic fusion imaging (including 11 ectopic lesions; 1 true positive lesion was a fusion of 2 lesions that could not be distinguished by this method). The sensitivity (79.9% vs. 74.8%, P=0.326), accuracy (79.2% vs. 75.7%, P=0.490) and positive predictive value (98.3% vs. 100%, P=0.499) of the two methods for detecting PHPT lesions were not significantly different. In the subgroups with PTH≤150 ng/L and PTH>150 ng/L, the sensitivity (79.1% vs. 80.5%, P=0.838), accuracy (77.5% vs. 80.8%, P=0.688), and positive predictive value (96.4% vs. 100%, P=0.219) of 99mTc-MIBI pinhole collimator diachronic imaging in detecting PHPT lesions were not significantly different; the sensitivity (71.6% vs. 77.6%, P=0.445), accuracy (73.2% vs. 77.9%, P=0.567), and positive predictive value (100% vs. 100%, P> 0.999) of SPECT/CT fusion imaging were also not significantly different. Conclusions Both 99mTc-MIBI pinhole collimator parathyroid duplex imaging and parallel-hole collimator SPECT/CT tomographic fusion imaging have good diagnostic ability for PHPT and are not significantly affected by changes in PTH levels. Due to the high resolution of 99mTc-MIBI pinhole collimator parathyroid duplex imaging, it is still an important basis for preoperative localization and diagnosis of PHPT, while parallel-hole collimator SPECT/CT tomographic fusion imaging has obvious advantages for the diagnosis of ectopic PHPT and is recommended in some special cases. 作者贡献：刘轶敏负责阅片及论文撰写；陈黎波负责论文审核；刘宇、王正华、胡楠、李从心、朱世坤、张正负责图像采集；景红丽、霍力负责阅片。利益冲突：所有作者均声明不存在利益冲突 -
图 1 1例52岁女性患者基线PTH为252.0 ng/L，血清钙、磷均正常，术前99mTc-MIBI双时相显像示甲状腺左叶上极外侧可见类圆形放射性摄取灶，判定为阳性病灶(A、B，绿色箭头)，SPECT/CT断层融合显像示甲状腺左叶上部前外侧(颈静脉内侧)软组织密度小结节，未见示踪剂摄取，判定为阴性病灶(C，红色箭头)，术后组织病理示甲状旁腺增生
MIBI：甲氧基异丁基异腈；SPECT：单光子发射计算机断层显像；PTH：同表 1
图 3 1例65岁女性患者基线PTH、血钙、血磷分别为81.3 ng/L、2.73 mmol/L、1.08 mmol/L，术前99mTc-MIBI双时相显像示甲状腺右叶中部与左叶下极均可见示踪剂摄取增高结节(A、B，绿色箭头)，均判定为阳性病灶，SPECT/CT断层融合显像示甲状腺右叶中部不均匀密度结节，CT示其位于甲状腺，前部示踪剂摄取增高，后部未见示踪剂摄取，考虑为甲状腺来源(C，红色箭头)，判定为阴性病灶(术后组织病理得到了证实)，甲状腺左叶下极后方(紧邻食管左侧壁)软组织密度结节，示踪剂摄取增高，判定为异位阳性病灶(C，绿色箭头)，术后组织病理示甲状旁腺腺瘤
表 1 135例疑诊PHPT患者术前基线临床资料(x±s)
指标 数值(正常值范围) PTH(ng/L) 231.6±330.0(15.0~65.0) 血钙(mmol/L) 2.71±0.24(2.13~2.7) 血磷(mmol/L) 1.38±0.11(0.81~1.45) 碱性磷酸酶(U/L) 120±118(45~125) 尿素氮(mmol/L) 4.61±1.43(2.78~7.14) 血肌酐(μmol/L) 64±16(59~104) 总25羟维生素D(μg/L) 18±8(≥20) PHPT：原发性甲状旁腺功能亢进症；PTH：甲状旁腺激素 
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