Preoperative parathyroid localization by superimposed Iodine-131 toluidine blue and technetium-99m pertechnetate imaging

A new parathyroid scintigraphic localization study by a dual radioisotope technique using radioiodinated toluidine blue (RTB) for the parathyroids and ^99mTc for thyroid imaging is presented. A simple RTB labeling procedure achieving 99% tagging of the ¹³¹I-TB was used. The RTB was found to be a highly specific parathyroid radiotracer, consequently enabling superimposition of the delineated thyroid gland over the RTB avid parathyroid foci without a need for subtraction of the thyroid or vascular background. Forty-six patients with primary hyperparathyroidism underwent scintigraphic study prior to cervical (41 patients) or mediastinal (5 patients) exploration and 67 pathological parathyroid glands (34 adenomas and 33 hyperplasias) were excised. On follow-up, serum calcium level returned to normal in all patients. Correlation of the scintigraphic results with the surgical findings disclosed a sensitivity of 93%, with a specificity of 80% and an overall accuracy of 87%. This new simplified and specific RTB scintigraphic method justifies its use as a routine procedure for preoperative parathyroid scintigraphic localization in primary hyperparathyroidism.