Authors' objectives: Due to several periods of shortage of 99m-Technetium (Tc-99m) supply- a radioactive element needed to perform preoperative Tc-99m-sestamibi scintigraphy in certain cases of hyperparathyroidism (HPT)- the Directorate General for Health (DGS) asked HAS to determine if, in the event of complete shortage of Tc-99m, one (or more) test(s) could replace it without risk to patients. The objective of this assessment is therefore not to call the reference strategy into question. Following laboratory confirmation of HPT, the preoperative first-line strategy provides for the combination of cervical ultrasonography (US) and 99mTc scintigraphy… Currently, 99mTc scintigraphy in addition to US is used to: • confirm the nature of a suspicious lesion seen on US; • detect a eutopic or ectopic abnormal parathyroid gland not seen on US. The imaging test(s) for the preoperative assessment are requested by the surgeon or endocrinologist, who always work together in collaboration, particularly with the nuclear medicine and radiology team.

Authors' recommendations: Eleven guidelines were identified for the final analysis of the literature overview. No relevant Heath technology assessment (HTA) reports were identified. The analysis of guidelines cannot be used to conclude directly on the question asked - as the hypothesis of Tc-99m shortage was not foreseen in these recommendations. However, it was possible, based on current knowledge, to identify two additional tests performed in addition (and not as a substitute) to scintigraphy, (with the exception of US which is still necessary), i.e contrastenhanced CT-scan and MRI, both of the cervical-mediastinal area. The latter two are used to localise pathological glands. It might be relevant, based on the guidelines, not to exclude the possibility of their use alone, in the absence of scintigraphy. Other tests available to the clinicians are not suitable to replace preoperative scintigraphy: • preoperative selective venous sampling of parathyroid hormone (too invasive); • US-guided biopsy with in situ PTH assay (only indicated in special cases); • Positron emission tomography (PET) with 18 F-choline (still within the domain of clinical research). Based on all the collected data, (including stakeholders' points of view) the new preoperative first-line strategy in the event of complete shortage of 99mTc might be: • cervical US which should be performed routinely in all patients to search for one (or several) parathyroid adenoma(s) and associated thyroid nodules; • the possible substitution of preoperative scintigraphy by contrast-enhanced multislice CT scan (multiphase four-dimensional 4D imaging)) of the cervical-mediastinal area, at best combined with a low radiation dose protocol; • in the event of contraindication to the contrast-enhanced CT scan1, a cervical-mediastinal MRI may be requested. Within a context of complete shortage of 99mTc, the representative of the NPB2 of endocrine surgeons advocates the temporary use of bilateral neck exploration for all patients until final validation of 4D CT-scan.

Project Status: Completed

Year Published: 2015

URL for published report: http://www.has-sante.fr/portail/upload/docs/application/pdf/2015-04/rapport_technetium_vd.pdf

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: France

Organisation Name: Haute Autorité de Santé

Contact Address: 2 avenue du Stade de France, 93218 Saint-Denis La Plaine Cedex, France. Tel: +33 01 55 93 71 88; Fax: +33 01 55 93 74 35;

Contact Name: has.seap.secretariat@has-sante.fr

Contact Email: has.seap.secretariat@has-sante.fr