Original article
Comparison of 99mTc-sestamibi and 11C-methionine PET/CT in the localization of parathyroid adenomas in primary hyperparathyroidism
Comparación del 99mTc-sestamibi y 11C-metionina PET/TC en la localización del adenoma de paratiroides en el hiperparatiroidismo primario
I. Martínez-Rodríguez
, N. Martínez-Amador, M. de Arcocha-Torres, R. Quirce, F. Ortega-Nava, S. Ibáñez-Bravo, C. Lavado-Pérez, Z. Bravo-Ferrer, J.M. Carril
Corresponding author
Nuclear Medicine, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
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La paciente presentaba un cáncer epidermoide de vulva de nuevo diagnóstico, y este hallazgo junto con la extensión del tumor vulvar condicionó la realización de un tratamiento de quimioterapia neoadyuvante, que retrasó la cirugía vulvar.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "V. Peiró, L. Chiva, A. González, R. Bratos, S. Alonso, R. Márquez, N. Carballo, J.C. Alonso-Farto" "autores" => array:8 [ 0 => array:2 [ "nombre" => "V." "apellidos" => "Peiró" ] 1 => array:2 [ "nombre" => "L." "apellidos" => "Chiva" ] 2 => array:2 [ "nombre" => "A." "apellidos" => "González" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Bratos" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Alonso" ] 5 => array:2 [ "nombre" => "R." "apellidos" => "Márquez" ] 6 => array:2 [ "nombre" => "N." "apellidos" => "Carballo" ] 7 => array:2 [ "nombre" => "J.C." 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Martínez-Rodríguez, N. Martínez-Amador, M. de Arcocha-Torres, R. Quirce, F. Ortega-Nava, S. Ibáñez-Bravo, C. Lavado-Pérez, Z. Bravo-Ferrer, J.M. Carril" "autores" => array:9 [ 0 => array:4 [ "nombre" => "I." "apellidos" => "Martínez-Rodríguez" "email" => array:1 [ 0 => "mimartinez@humv.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "N." "apellidos" => "Martínez-Amador" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "de Arcocha-Torres" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Quirce" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Ortega-Nava" ] 5 => array:2 [ "nombre" => "S." "apellidos" => "Ibáñez-Bravo" ] 6 => array:2 [ "nombre" => "C." "apellidos" => "Lavado-Pérez" ] 7 => array:2 [ "nombre" => "Z." "apellidos" => "Bravo-Ferrer" ] 8 => array:2 [ "nombre" => "J.M." "apellidos" => "Carril" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Nuclear Medicine, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación del <span class="elsevierStyleSup">99m</span>Tc-sestamibi y <span class="elsevierStyleSup">11</span>C-metionina PET/TC en la localización del adenoma de paratiroides en el hiperparatiroidismo primario" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1785 "Ancho" => 2155 "Tamanyo" => 241473 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Axial, sagittal and coronal views of <span class="elsevierStyleSup">99m</span>Tc-MIBI-SPECT, (b) PET and (c) fused <span class="elsevierStyleSup">11</span>C-methionine-PET/CT show an abnormal focal uptake localized in the retro-esophageal region corresponding to an ectopic parathyroid adenoma (arrows). Also, a diffuse and higher uptake was seen in the enlarged thyroid gland.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Primary hyperparathyroidism (PH) is characterized by the increased production of parathyroid hormone (PTH) and is the most often cause of hypercalcemia. It is caused by a solitary parathyroid adenoma in 80–85% of cases, by hyperplasia in 15% and by carcinoma in approximately 1% of cases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> The diagnosis of PH is established by biochemical data (elevated serum PTH and calcium levels) and the treatment of choice is surgical resection. Currently, and, in order to reduce the extent and duration of the intervention and the post-operative morbidity, a minimal invasive surgery focused in the resection of the enlarged gland is the ideal approach.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> However, the success of the surgical procedure depends on the accurate preoperative localization of the abnormal glands. The anatomical imaging techniques (ultrasonography, computerized tomography and magnetic resonance imaging) show low sensitivity.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The improvement of the nuclear medicine imaging techniques has greatly contributed to the development of the minimally invasive surgery and, in this context, double-phase <span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy (MIBI) is a widespread technique generally applied for the preoperative localization of the gland responsible of the PH with sensitivities up to 90%<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> specially when SPECT and SPECT/CT is applied.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9–11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Other radiotracers have been used for the localization of parathyroid adenomas. Methionine labeled with <span class="elsevierStyleSup">75</span>Selenium was introduced in 1964 and was the first radiotracer used for in vivo imaging of the hyper functioning parathyroid glands.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a> However, suboptimal results were obtained due to the physical characteristics of the <span class="elsevierStyleSup">75</span>Selenium and the imaging technology used.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The introduction of the new PET instrumentation along with the general acceptance of the technique in oncology raised the possibility of evaluating new PET radiotracers for the preoperative localization of the parathyroid adenoma.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The first PET radiotracer used for this purpose was the <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose (FDG), widely applied in oncological processes. Only a few studies applying FDG in PH have been published<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14,15</span></a> and only in one of them a direct comparison with MIBI was performed showing a higher sensitivity but a lower specificity for FDG.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Although methionine was previously applied for the detection of parathyroid adenomas, the availability of methionine labeled with <span class="elsevierStyleSup">11</span>Carbon deserves a new evaluation of that radiotracer.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The first approaches to <span class="elsevierStyleSup">11</span>C-methionine-PET were done in the mid-1990s, with contradictory results. Hellman et al. described low sensitivity probably related to the heterogeneity of the population evaluated<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and Beggs and Hain reported a greater sensibility in a selected group of patients with negative conventional imaging techniques.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">More recently, the hybrid PET/CT technology has been included to the diagnostic arsenal available for the preoperative study of patients with hyperparathyroidism. However, only a few reports using <span class="elsevierStyleSup">11</span>C-methionine PET/CT (MET) have been published, although based in different designs, populations and methodologies.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19–21</span></a> In this context, a preoperative evaluation of the contribution of MET compared to MIBI in the parathyroid localization is still needed.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Another interesting issue concerns the acquisition protocol of images. For MIBI, this aspect has been previously assessed in detail; however, for MET only a few authors investigated this issue that should be evaluated in a deep way.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Our aim was to evaluate the usefulness of MET in the localization of pathological parathyroid glands in patients with PH and to compare the results with those obtained with MIBI. Also, we evaluated the optimal timing of MET imaging.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0055" class="elsevierStylePara elsevierViewall">This prospective study included 14 patients (10 women, mean age: 65.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.7 years) with biochemical evidence of PH and underwent surgical treatment. The mean serum intact parathyroid hormone (iPTH) was 215.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>108<span class="elsevierStyleHsp" style=""></span>pg/mL (normal range, 10–55) and the mean serum calcium was 10.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9<span class="elsevierStyleHsp" style=""></span>mg/dL (normal range, 8.1–10.4). In all patients a preoperatively MIBI and MET were performed. The interval between both scans was 25.2<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>46.3 days. Nine patients had concomitant multinodular goiter and in 2 patients a previous surgery was performed and showed recurrent PH. An additional thyroid scan with <span class="elsevierStyleSup">99m</span>Tc-pertechnetate using a pin-hole collimator was acquired if necessary.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Written informed consent for MET scan was obtained in all patients. Surgery and histopathological analysis were performed in the 14 patients; in all of them a parathyroid adenoma was found and 2 of them showed a concomitant differentiated thyroid cancer.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Double-phase <span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy protocol</span><p id="par0065" class="elsevierStylePara elsevierViewall">MIBI was acquired after intravenous injection of 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) of <span class="elsevierStyleSup">99m</span>Tc-sestamibi (Cardiolite, Bristol-Myers Squibb, Munich, Germany; labeling efficiency more than 95%), using a double-headed Siemens E.cam gammacamera equipped with low-energy, parallel hole high-resolution collimators. Anterior planar images (matrix: 128<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>128 and 10<span class="elsevierStyleHsp" style=""></span>min/image) of the neck and thorax at 10<span class="elsevierStyleHsp" style=""></span>min and 2–3<span class="elsevierStyleHsp" style=""></span>h after injection were acquired. Also, an early SPECT was acquired immediately after the early planar image (matrix: 128<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>128, 64 projections, 20<span class="elsevierStyleHsp" style=""></span>s/projection).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085"><span class="elsevierStyleSup">11</span>C-methionine PET/CT protocol</span><p id="par0070" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleSup">11</span>CO<span class="elsevierStyleInf">2</span> was produced in a PETtrace cyclotron (General Electric, Uppsala, Sweden) by the nuclear reaction <span class="elsevierStyleSup">14</span>N(p,α) <span class="elsevierStyleSup">11</span>C. The <span class="elsevierStyleSup">11</span>C-<span class="elsevierStyleSmallCaps">l</span>-methionine was synthesized in a Tracerlab FX<span class="elsevierStyleInf">N</span> module (General Electric, Uppsala, Sweden) by direct methylation of precursor L-Homocysteine thiolactone hydrochloride (ABX, Germany).</p><p id="par0075" class="elsevierStylePara elsevierViewall">MET was acquired 10<span class="elsevierStyleHsp" style=""></span>min and 40<span class="elsevierStyleHsp" style=""></span>min after intravenous injection of 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) of <span class="elsevierStyleSup">11</span>C-methionine, using a Biograph LSO Pico3D Siemens equipment. First, a non-contrast low dose CT for attenuation correction and anatomical localization was performed. Then, PET scan was acquired early at 10<span class="elsevierStyleHsp" style=""></span>min and delayed at 40<span class="elsevierStyleHsp" style=""></span>min after injection, including the neck and thorax (two beds, 3<span class="elsevierStyleHsp" style=""></span>min/bed in the early scan and 4<span class="elsevierStyleHsp" style=""></span>min/bed in the delayed scan).</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Image analysis</span><p id="par0080" class="elsevierStylePara elsevierViewall">A separate visual analysis of MET and MIBI images was done by two specialists in nuclear medicine, blinded to clinical and laboratory data.</p><p id="par0085" class="elsevierStylePara elsevierViewall">First of all, MIBI and MET images were classified into negative and positive for parathyroid adenoma and, if positive, the localization of the adenoma was specified. The results obtained with both techniques were compared with the histopathological result. Then, MET images at 10<span class="elsevierStyleHsp" style=""></span>min and 40<span class="elsevierStyleHsp" style=""></span>min were evaluated separately, by grading from score 0 (no abnormal uptake) to 3 (intense uptake suggesting a parathyroid adenoma) and both results were compared.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0090" class="elsevierStylePara elsevierViewall">In <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> we describe the MIBI and MET results in the 14 patients. MIBI and MET were positive in 11 of the 14 patients (78.6%). A parathyroid adenoma was correctly localized by both studies in 10 of these 11 patients (90.9%) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and incorrectly in 1 (9.1%). One of these 10 parathyroid adenomas correctly localized was found in an ectopic retro-esophageal location (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). On the other hand, MIBI was positive and MET negative in 3 of the 14 patients (21.4%), in 2 of them MIBI correctly localized the parathyroid adenoma (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) but in 1 the localization was incorrect.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">The sensitivity achieved for the correct localization of the pathological gland was 100% for MIBI and 76.9% for MET and the positive predictive value was 85.7% and 90.0%, respectively (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">We also analyzed the results obtained for MET according to the timing of imaging. In 10/14 patients (71.4%) both acquisitions (early at 10<span class="elsevierStyleHsp" style=""></span>min and delayed at 40<span class="elsevierStyleHsp" style=""></span>min) showed the same score (in 3 of them the score was 0 and in 7 it was 3). In the other 4 patients (28.6%) the score was different, in 3 the score was higher in the early acquisition and in 1 the parathyroid adenoma was only detected in the delayed acquisition (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">The results reported in this paper correspond to the evaluation of an old molecule, methionine, previously applied labeled with <span class="elsevierStyleSup">75</span>Selenium and using old imaging technology like rectilinear scanners and gammacameras. However, in our case the label of the same molecule with a positron emitter isotope like <span class="elsevierStyleSup">11</span>Carbon along the introduction of a new imaging technology like PET/CT offers a new framework for a new radiotracer <span class="elsevierStyleSup">11</span>C-methionine. Its application for the localization of parathyroid adenoma, however, offers a difficult challenge as there is already a well established cheap and accurate technique like MIBI. Therefore, such a sophisticated technique like PET/CT should justify its use in the clinical setting.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Although some studies have been published using <span class="elsevierStyleSup">11</span>C-methionine as a radiotracer, most of them used PET technology<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18,22–25</span></a> and in only a few studies PET/CT was applied, and only in one of them the design was prospective and a comparison of MET and MIBI results for the accurate preoperative localization of parathyroid adenomas was specifically addressed.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Our results showed a sensitivity of 100% for MIBI in the localization of parathyroid adenomas, higher to those obtained by Tang et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> However, our sensitivity for MET was lower (76.9% vs. 92%). These results could be related to different causes, such as the acquisition protocols used, the sample size and the different population included.</p><p id="par0120" class="elsevierStylePara elsevierViewall">MIBI and MET correctly localized the parathyroid adenoma in 10 patients. One of these 10 parathyroid adenomas was correctly localized, both for MIBI and MET, in the retro-esophageal space corresponding to an ectopic parathyroid gland (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). In this patient, the anatomic information provided by the CT component of the PET/CT was essential to address surgery. In two of these 10 patients a parathyroid adenoma was excised in a previous successful surgery, however several months later the hyperparathyroidism recurred with high PTH and calcium serum levels, and a new scintigraphy was requested. MIBI and MET scans correctly localized a new parathyroid adenoma that was successfully excised, with normal iPTH after one year of follow-up.</p><p id="par0125" class="elsevierStylePara elsevierViewall">One of the 14 patients was MIBI and MET positive at the same localization. However, this finding was not confirmed during surgery, and a contra-lateral parathyroid adenoma was excised with normalization of the iPTH level. One explanation for this false result is that the excised parathyroid adenoma had a small size (1.2<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.7<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>0.4<span class="elsevierStyleHsp" style=""></span>cm) and weight (190<span class="elsevierStyleHsp" style=""></span>mg). It is well known that the size and weight of the parathyroid adenoma may affect the accuracy of the preoperative localization with MIBI.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> A correlation between <span class="elsevierStyleSup">11</span>C-methionine using PET and the weight and size of the parathyroid adenoma was also reported and a weight of 200<span class="elsevierStyleHsp" style=""></span>mg and a diameter of 7.5<span class="elsevierStyleHsp" style=""></span>mm have been suggested as the minimum required for its detection.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,25</span></a> For the abnormal uptake detected on the contralateral side of the neck by both radiotracers, the very likely explanation is that the patient had several nodules involving both thyroid lobes (identified in a previous ultrasound neck study and <span class="elsevierStyleSup">99</span><span class="elsevierStyleSup">m</span>Tc-perthecnetate thyroid scintigraphy) and also a Hashimotos’ thyroiditis. This is not a new finding as lymphocytic thyroiditis has been reported as the cause of false positive results for MIBI and FDG.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> According to some authors, any inflammation could also be the cause of MET uptake<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> and should be taken into account when interpreting parathyroid images.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Three of the 14 patients were MIBI positive and MET negative and, in 2 of them MIBI correctly localized the parathyroid adenoma. In the other one the abnormal MIBI uptake was contralateral to the parathyroid adenoma, that is, in the other side of the neck; in this sense, the MIBI scan was false positive. The iPTH and calcium levels after surgery and during the follow-up remained normal.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Although there are many studies which approached in depth the MIBI acquisition protocol,<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,28–31</span></a> the topic did not deserve the same interest when it applies to MET. Sundin et al. studied the kinetics of <span class="elsevierStyleSup">11</span>C-MET and found that it is taken up by parathyroid adenomas that reach the peak of activity in the first minute post injection and decline over the next 5<span class="elsevierStyleHsp" style=""></span>min to half of the activity.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> These results were reproduced in other groups.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,26</span></a> The image quality is dependent on many factors such as the amino acid influx into the stimulated parathyroid tissue, the ratio target tissue/background and the histophatological features of the parathyroid lesions. In our study, we compared the MET results obtained with both acquisitions, at 10<span class="elsevierStyleHsp" style=""></span>min (early) and 40<span class="elsevierStyleHsp" style=""></span>min (delayed), in order to evaluate the diagnostic efficacy. The early and delayed acquisitions showed the same score in most of the patients (10 of 14). Only in 4 of the 14 patients the intensity of the uptake showed some differences between both acquisitions as in 3 it was one grade higher at the early acquisition. The other patient only showed uptake at the delayed acquisition and, therefore, although the acquisition at 10<span class="elsevierStyleHsp" style=""></span>min allows a more confident report, the delayed should be also included in the MET protocol.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In conclusion, MIBI remains the technique of choice for the localization of parathyroid adenomas in patients with PH. MET may have a complementary role in selected patients in whom MIBI fails to correctly localize the parathyroid adenoma. The delayed acquisition should be included in the MET protocol when the early acquisition is negative.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of interest</span><p id="par0145" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:2 [ "identificador" => "xres315474" "titulo" => array:5 [ 0 => "Abstract" 1 => "Aim" 2 => "Material and methods" 3 => "Results" 4 => "Conclusion" ] ] 1 => array:2 [ "identificador" => "xpalclavsec298216" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres315473" "titulo" => array:5 [ 0 => "Resumen" 1 => "Objetivos" 2 => "Material y métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec298215" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Material and methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Double-phase Tc-sestamibi scintigraphy protocol" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "C-methionine PET/CT protocol" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Image analysis" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-06-21" "fechaAceptado" => "2013-08-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec298216" "palabras" => array:5 [ 0 => "<span class="elsevierStyleSup">11</span>C-methionine PET/CT" 1 => "<span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy" 2 => "Parathyroid adenoma" 3 => "Primary hyperparathyroidism" 4 => "Minimally invasive surgery" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec298215" "palabras" => array:5 [ 0 => "<span class="elsevierStyleSup">11</span>C-metionina PET/TC" 1 => "Gammagrafía con <span class="elsevierStyleSup">99m</span>Tc-sestamibi" 2 => "Adenoma de paratiroides" 3 => "Hiperparatiroidismo primario" 4 => "Cirugía mínimamente invasiva" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To evaluate the usefulness of <span class="elsevierStyleSup">11</span>C-methionine PET/CT (MET) in the localization of the parathyroid adenomas and to compare the results with those obtained with the conventional technique in double-phase <span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy (MIBI). We evaluated the optimal timing to acquire MET images.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective study that included 14 patients (mean age: 65.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9.7 years) with primary hyperparathyroidism (PH) who underwent surgery was performed. Mean serum iPTH was 215.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>108<span class="elsevierStyleHsp" style=""></span>pg/mL and serum calcium 10.8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0.9<span class="elsevierStyleHsp" style=""></span>mg/dL. MIBI (planar and SPECT) was obtained 10 min and 2–3<span class="elsevierStyleHsp" style=""></span>h after injection of 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) of <span class="elsevierStyleSup">99m</span>Tc-sestamibi. MET was obtained 10 min and 40 min after injection of 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) of <span class="elsevierStyleSup">11</span>C-methionine. MIBI and MET images were visually evaluated and compared. A score for 10 min and 40 min MET images from 0 (no abnormal uptake) to 3 (intense uptake) was assigned.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">MIBI and MET were positive and concordant in 11/14 patients and in 10 of them the parathyroid adenoma was correctly localized. In 3/14 MIBI was positive and MET negative (MIBI correctly localized the parathyroid adenoma in 2 of them). According to the timing of MET imaging acquisition, the 10 min and 40 min acquisition showed the same score in 10 patients, it was higher at 10 min acquisition in 3 and in 1 the parathyroid adenoma was only detected at 40 min acquisition.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">MIBI remains the technique of choice for the localization of parathyroid adenomas in patients with PH. MET may play a complementary role in selected patients. Delayed acquisition should be included in the MET protocol when the early acquisition is negative.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Evaluar la utilidad de la <span class="elsevierStyleSup">11</span>C-metionina PET/TC (MET) en la localización de adenoma de paratiroides comparado con la técnica convencional en doble fase con <span class="elsevierStyleSup">99m</span>Tc-sestamibi (MIBI). Evaluar el tiempo adecuado para la adquisición de imágenes MET.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este estudio prospectivo incluyó 14 pacientes (edad: 65,5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>9,7 años) con hiperparatiroidismo primario (HPTP) sometidos a cirugía. La iPTH fue de 215,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>108<span class="elsevierStyleHsp" style=""></span>pg/mL y el calcio sérico 10,8<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>0,9<span class="elsevierStyleHsp" style=""></span>mg/dL. El MIBI (planar, SPECT) fue realizado a los 10 min y 2–3 horas tras la inyección de 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) de MIBI. La MET fue realizada 10 min y 40 min tras la inyección de 740<span class="elsevierStyleHsp" style=""></span>MBq (20<span class="elsevierStyleHsp" style=""></span>mCi) de MET. Las imágenes fueron evaluadas visualmente y comparadas. Las imágenes con MET a 10 min y 40 min fueron valoradas según el grado de captación (0[no captación] a 3[intensa]).</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">MIBI y MET fueron positivos y concordantes en 11/14 pacientes, en 10 de ellos el adenoma de paratiroides fue correctamente localizado. En 3/14 el MIBI fue positivo y la MET negativa (el MIBI localizó correctamente 2). Con respecto al tiempo de adquisición imágenes MET a los 10 min y 40 min se observó la misma puntuación en 10 pacientes, fue mayor a los 10 min en 3 y en unpaciente sólo fue positivo a los 40 min.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El MIBI continúa siendo la técnica de elección para la localización del adenoma de paratiroides en pacientes con HPTP. La MET podría tener un papel complementario en pacientes seleccionados. La adquisición tardía de la MET debería ser incluida cuando la imagen precoz sea negativa.</p>" ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1991 "Ancho" => 2359 "Tamanyo" => 284054 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">(a) Axial, sagittal and coronal <span class="elsevierStyleSup">99m</span>Tc-MIBI-SPECT views show an abnormal uptake below the left thyroid lobe, (b) axial, sagittal and coronal PET and (c) fused <span class="elsevierStyleSup">11</span>C-methionine PET/CT views show the same abnormal uptake corresponding to a left inferior parathyroid adenoma successfully excised (arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1785 "Ancho" => 2155 "Tamanyo" => 241473 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">(a) Axial, sagittal and coronal views of <span class="elsevierStyleSup">99m</span>Tc-MIBI-SPECT, (b) PET and (c) fused <span class="elsevierStyleSup">11</span>C-methionine-PET/CT show an abnormal focal uptake localized in the retro-esophageal region corresponding to an ectopic parathyroid adenoma (arrows). Also, a diffuse and higher uptake was seen in the enlarged thyroid gland.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1793 "Ancho" => 2069 "Tamanyo" => 258452 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">(a) Axial, sagittal and coronal <span class="elsevierStyleSup">99m</span>Tc-MIBI-SPECT views show an abnormal uptake below the right thyroid lobe corresponding to parathyroid adenoma (arrows). (b) PET and (c) fused <span class="elsevierStyleSup">11</span>C-methionine-PET/CT views do not show any focal abnormal uptake of the radiotracer in the neck and upper chest scan.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">MIBI, <span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy; MET, <span class="elsevierStyleSup">11</span>C-methionine PET/CT.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">No. patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Correct localization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Incorrect localization \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MIBI+ and MET + \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MIBI+ and MET− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MIBI− and MET+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463984.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">MIBI and MET results in 14 patients and surgical localization of the parathyroid adenoma.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">MIBI, <span class="elsevierStyleSup">99m</span>Tc-sestamibi scintigraphy; MET, <span class="elsevierStyleSup">11</span>C-methionine PET/CT.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MIBI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">MET \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Positive predictive value (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">85.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">90.9 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463985.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Efficacy of MIBI and MET in the correct detection of parathyroid adenomas.</p>" ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">MET, <span class="elsevierStyleSup">11</span>C-methionine PET/CT.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Patient no. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Early acquisition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Delayed acquisition \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab463986.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">MET score, grading from 0 to 3, at the early (10′) and delayed (40′) acquisition.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:31 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Continuing evolution in the operative management of primary hyperparathyroidism" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.I. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 October | 1 | 1 | 2 |
| 2022 March | 1 | 2 | 3 |
| 2021 September | 1 | 0 | 1 |
| 2021 March | 10 | 2 | 12 |
| 2020 January | 1 | 0 | 1 |
| 2019 April | 1 | 2 | 3 |
| 2019 January | 1 | 2 | 3 |
| 2018 April | 1 | 0 | 1 |
| 2018 February | 19 | 1 | 20 |
| 2018 January | 17 | 2 | 19 |
| 2017 December | 23 | 2 | 25 |
| 2017 November | 25 | 3 | 28 |
| 2017 October | 35 | 2 | 37 |
| 2017 September | 25 | 11 | 36 |
| 2017 August | 25 | 2 | 27 |
| 2017 July | 29 | 2 | 31 |
| 2017 June | 36 | 5 | 41 |
| 2017 May | 48 | 2 | 50 |
| 2017 April | 34 | 6 | 40 |
| 2017 March | 24 | 23 | 47 |
| 2017 February | 37 | 4 | 41 |
| 2017 January | 34 | 4 | 38 |
| 2016 December | 44 | 4 | 48 |
| 2016 November | 53 | 4 | 57 |
| 2016 October | 61 | 2 | 63 |
| 2016 September | 54 | 7 | 61 |
| 2016 August | 41 | 7 | 48 |
| 2016 July | 26 | 3 | 29 |
| 2016 June | 35 | 24 | 59 |
| 2016 May | 23 | 12 | 35 |
| 2016 April | 29 | 14 | 43 |
| 2016 March | 39 | 22 | 61 |
| 2016 February | 0 | 3 | 3 |
| 2016 January | 8 | 4 | 12 |
| 2015 December | 25 | 12 | 37 |
| 2015 November | 27 | 20 | 47 |
| 2015 October | 28 | 15 | 43 |
| 2015 September | 26 | 14 | 40 |
| 2015 August | 49 | 10 | 59 |
| 2015 July | 26 | 9 | 35 |
| 2015 June | 12 | 11 | 23 |
| 2015 May | 19 | 10 | 29 |
| 2015 April | 25 | 11 | 36 |
| 2015 March | 38 | 5 | 43 |
| 2015 February | 10 | 0 | 10 |
| 2015 January | 17 | 1 | 18 |
| 2014 December | 14 | 1 | 15 |
| 2014 November | 2 | 0 | 2 |
| 2014 October | 5 | 1 | 6 |
| 2014 September | 4 | 3 | 7 |
| 2014 August | 1 | 1 | 2 |
| 2014 July | 3 | 0 | 3 |
| 2014 June | 3 | 2 | 5 |
| 2014 May | 6 | 5 | 11 |
| 2014 April | 6 | 5 | 11 |
| 2014 March | 0 | 6 | 6 |
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