Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism

Abstract

IMPORTANCE Emerging computed tomographic (CT) imaging techniques for the localization of primary hyperparathyroidism (PHPT) may be superior to the current imaging standard, thus necessitating a critical review and pooling of available evidence.OBJECTIVE Primary hyperparathyroidism requires accurate imaging to guide definitive surgical management. Advanced techniques including 4-dimensional computed tomographic (4D-CT) scan have been investigated over the past decade. We sought to evaluate the efficacy of these emerging imaging techniques through pooled analysis of the existing evidence.DATA SOURCES PubMed, Embase, and Web of Science databases were queried for original English articles without any restrictions on date.STUDY SELECTION We included comparative observational studies but excluded animal studies, case reports, and case series. Overall, 353 abstracts were screened independently by 2 investigators along with a third reviewer to resolve conflicts. A total of 26 full-text articles were included in this review.DATA EXTRACTION AND SYNTHESIS This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data was independently extracted by 2 investigators and subsequently pooled into a metaanalysis using a random-effects model. MAIN OUTCOMES AND MEASURESMeasures of imaging diagnostic performance such as sensitivity, specificity, positive predictive value, and negative predictive value were the primary outcomes of interest.RESULTS Overall, of 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Of the 26 studies included, there were 5845 patients, of which 4176 were women (79.2%). The average of mean ages reported in 23 studies was 60.9 years. Meta-analysis in all patients with PHPT revealed pooled sensitivity that was greater with 4D-CT (81%; 95% CI, 77%-84%; I 2 = 88%) compared with the current first-line modality of sestamibi-single-photon emission CT (SPECT/CT) (65%; 95% CI, 59%-70%; I 2 = 93%). For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I 2 = 93%) in contrast to 53% (95% CI, 35%-71%; I 2 = 81%) for sestamibi-SPECT/CT. The overall quality of the 26 studies was moderate with a median (range) Methodological Index for Nonrandomized Studies score for all included studies of 15.5 (13)(14)(15)(16)(17)(18)(19). CONCLUSIONS AND RELEVANCEThe findings of this systematic review and with meta-analyses of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed to determine the clinical significance of this improvement in localization.

Head-to-head comparison of [11C]methionine PET, [11C]choline PET, and 4-dimensional CT as second-line scans for detection of parathyroid adenomas in primary hyperparathyroidism

“…However, the main advantage of 4D-CT lies in its wide availability in most clinical environments, its detailed anatomical information, the absence of the need for tracer production, and due to more accessible patient preparation, no uptake time (and related waiting time) of tracer is necessary. The performance of 4D-CT in this study is relatively poor compared to previous studies (sensitivity of 75 to 80%) [ 43 – 45 ]. We hypothesize that this is due to the highly selected group of patients with previous negative imaging results.…”

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

“…4D-CT is an effective method for localizing the pathological gland, and the pooled sensitivity in reoperative cases is 81% (95% CI, 64%–98%). [ 99 ] The sensitivity of 4D-CT is significantly higher than both scintigraphy and USG in lateralizing recurrent cases (77.4%, 46%, and 38.5%, respectively). [ 92 ]…”

The impact of perioperative diagnostic tools on clinical outcomes and cost-effectiveness in parathyroid surgery: a health economic evaluation

“…17 The sensitivity and positive predictive value (PPV) of ultrasonography in MGD were obtained from a systematic literature review between 1995 and 2003. 7 The sensitivity and PPV of SPECT/CT, 4D-CT and FCH-PET/CT were retrieved from the latest systematic reviews 6,8 , whereas the sensitivity and PPV for FCH-PET/CT in MGD was taken from a single-institution study. 9 The sensitivity and specificity of the different ioPTH criteria were estimated from two single-institution studies with 570 patients.…”

“…5 However, the sensitivity and specificity of a preoperative localization vary not only between the different preoperative diagnostic modalities but also between single adenomas and MGD. [6][7][8][9] If an FP is performed, an intraoperative parathyroid hormone (ioPTH) monitoring is recommended to exclude MGD and to avoid reoperations. 10 The two most common criteria for defining surgical success, measured as a 50% decline of the ioPTH level 10 minutes after resection, use different baselines.…”