Parathyroid imaging with 18F-fluorocholine PET/CT as a first-line imaging modality in primary hyperparathyroidism: a retrospective cohort study

Abstract

Background 18 F-fluorocholine (FCH) PET/CT is a promising technique for visualizing hyperfunctioning parathyroid glands in hyperparathyroidism. It is still under debate whether to use this technique as a first-line imaging modality or to use it when conventional techniques such as 99m Tc-sestamibi scintigraphy or ultrasonography are inconclusive. This study evaluates FCH PET/CT as a first-line modality. Methods Patients with primary hyperparathyroidism, referred between June 2015 and December 2018 for FCH PET/CT as a first-line imaging method, were included in this study. Baseline characteristics, clinical data, scan results, and type of treatment were recorded. The rate of correct detection was calculated on a per patient-based and a per lesion-based analysis. The reference standard comprised histopathological results, intraoperative response to parathyroidectomy, and clinical follow-up. Results Two hundred and seventy-one patients were included, of which 139 patients underwent parathyroidectomy, 48 were treated with calcimimetics, and 84 patients received further follow-up without active treatment. In the surgically treated group, a single adenoma was suspected in 127 scans, double adenoma in three scans, and one scan showed evidence of three hyperfunctioning glands. In eight scans, no lesions were visualized. A total of 154 parathyroid glands were surgically removed. The rate of correct detection was calculated at 96% and 90%, on a per patient-based and per lesion-based analysis, respectively. Conclusion This retrospective study in a large cohort shows high detection rates of FCH PET/CT in primary hyperparathyroidism, which is in accordance to literature. The use of FCH PET/CT as a first-line imaging modality in preoperative planning of parathyroid surgery may therefore be a suitable choice.

Upfront F18-choline PET/CT versus Tc99m-sestaMIBI SPECT/CT guided surgery in primary hyperparathyroidism: the randomized phase III diagnostic trial APACH2

“…Recent studies and the results of our phase II study APACH1 concordantly suggest the superiority of F18-choline (FCH) PET/CT for PTA localization [ 5 , 11 – 13 ]. In the APACH1 study [ 12 ], 25 patients with PHPT and negative or inconclusive MIBI SPECT/CT results underwent FCH PET/CT, resulting in 22 FCH PET/CT guided surgeries: 17 MIPs, 1 bilateral cervical exploration for multifocality and 4 other surgical procedures.…”

Pathological uptake with 18-Fluorocholine versus 99mTc-MIBI in the location of the parathyroid glands in hyperparathyroidism. Systematic review and meta-analysis

“…Negative localization studies make surgical treatment difficult. In both the selected articles in our meta-analysis and in previous meta-analysis, CH localization studies have shown greater ability to locate pathological glands [34,[42][43][44][45] than MIBI or methionine [46][47][48] in both first exploration and rescue scan [31,49]. The probability of uptake with CH is above 0.9 on both first scans and scans performed after negative MIBI study (in these cases the combination of both techniques reaches a prevalence of uptake of 0.97).…”

Misleading localization by 18F-fluorocholine PET/CT in familial hypocalciuric hypercalcemia type-3: a case report

“…Recently, 18 F-fluorocholine positron emission tomography/computed tomography (FCH-PET/CT) has shown superior sensitivity in localizing parathyroid adenomas than conventional morphological and functional imaging [ 15 – 18 ]. FCH-PET/CT has been recommended when conventional imaging is negative or discordant [ 19 – 24 ] and also as first line imaging [ 25 ]. However, FCH-PET/CT specificity for parathyroid tissue (vs. other neck tissues) and its sensitivity in visualising hyperplastic parathyroid glands of FHH that are usually smaller than parathyroid adenomas, are not well known.…”