Primary Hyperparathyroidism: Defining the Appropriate Preoperative Imaging Algorithm

Abstract

Primary hyperparathyroidism is a common and potentially debilitating endocrine disorder for which surgery is the only curative treatment. Preoperative imaging is always recommended, even in cases of conventional bilateral neck exploration, with a recognized role for 99m Tcsestamibi scintigraphy in depicting ectopic parathyroid lesions. Scintigraphy can also play a major role in guiding a targeted, minimally invasive parathyroidectomy. However, the ability to recognize multiple-gland disease (MGD) varies greatly depending on the imaging protocol used. Preoperative diagnosis of MGD is important to reduce the risks of conversion to bilateral surgery or failure. In this article we discuss imaging strategies before first surgery as well as in the case of repeat surgery for persistent or recurrent primary hyperparathyroidism. We describe a preferred algorithm and alternative options. Dualtracer 99m Tc-sestamibi/ 123 I subtraction scanning plus neck ultrasound is the preferred first-line option. This approach should improve MGD detection and patient selection for minimally invasive parathyroidectomy. Second-line imaging procedures in case of negative or discordant first-line imaging results are presented. High detection rates can be obtained with 18 F-fluorocholine PET/CT or with 4-dimensional CT. The risk of false-positive results should be kept in mind, however. Adding a contrast-enhanced arterial-phase CT acquisition to conventional 18 F-fluorocholine PET/CT can be a way to improve accuracy. We also briefly discuss other localization procedures, including 11 C-methionine PET/CT, MRI, ultrasound-guided fine-needle aspiration, and selective venous sampling for parathyroid hormone measurement.

Cirugía radioguiada de paratiroides con 18FCH. Mito o realidad

“…Las lesiones paratiroideas identificadas mediante PET-TC con 18 FCH en segunda línea suelen ser pequeñas o estar profundamente asentadas o tener una interposición ósea, por lo que la menor resolución de la SPECT-TC y atenuación de los tejidos pueden contribuir a la negatividad de los resultados de las imágenes de 99m Tc-MIBI [48].…”

18F-Fluorocholine PET and 4D-CT in Patients with Persistent and Recurrent Primary Hyperparathyroidism

“…Surgical removal of pathological parathyroid prevents severe hypercalcemia-related complications and remains the sole treatment with curative intent in symptomatic patients [ 1 , 2 ]. A safe and successful surgical approach for pHPT depends on the surgeon’s ability to accurately identify all abnormal parathyroid glands [ 3 ]. Otherwise, long-term persistent disease can occur.…”

Detection of an undescended parathyroid adenoma with 18F-fluorocholine PET/CT

“…The indication for parathyroidectomy was the severe hypercalciemia. As part of his preoperative workup he initially underwent first-line imaging, existing of sonography of the neck as well dual-tracer [ 99m Tc]tetrofosmin/[ 123 I]NaI SPECT/low-dose CT subtraction imaging (Hindié et al 2021 ). A PTA was not detected on sonography, and the result of the SPECT examination was inconclusive.…”

“…A PTA was not detected on sonography, and the result of the SPECT examination was inconclusive. Consequently, second-line imaging was performed by acquiring a [ 18 F]fluorocholine PET/high-dose CT scan (Hindié et al 2021 ) (Fig. 1 ).…”

“…1 ). This preoperative imaging algorithm was chosen, based on recent recommendations (Hindié et al 2021 ). The PET scan was acquired on a Siemens Biograph mCT system, according to recent guidelines (Petranović Ovčariček et al 2021 ).…”