Abstract
PurposeTo evaluate the sensitivity of F18-choline (FCH) PET/CT for parathyroid adenoma detection prior to surgery in patients with primary hyperparathyroidism and negative or inconclusive cervical ultrasound and Tc99m-sestaMIBI SPECT/CT.MethodsWe conducted a prospective bicentric study (NCT02432599). All patients underwent FCH PET/CT. The result was scored positive, inconclusive or negative. The number of uptakes and their sites were recorded. The FCH PET/CT result guided the surgical procedure (minimally invasive parathyroidectomy, bilateral cervical exploration, or other in case of multiple or ectopic foci). FCH PET/CT results were compared to the surgical and pathological findings and the follow-up.ResultsTwenty-five patients were included. Mean calcium and PTH levels prior to surgery were 2.76 ± 0.17 mmol/l and 94.8 ± 37.4 ng/l. Nineteen (76%) FCH PET/CTs were scored positive, 3 (12%) inconclusive and 3 (12%) negative, showing 21 cases of uniglandular disease, including 1 ectopic localization and 1 case of multiglandular (3 foci) disease. Mean lesion size was 13.1 ± 8.6 mm. Twenty-four patients underwent surgery. FCH PET/CT guided surgery in 22 (88%) patients, allowing for 17 minimally invasive parathyroidectomies, 1 bilateral cervical exploration for multifocality and 4 other surgical procedures. Two patients with negative FCH-PET/CT underwent bilateral cervical exploration. When dichotomizing the FCH PET/CT results, thereby classifying the inconclusive FCH PET/CT results as positive, the per lesion and per patient sensitivities were 91.3% (95%CI: 72.0–98.9) and 90.5% (95%CI: 69.6–98.8) and the corresponding positive predictive values were 87.5% (95%CI: 67.6–97.3) and 86.4% (95%CI: 65.1–97.1), respectively.Twenty-one (88%) patients were considered cured after surgery. Their mean calcium level after surgery was 2.36 ± 0.17 mmol/l.ConclusionsPreoperative FCH PET/CT has a high sensitivity and positive predictive value for parathyroid adenoma detection in patients with primary hyperparathyroidism and negative or inconclusive conventional imaging results. Bilateral cervical exploration could be avoided in the majority (75%) of patients.
Highlights
Preoperative localisation of hyperfunctioning parathyroid tissue in primary hyperparathyroidism (PHPT) is a prerequisite for minimally invasive parathyroidectomy (MIP)
Its detection rate and sensitivity for parathyroid adenoma (PTA) imaging are mediocre; reported sensitivities vary from 57% to 76% [2,3,4], and deep-laying or ectopic PTAs will go undetected [4, 5]
Parathyroid scintigraphy, ideally including a SPECT/CT acquisition, is a non-invasive, slightly irradiating and readily available imaging method allowing for the detection of approximately two-thirds of PTAs in our population [6]
Summary
Preoperative localisation of hyperfunctioning parathyroid tissue in primary hyperparathyroidism (PHPT) is a prerequisite for minimally invasive parathyroidectomy (MIP). The most frequently used imaging methods are cervical ultrasound and Tc99m-sestamibi (MIBI) parathyroid scintigraphy. Cervical ultrasound is a non-invasive, non-irradiating, low-cost and readily available imaging modality for parathyroid imaging, and it allows for the analysis of any concomitant thyroid nodules [1]. Its detection rate and sensitivity for parathyroid adenoma (PTA) imaging are mediocre; reported sensitivities vary from 57% to 76% [2,3,4], and deep-laying or ectopic PTAs will go undetected [4, 5]. Parathyroid scintigraphy, ideally including a SPECT/CT acquisition, is a non-invasive, slightly irradiating and readily available imaging method allowing for the detection of approximately two-thirds of PTAs in our population [6]. Scintigraphy can detect deep-laying or ectopic PTAs
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