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Chakrabarty N, Mahajan A, Basu S, D’Cruz AK. Imaging Recommendations for Diagnosis and Management of Primary Parathyroid Pathologies: A Comprehensive Review. Cancers (Basel) 2024; 16:2593. [PMID: 39061231 PMCID: PMC11274996 DOI: 10.3390/cancers16142593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Revised: 07/06/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Parathyroid pathologies are suspected based on the biochemical alterations and clinical manifestations, and the predominant roles of imaging in primary hyperparathyroidism are localisation of tumour within parathyroid glands, surgical planning, and to look for any ectopic parathyroid tissue in the setting of recurrent disease. This article provides a comprehensive review of embryology and anatomical variations of parathyroid glands and their clinical relevance, surgical anatomy of parathyroid glands, differentiation between multiglandular parathyroid disease, solitary adenoma, atypical parathyroid tumour, and parathyroid carcinoma. The roles, advantages and limitations of ultrasound, four-dimensional computed tomography (4DCT), radiolabelled technetium-99 (99mTc) sestamibi or dual tracer 99mTc pertechnetate and 99mTc-sestamibi with or without single photon emission computed tomography (SPECT) or SPECT/CT, dynamic enhanced magnetic resonance imaging (4DMRI), and fluoro-choline positron emission tomography (18F-FCH PET) or [11C] Methionine (11C -MET) PET in the management of parathyroid lesions have been extensively discussed in this article. The role of fluorodeoxyglucose PET (FDG-PET) has also been elucidated in this article. Management guidelines for parathyroid carcinoma proposed by the American Society of Clinical Oncology (ASCO) have also been described. An algorithm for management of parathyroid lesions has been provided at the end to serve as a quick reference guide for radiologists, clinicians and surgeons.
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Affiliation(s)
- Nivedita Chakrabarty
- Department of Radiodiagnosis, Advanced Centre for Treatment, Research and Education in Cancer (ACTREC), Tata Memorial Centre, Homi Bhabha National Institute (HBNI), Parel, Mumbai 400012, Maharashtra, India;
| | - Abhishek Mahajan
- Department of Imaging, The Clatterbridge Cancer Centre NHS Foundation Trust, 65 Pembroke Place, Liverpool L7 8YA, UK
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - Sandip Basu
- Radiation Medicine Centre, Bhabha Atomic Research Centre, Tata Memorial Hospital Annexe, Homi Bhabha National Institute (HBNI), Parel, Mumbai 400012, Maharashtra, India;
| | - Anil K. D’Cruz
- Apollo Hospitals, Navi Mumbai 400614, Maharashtra, India;
- Foundation of Head Neck Oncology, Mumbai 400012, Maharashtra, India
- Union International Cancer Control (UICC), 1202 Geneva, Switzerland
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Warshavsky A, Rubin R, Carmel-Neidermann NN, Brenner A, Shendler G, Kampel L, Izkhakov E, Muhanna N, Horowitz G. 4DCT in Discordant Parathyroid Adenoma Scans: Case Series and Meta-Analysis. Laryngoscope 2024; 134:2198-2205. [PMID: 37929814 DOI: 10.1002/lary.31142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 10/08/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To evaluate the accuracy of four-dimensional computerized-tomography (4DCT) for localizing parathyroid adenomas (PTAs) in cases with discordant or non-localizing ultrasonography (US) and Technetium-99 sestamibi (MIBI) scans. DATA SOURCES Retrospective case series and systematic review. REVIEW METHODS A case series and meta-analysis of patients diagnosed with primary hyperparathyroidism and discordant US and MIBI scans who underwent 4DCT prior to surgery. A comprehensive search for all relevant publications in the English literature between December 2006 and March 2022 was conducted for the meta-analysis. Patients undergoing parathyroidectomy between January 2015 and December 2021 were identified from the institutional electronic database for the case series. All studies were analyzed for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 4DCT adenoma localization capabilities. RESULTS Thirteen retrospective studies that included 379 patients and one case series that included 37 patients were identified and analyzed. A per-patient analysis revealed sensitivity for lateralization to the correct side (n = 181) ranging from 80% to 100% with a fixed effects model of 89% (95%confidence interval [CI]: 82%-93%) and a PPV for lateralization ranging from 63%-95% with a random effects model of 87% (95% CI: 77%-95%). Sensitivity of localization to the correct quadrant (n = 172) ranged from 53% to 100% with a random effects model of 90.4% (95% CI: 76%-99%), and the PPV for localization ranged from 52% to 100% with a random effects model of 82% (95% CI: 73%-89%). CONCLUSION 4DCT enhances imaging capabilities of localizing PTAs in cases of discordant or non-localizing US and MIBI scans. LEVEL OF EVIDENCE NA Laryngoscope, 134:2198-2205, 2024.
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Affiliation(s)
- Anton Warshavsky
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Raz Rubin
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Narin Nard Carmel-Neidermann
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Adi Brenner
- Radiology and Imaging, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Genady Shendler
- Radiology and Imaging, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Liyona Kampel
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Elena Izkhakov
- The Institute of Endocrinology, School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Gilad Horowitz
- Department of Otolaryngology, Head & Neck Surgery and Maxillofacial Surgery and The Department of Radiology and Imaging, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Adarve Castro A, Domínguez Pinos D, Soria Utrilla V, O'Farrell Del Campo JA, Sendra Portero F, Ruiz-Gómez MJ. Update in imaging tests used for the localization of parathyroid pathology. RADIOLOGIA 2024; 66:236-247. [PMID: 38908885 DOI: 10.1016/j.rxeng.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/28/2023] [Indexed: 06/24/2024]
Abstract
Preoperative localization of parathyroid pathology, generally a parathyroid adenoma, can be difficult in some cases due to the anatomical variants that these glands present. The objective of this review is to analyse the different imaging techniques used for preoperative localization of parathyroid pathology (scintigraphy, ultrasound, CT, MRI and PET). There is great variability between the different tests for the preoperative localization of parathyroid pathology. The importance of knowing the different diagnostic options lies in the need to choose the most suitable test at each moment and for each patient for an adequate management of primary hyperparathyroidism (PHP) with surgical criteria.
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Affiliation(s)
- A Adarve Castro
- Departamento de Radiología y Medicina Física, Facultad de Medicina, Universidad de Málaga, Málaga, Spain; Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - D Domínguez Pinos
- Departamento de Radiología y Medicina Física, Facultad de Medicina, Universidad de Málaga, Málaga, Spain; Hospital Universitario Virgen de la Victoria, Málaga, Spain.
| | | | | | - F Sendra Portero
- Departamento de Radiología y Medicina Física, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
| | - M J Ruiz-Gómez
- Departamento de Radiología y Medicina Física, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
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Treglia G, Rizzo A, Piccardo A. Expanding the clinical indications of [ 18F]fluorocholine PET/CT in primary hyperparathyroidism: the evidence cannot be evaded. Eur J Nucl Med Mol Imaging 2024; 51:1345-1348. [PMID: 38135848 DOI: 10.1007/s00259-023-06573-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Affiliation(s)
- Giorgio Treglia
- Division of Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona and Lugano, Switzerland.
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland.
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland.
| | - Alessio Rizzo
- Department of Nuclear Medicine, Candiolo Cancer Institute, FPO-IRCCS, Turin, Italy
| | - Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. "Ospedali Galliera", Genoa, Italy
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Metrard G, Cohen C, Bailly M. Comprehensive literature review of oral and intravenous contrast-enhanced PET/CT: a step forward? Front Med (Lausanne) 2024; 11:1373260. [PMID: 38566921 PMCID: PMC10985176 DOI: 10.3389/fmed.2024.1373260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
The integration of diagnostic CT scans into PET/CT facilitates a comprehensive single examination, presenting potential advantages for patients seeking a thorough one-shot check-up. The introduction of iodinated contrast media during PET scanning raises theoretical concerns about potential interference with uptake quantification, due to the modification of tissue density on CT. Nevertheless, this impact appears generally insignificant for clinical use, compared to the intrinsic variability of standardized uptake values. On the other hand, with the growing indications of PET, especially 18F-FDG PET, contrast enhancement increases the diagnostic performances of the exam, and provides additional information. This improvement in performance achieved through contrast-enhanced PET/CT must be carefully evaluated considering the associated risks and side-effects stemming from the administration of iodinated contrast media. Within this article, we present a comprehensive literature review of contrast enhanced PET/CT, examining the potential impact of iodinated contrast media on quantification, additional side-effects and the pivotal clinically demonstrated benefits of an all-encompassing examination for patients. In conclusion, the clinical benefits of iodinated contrast media are mainly validated by the large diffusion in PET protocols. Contrary to positive oral contrast, which does not appear to offer any major advantage in patient management, intravenous iodine contrast media provides clinical benefits without significant artifact on images or quantification. However, studies on the benefit-risk balance for patients are still lacking.
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Affiliation(s)
- Gilles Metrard
- Nuclear Medicine Department, Orléans University Hospital, Orléans, France
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d’Orléans, Orléans, France
| | - Clara Cohen
- Radiology Department, Orléans University Hospital, Orléans, France
| | - Matthieu Bailly
- Nuclear Medicine Department, Orléans University Hospital, Orléans, France
- Centre de Biophysique Moléculaire, CNRS UPR 4301, Université d’Orléans, Orléans, France
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Leoncini A, Deandrea M, Retta F, Trimboli P. Treating intra-thyroid parathyroid adenoma by radiofrequency is a valuable alternative to hemithyroidectomy. Int J Hyperthermia 2023; 40:2282935. [PMID: 38151705 DOI: 10.1080/02656736.2023.2282935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/09/2023] [Indexed: 12/29/2023] Open
Abstract
BACKGROUND Parathyroid adenoma (PA) is the most common cause of primary hyperparathyroidism (PHPT). One infrequent scenario (0.7%-6%) is represented by intra-thyroid PA (I-PA), an ectopic variant of the parathyroid gland included in the thyroid parenchyma. Radiofrequency (RF) of I-PA seems to be an excellent alternative to hemithyroidectomy for these patients. The present study aimed to report three cases of PHPT and I-PA treated with RF at two institutions. MATERIALS AND METHODS These two institutions share guidelines for thyroid RF. At both institutions, cases with surgical indication and difficult PA localization are discussed during thyroid multidisciplinary meetings involving all disciplines involved in managing these cases. RF was performed using a Viva RF System generator (STARMED). Ultrasound contrast evaluation was performed using a SonoVue (Bracco). All patients were followed-up by an expert endocrinologist. RESULTS Three cases had indications for treating I-PA. All patients were proposed to undergo RF rather than hemithyroidectomy, and accepted this option. RF of I-PA was performed with a power of 30-50 W and delivering a total between 0.02 and 0.69 Kcal. The active treatment lasted just more than 1 min. Post-treatment follow-up revealed PTH and calcium normalization. CONCLUSION This study showed highly encouraging results in favor of treating I-PA with RF.
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Affiliation(s)
- Andrea Leoncini
- Servizio di Radiologia e Radiologia Interventistica, Istituto di Imaging Della Svizzera Italiana (IIMSI), Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
| | - Maurilio Deandrea
- Endocrinology, Diabetes and Metabolism Department and Center for Thyroid Diseases, Ordine Mauriziano Hospital, Turin, Italy
| | - Francesca Retta
- Endocrinology, Diabetes and Metabolism Department and Center for Thyroid Diseases, Ordine Mauriziano Hospital, Turin, Italy
| | - Pierpaolo Trimboli
- Servizio di Endocrinologia e Diabetologia, Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale (EOC), Lugano, Switzerland
- Facoltà di Scienze Biomediche, Università Della Svizzera Italiana (USI), Lugano, Switzerland
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Lalonde MN, Correia RD, Syktiotis GP, Schaefer N, Matter M, Prior JO. Parathyroid Imaging. Semin Nucl Med 2023; 53:490-502. [PMID: 36922339 DOI: 10.1053/j.semnuclmed.2023.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
Primary hyperparathyroidism (1° HPT) is a relatively common endocrine disorder usually caused by autonomous secretion of parathormone by one or several parathyroid adenomas. 1° HPT causing hypercalcemia, kidney stones and/or osteoporosis should be treated whenever possible by parathyroidectomy. Accurate preoperative location of parathyroid adenomas is crucial for surgery planning, mostly when performing minimally invasive surgery. Cervical ultrasonography (US) is usually performed to localize parathyroid adenomas as a first intention, followed by 99mTc- sestamibi scintigraphy with SPECT/CT whenever possible. 4D-CT is a possible alternative to 99mTc- sestamibi scintigraphy. Recently, 18F-fluorocholine positron emission tomography/computed tomography (18F-FCH PET/CT) has made its way in the clinics as it is the most sensitive method for parathyroid adenoma detection. It can eventually be combined to 4D-CT to increase its diagnostic performance, although this results in higher dose exposure to the patient. Other forms of hyperparathyroidism consist in secondary (2° HPT) and tertiary hyperparathyroidism (3° HPT). As parathyroidectomy is not usually part of the management of patients with 2° HPT, parathyroid imaging is not routinely performed in these patients. In patients with 3° HPT, total or subtotal parathyroidectomy is often performed. Localization of hyperfunctional glands is an important aid to surgery planning. As 18F-FCH PET/CT is the most sensitive modality in multigland disease, it is the preferred imaging technic in 3° HPT patients, although its cost and availability may limit its widespread use in this setting.
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Affiliation(s)
- Marie Nicod Lalonde
- Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Ricardo Dias Correia
- Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Gerasimos P Syktiotis
- Diabetology and Endocrinology Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Niklaus Schaefer
- Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, Lausanne, Switzerland
| | - Maurice Matter
- Visceral Surgery Department, Lausanne University Hospital, Lausanne, Switzerland
| | - John O Prior
- Nuclear Medicine and Molecular Imaging Department, Lausanne University Hospital, Lausanne, Switzerland.
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Wakankar R, Dharmashaktu Y, Damle AN, Kumar P, Bal C, Kumar R, Tripathi M, Agarwal S, Khadgawat R, Chumber S, Kumar C. Role of 18Fluorocholine Positron Emission Tomography/Computed Tomography in the Localization of Culprit Lesions in Patients of Persistent/Recurrent Primary Hyperparathyroidism: A Prospective Study in COVID Times. Indian J Nucl Med 2023; 38:218-223. [PMID: 38046977 PMCID: PMC10693358 DOI: 10.4103/ijnm.ijnm_31_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 12/05/2023] Open
Abstract
Introduction Recurrent/persistent primary hyperparathyroidism in patients who have undergone previous parathyroidectomy is a challenging condition. Imaging is important for localizing the parathyroid adenoma for re-exploration and 18F-Fluorocholine (18F-FCH) positron emission tomography/computed tomography (PET/CT) seems ideal for this purpose. Aim This prospective study attempted to ascertain the utility of 18F-FCH PET/CT as an investigation in preoperative localization of abnormal parathyroid tissue in recurrent/persistent primary hyperparathyroidism while comparing it with 99mTc-Sestamibi dual-phase scintigraphy with early single-photon emission CT (SPECT)/CT and neck ultrasonography (USG). Methods Twenty patients with biochemical features of recurrent/persistent primary hyperparathyroidism were enrolled into this study. They underwent neck USG, 99mTc-Sestamibi dual-phase scintigraphy with early SPECT/CT and 18F-FCH PET/CT for localization of parathyroid lesions. Six patients underwent surgical resection of the detected lesions, 3 were awaiting surgery, and 11 were managed conservatively. One patient died due to COVID. Results The calculated positive predictive values on a per-lesion basis of neck USG, 99mTc-sestamibi scintigraphy and early SPECT/CT and 18F-FCH PET/CT in the cohort of the 5 operated patients were 75% (3/4), 71.4% (5/7), and 71.4% (5/7), respectively. On a per-patient basis, the lesion detection rate was 100% for 99mTc-sestamibi scan and FCH PET (5/5) and 80% on neck USG (4/5). Conclusion 18F-FCH PET/CT is a highly accurate imaging modality for the detection of parathyroid lesions in patients with recurrent/persistent primary hyperparathyroidism.
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Affiliation(s)
- Ritwik Wakankar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Yamini Dharmashaktu
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - A. Nishikant Damle
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhavi Tripathi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Khadgawat
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Sunil Chumber
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Chitresh Kumar
- Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
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Abhishek B, Wakankar R, Dharmashaktu Y, Damle NA, Kumar P, Bal C, Tripathi M, Kandasamy D, Khadgawat R, Agarwal S, Vuthaluru S, Chumber S. Comparison of Neck Ultrasonography, Dual Phase 99mTc-Sestamibi with early SPECT-CT & 18F-Fluorocholine PET-CT as First Line Imaging in Patients with Primary Hyperparathyroidism. Indian J Nucl Med 2023; 38:208-217. [PMID: 38046978 PMCID: PMC10693368 DOI: 10.4103/ijnm.ijnm_28_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 04/13/2022] [Accepted: 04/25/2022] [Indexed: 12/05/2023] Open
Abstract
Introduction Successful surgical treatment for primary hyperparathyroidism requires accurate localization of abnormal parathyroid tissue in terms of location and number. Imaging is important for localizing the parathyroid adenoma, and there has been significant interest in 18F-fluorocholine (FCH) positron emission tomography/computed tomography (PET/CT) for this purpose. Aim This study attempted to ascertain the utility of 18F-FCH PET/CT as a first-line investigation in preoperative localization of abnormal parathyroid tissue in primary hyperparathyroidism, in comparison with 99mTc-sestamibi dual-phase scintigraphy with early single-photon emission computed tomography (SPECT)/CT and neck ultrasonography. Materials and Methods Fifty-five patients with biochemical features of primary hyperparathyroidism were enrolled in this study. They underwent neck ultrasonography, 99mTc-sestamibi dual-phase scintigraphy with early SPECT/CT, and 18F-FCH PET/CT for localization of parathyroid lesions. Thirty-three patients underwent surgical resection of the detected lesions. For two patients, clinical and biochemical follow-up was used as a gold standard. Results A total of 40 lesions were resected in the 33 patients who underwent surgery. A further two lesions were localized in two patients with clinical and biochemical follow-up as the gold standard. Of these 42 lesions, 41 were detected in preoperative imaging and 1 lesion was noted intraoperatively and resected. 41/42 lesions were detected by 18F-FCH PET/CT (detection rate: 97.6%), 33/42 by 99mTc-sestamibi dual-phase scintigraphy with early SPECT/CT (detection rate: 78.5%), and 30/42 by neck ultrasonography (detection rate: 71.4%). Conclusion Detection rates on 18F-FCH PET/CT were superior to both 99mTc-sestamibi dual-phase scintigraphy with early SPECT/CT and neck ultrasonography in preoperative localization of parathyroid lesions in patients with primary hyperparathyroidism.
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Affiliation(s)
- Behera Abhishek
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ritwik Wakankar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Yamini Dharmashaktu
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Praveen Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Chandrasekhar Bal
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Madhavi Tripathi
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rajesh Khadgawat
- Department of Endocrinology, All India Institute of Medical Sciences, New Delhi, India
| | - Shipra Agarwal
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Seenu Vuthaluru
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - Sunil Chumber
- Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
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10
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Imperiale A, Bani J, Bottoni G, Latgé A, Heimburger C, Catrambone U, Vix M, Treglia G, Piccardo A. Does 18F-Fluorocholine PET/CT add value to positive parathyroid scintigraphy in the presurgical assessment of primary hyperparathyroidism? Front Med (Lausanne) 2023; 10:1148287. [PMID: 37181366 PMCID: PMC10172498 DOI: 10.3389/fmed.2023.1148287] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 04/07/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction To investigate the value of presurgical 18F-FCH PET/CT in detecting additional hyperfunctioning parathyroids despite a positive 99mTc-sestamibi parathyroid scintigraphy in patients with primary hyperparathyroidism (pHPT). Methods This is a retrospective study involving patients with pHPT, positive parathyroid scintigraphy performed before 18F-FCH PET/CT, and parathyroid surgery achieved after PET/CT. Imaging procedures were performed according to the EANM practice guidelines. Images were qualitatively interpreted as positive or negative. The number of pathological findings, their topography, and ectopic location were recorded. Histopathology, Miami criterion, and biological follow-up were considered to ensure effective parathyroidectomy confirming the complete excision of all hyperfunctioning glands. The impact of 18F-FCH PET/CT on therapeutic strategy was recorded. Results 64/632 scanned pHPT patients (10%) were included in the analysis. According to a per lesion-based analysis, sensitivity, specificity, positive predictive value, and negative predictive value of 99mTc-sestamibi scintigraphy were 82, 95, 87, and 93%, respectively. The same values for 18F-FCH PET/CT were 93, 99, 99, and 97%, respectively. 18F-FCH PET/CT showed a significantly higher global accuracy than 99mTc-sestamibi scintigraphy: 98% (CI: 95-99) vs. 91% (CI: 87-94%). Youden Index was 0.79 and 0.92 for 99mTc-sestamibi scintigraphy and 18F-FCH PET/CT, respectively. Scintigraphy and PET/CT were discordant in 13/64 (20%) patients (49 glands). 18F-FCH PET/CT identified nine pathologic parathyroids not detected by 99mTc-sestamibi scintigraphy in 8 patients (12.5%). Moreover, 18F-FCH PET/CT allowed the reconsideration of false-positive scintigraphic diagnosis (scinti+/PET-) for 8 parathyroids in 7 patients (11%). The 18F-FCH PET/CT influenced the surgical strategy in 7 cases (11% of the study population). Conclusion In a preoperative setting, 18F-FCH PET/CT seems more accurate and useful than 99mTc-sestamibi scan in pHPT patients with positive scintigraphic results. Positive parathyroid scintigraphy could be not satisfactory before neck surgery particularly in patients with multiglandular disease, suggesting a need to evolve the practice and define new preoperative imaging algorithms including 18F-FCH PET/CT at the fore-front in pHPT patients.
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Affiliation(s)
- Alessio Imperiale
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University Hospitals, Strasbourg, France
- Molecular Imaging, DRHIM, Institut Pluridisciplinaire Hubert Curien (IPHC), UMR7178, CNRS, University of Strasbourg, Strasbourg, France
| | - Jacob Bani
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University Hospitals, Strasbourg, France
| | - Gianluca Bottoni
- Nuclear Medicine, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
| | - Adrien Latgé
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University Hospitals, Strasbourg, France
| | - Céline Heimburger
- Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), Strasbourg University Hospitals, Strasbourg, France
- Nuclear Medicine, Hopital Civil de Haguenau, Haguenau, France
| | - Ugo Catrambone
- General Surgery, Ente Ospedaliero "Ospedali Galliera“, Genoa, Italy
| | - Michel Vix
- General, Digestive, and Endocrine Surgery, IRCAD-IHU, Strasbourg University Hospitals, Strasbourg, France
| | - Giorgio Treglia
- Clinic for Nuclear Medicine, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Nuclear Medicine and Molecular Imaging, Lausanne University Hospital, Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
- Faculty of Biomedical Sciences, Università Della Svizzera Italiana, Lugano, Switzerland
| | - Arnoldo Piccardo
- Nuclear Medicine, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
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11
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Aymard S, Leroy-Freschini B, Kaseb A, Marx D, Helali M, Averous G, Betz V, Riehm S, Vix M, Perrin P, Imperiale A. 18F-Fluorocholine PET/CT Compared with Current Imaging Procedures for Preoperative Localization of Hyperfunctioning Parathyroids in Patients with Chronic Kidney Disease. Diagnostics (Basel) 2023; 13:diagnostics13081374. [PMID: 37189475 DOI: 10.3390/diagnostics13081374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Hyperparathyroidism (HPT) in patients with chronic kidney disease (CKD) includes secondary (sHPT) and tertiary hyperparathyroidism (tHPT). Considering that the role of preoperative imaging in the clinical setting is controversial, in the present study we have retrospectively compared pre-surgical diagnostic performances of 18F-Fluorocholine (18F-FCH) PET/CT, cervical ultrasonography (US), parathyroid scintigraphy, and 4D-CT in a group of 30 patients with CKD and HPT (18/12 sHPT/tHPT), 21 CKD G5 including 18 in dialysis, and 9 kidney transplant recipients. All patients underwent 18F-FCH, and 22 had cervical US, 12 had parathyroid scintigraphy, and 11 had 4D-CT. Histopathology was the gold standard. Seventy-four parathyroids were removed: 65 hyperplasia, 6 adenomas, and 3 normal glands. In the whole population, in a per gland analysis, 18F-FCH PET/CT was significantly more sensitive and accurate (72%, 71%) than neck US (25%, 43%), parathyroid scintigraphy (35%, 47%), and 4D-CT (40%, 47%). The specificity of 18F-FCH PET/CT (69%) was lower than that of neck US (95%) and parathyroid scintigraphy (90%), without, however, achieving significance. 18F-FCH PET/CT was more accurate than all other diagnostic techniques when sHPT and tHPT patients were considered separately. 18F-FCH PET/CT sensitivity was significantly higher in tHPT (88%) than in sHPT (66%). Three ectopic hyperfunctioning glands (in three different patients) were all detected by 18F-FCH PET/CT, two by parathyroid scintigraphy, and none by cervical US and 4D-CT. Our study confirms that 18F-FCH PET/CT is an effective preoperative imaging option in patients with CKD and HPT. These findings may be of greater importance in patients with tHPT (who could benefit from minimally invasive parathyroidectomy) than in patients with sHPT, who often undergo bilateral cervicotomy. In these cases, preoperative 18F-FCH PET/CT may be helpful in locating ectopic glands and may guide the surgical choice for gland preservation.
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Affiliation(s)
- Samuel Aymard
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Benjamin Leroy-Freschini
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Ashjan Kaseb
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
- Department of Radiology, College of Medicine, University of Jeddah, Jeddah 23890, Saudi Arabia
| | - David Marx
- Department of Medicine C, Hôpital de Sélestat, 67600 Sélestat, France
- Department of Nephrology and Transplantation, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Mehdi Helali
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
| | - Gerlinde Averous
- Department of Pathology, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Valérie Betz
- Department of Nephology, Hôpital de Colmar, 68024 Colmar, France
- AURAL Dialysis Center, 68000 Colmar, France
| | - Sophie Riehm
- Department of Radiology, Strasbourg University Hospitals, 67098 Strasbourg, France
| | - Michel Vix
- Department of General, Digestive, and Endocrine Surgery, IRCAD-IHU, Strasbourg University Hospitals, 67000 Strasbourg, France
| | - Peggy Perrin
- Department of Nephrology and Transplantation, Strasbourg University Hospitals, University of Strasbourg, 67000 Strasbourg, France
| | - Alessio Imperiale
- Department of Nuclear Medicine and Molecular Imaging, Institut de Cancérologie de Strasbourg Europe (ICANS), University of Strasbourg, 67200 Strasbourg, France
- Department of General, Digestive, and Endocrine Surgery, IRCAD-IHU, Strasbourg University Hospitals, 67000 Strasbourg, France
- Molecular Imaging-DRHIM, IPHC, UMR 7178, CNRS, University of Strasbourg, 67093 Strasbourg, France
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12
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Centello R, Sesti F, Feola T, Sada V, Pandozzi C, Di Serafino M, Pacini P, Cantisani V, Giannetta E, Tarsitano MG. The Dark Side of Ultrasound Imaging in Parathyroid Disease. J Clin Med 2023; 12:jcm12072487. [PMID: 37048571 PMCID: PMC10095081 DOI: 10.3390/jcm12072487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/14/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
The diagnosis of parathyroid diseases by imaging still has some intrinsic technical limitations due to the differential diagnosis of different structures of the neck that mimic the parathyroid glands. In this view, ultrasound (US) is an established, low-cost, and non-invasive imaging technique that still represents the first-line approach for evaluating patients with parathyroid disease. The objective of this article is to provide a comprehensive review of the applications of USs in clinical practice, discussing the histopathological and US characteristics of the parathyroid glands in normal and pathological conditions, the advantages of preoperative imaging, and novel updates on the most useful and currently available multiparameter US techniques.
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13
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Seyedinia SS, Mirshahvalad SA, Schweighofer-Zwink G, Hehenwarter L, Rendl G, Pirich C, Beheshti M. Evolving Role of [ 18F]Flurocholine PET/CT in Assessing Primary Hyperparathyroidism: Can It Be Considered the First-Line Functional Imaging Approach? J Clin Med 2023; 12:jcm12030812. [PMID: 36769460 PMCID: PMC9917644 DOI: 10.3390/jcm12030812] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/25/2022] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
The accurate detection of hyperfunctioning parathyroid tissue (HFPT) is pivotal in the preoperative assessment of primary hyperparathyroidism (PHPT). PET/CT using [18F]fluorocholine ([18F]FCH) showed superior diagnostic performance compared to conventional functional imaging modalities. We aimed to evaluate the diagnostic performance of [18F]FCH PET/CT as a first-line functional imaging approach in patients with clinically diagnosed PHPT. The imaging and clinical data of 321 PHPT patients, including 271 overt PHPT and 50 mild PHPT, who underwent [18F]FCH PET/CT as first-line imaging were analysed in this retrospective study. Histopathology was the reference standard. In case of no available histopathology evaluation (conservative management), imaging and clinical follow-ups were considered reference standards. In the overt group (n = 271), [18F]FCH PET/CT showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 0.99, 0.91, 1.00, 0.80, and 0.99, respectively. Regarding the correlation of the index lesions and initial laboratory data, all [18F]FCH PET/CT parameters (SUVs, SULs, and mSAD) were significantly correlated with the serum iPTH level. Additionally, SUVmax, SULpeak, and mSAD were significantly associated with the serum calcium level. In the mild group (n = 50), [18F]FCH PET/CT showed a sensitivity, specificity, PPV, NPV, and accuracy of 0.93, 0.75, 0.95, 0.67, and 0.90. In conclusion, [18F]FCH PET/CT revealed high diagnostic performance in the detection of HFPTs and the potential to be considered as a first-line imaging modality in the assessment of PHPT, including both overt and mild types. However, its cost-benefit concerning the clinical impact of early PHPT detection should be investigated in future studies.
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Affiliation(s)
- Seyedeh Sara Seyedinia
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Seyed Ali Mirshahvalad
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Joint Department of Medical Imaging, University Health Network, University of Toronto, Toronto, ON M5G 2M2, Canada
| | - Gregor Schweighofer-Zwink
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Lukas Hehenwarter
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Gundula Rendl
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christian Pirich
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Mohsen Beheshti
- Division of Molecular Imaging & Theranostics, Department of Nuclear Medicine, University Hospital Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-(0)5-7255-26602
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14
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Patel DD, Bhattacharjee S, Pandey AK, Kopp CR, Ashwathanarayana AG, Patel HV, Barnabas R, Bhadada SK, Dodamani MH. Comparison of 4D computed tomography and F-18 fluorocholine PET for localisation of parathyroid lesions in primary hyperparathyroidism: A systematic review and meta-analysis. Clin Endocrinol (Oxf) 2023. [PMID: 36593125 DOI: 10.1111/cen.14875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 12/05/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
Minimally invasive parathyroidectomy (MIP) is the standard of care for primary hyperparathyroidism (PHPT). Four dimensional computed tomography(4DCT) and F-18 Fluorocholine positron emission tomography/computed tomography (FCH PET/CT) localize adenomas accurately to perform MIP. We aimed to conduct a systematic review and metanalysis to evaluate the diagnostic performance of 4DCT and FCH PET/CT scan for quadrant wise localisation in PHPT patients and to do head-to-head comparison between these two modalities. DESIGN, PATIENTS AND MEASUREMENT : After searching through PubMed and EMBASE databases, 46 studies (using histology as a gold standard) of 4DCT and FCH PET/CT were included. RESULTS: Total number of patients included were 1651 and 952 for 4DCT scan (studies n = 26) and FCH PET/CT scan (studies n = 24) respectively. In per patient analysis, FCH PET/CT and 4DCT had pooled sensitivities of 92% (88-94) and 85% (73-92) respectively and in per lesion analysis, 90% (86-93) and 79% (71-84), respectively. In the subgroup with negative conventional imaging/persistent PHPT, FCH PET/CT had comparable sensitivity to 4DCT (84% [74-90] vs. 72% [46-88]). As per patient wise analysis, FCH PET/CT had better detection rates than 4DCT ([92.4 vs. 76.85], odds ratio -3.89 [1.6-9.36] p = .0024) in the subpopulation where both FCH PET/CT and 4DCT were reported. CONCLUSION: Both 4DCT and FCH PET/CT scan performed well in newly diagnosed patients, patients with persistent disease and in those with inconclusive conventional imaging results. FCH PET/CT scan had a higher pooled sensitivity than 4DCT in detecting patients with PHPT in head to head comparison.
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Affiliation(s)
| | - Samiksha Bhattacharjee
- Department of Pharmacology, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Avaneesh Kumar Pandey
- Department of Pharmacology, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chirag Rajkumar Kopp
- Department of Rheumatology, Post-graduate Institute of Medical Education and Research, Chandigarh, India
| | - Abhiram G Ashwathanarayana
- Consultant and head of department of nuclear medicine and PET/CT, Sanjeevani CBCC USA Cancer hospital, Raipur, India
| | - Himani Vinayak Patel
- Department of Radiology, G.M.E.R.S. Medical college and hospital, Junagadh, India
| | - Rohit Barnabas
- Department of Endocrinology and metabolism, Seth G.S. Medical College & King Edward Memorial hospital, Mumbai, India
| | | | - Manjunath Havalappa Dodamani
- Department of Endocrinology and metabolism, Seth G.S. Medical College & King Edward Memorial hospital, Mumbai, India
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15
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Saha S, Vierkant RA, Johnson GB, Parvinian A, Wermers RA, Foster T, McKenzie T, Dy B, Lyden M. C 11 choline PET/CT succeeds when conventional imaging for primary hyperparathyroidism fails. Surgery 2023; 173:117-123. [PMID: 36229257 DOI: 10.1016/j.surg.2022.08.024] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/14/2022] [Accepted: 08/09/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Focused parathyroidectomy in primary hyperparathyroidism is possible with accurate preoperative localization. A growing body of data exists regarding the role of radio-labeled C11 choline positron emission tomography/computed tomography. In cases of nonlocalized disease, it may be a useful adjunct to ultrasound, (123)I/(99)Tc-sestamibi (I-123 sestamibi), or 4-dimensional computed tomography imaging. METHODS Patients who received a neck and chest limited coverage C11 choline positron emission tomography/computed tomography for evaluation of primary hyperparathyroidism from 2017 to 2021 at a single institution were retrospectively reviewed. We assessed the sensitivity, positive predictive value, and false negative rate. We also compared these rates to the standard modalities of ultrasound, I-123 sestamibi, 4-dimensional computed tomography, and examined concordance rates. RESULTS We identified 43 patients, of whom 33 had a positive C11 choline positron emission tomography/computed tomography finding. This cohort of patients had failed to localize on multiple standard imaging modalities. Twenty-five patients proceeded to surgery, 72% of whom were reoperative cases. Twenty (80%) achieved an intraoperative cure. Analysis showed that C11 choline positron emission tomography/computed tomography achieved a sensitivity of 64% (95% confidence interval 47%-82%) and positive predictive value of 72% (95% confidence interval 54%-90%). There were 5/25 (20%) false positive positron emission tomography C11 choline results found to be lymph nodes, normal parathyroid, and 1 recurrent laryngeal nerve neuroma. CONCLUSION C11 choline positron emission tomography/computed tomography is a useful adjunct for parathyroid localization in a complex population of patients who have failed standard localization techniques including ultrasound, I-123 sestamibi, or 4-dimensional computed tomography and/or prior operations. Although routine inclusion of C11 choline positron emission tomography/computed tomography imaging may not be necessary, it may aid in preoperative localization in the reoperative setting.
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Affiliation(s)
- Sujata Saha
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN
| | | | - Geoffrey B Johnson
- Division of Nuclear Medicine, Department of Radiology and Department of Immunology, Mayo Clinic, Rochester, MN
| | - Ahmad Parvinian
- Division of Nuclear Medicine, Department of Radiology and Department of Immunology, Mayo Clinic, Rochester, MN
| | - Robert A Wermers
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition and Department of Medicine, Mayo Clinic, Rochester, MN
| | - Trenton Foster
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN
| | - Travis McKenzie
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN
| | - Benzon Dy
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN
| | - Melanie Lyden
- Division of Endocrine and Metabolic Surgery, Mayo Clinic, Rochester, MN.
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16
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Innovations in Parathyroid Localization Imaging. Surg Oncol Clin N Am 2022; 31:631-647. [DOI: 10.1016/j.soc.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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17
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Jacquet-Francillon N, Morelec I, Germain N, Prades JM, Habouzit V, Mariat C, Bonnefoy PB, Prevot N. Performance of quantitative measurements in [18F]fluorocholine positron emission tomography/computed tomography for parathyroid imaging (P2TH study). Front Med (Lausanne) 2022; 9:956580. [PMID: 35983092 PMCID: PMC9380568 DOI: 10.3389/fmed.2022.956580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objective [18F]Fluorocholine positron emission tomography/computed tomography (PET/CT) is used frequently in addition to [99mTc]Tc-Sestamibi scintigraphy and ultrasonography for the location of hyperfunctioning parathyroid glands. The aim of this study is to evaluate the performance of quantitative criteria in [18F]fluorocholine PET/CT for localization of hyperfunctioning parathyroid glands. The secondary objective is to highlight a correlation between the detection rate of [18F]fluorocholine PET/CT and serum parathyroid hormone (PTH) level. Materials and methods In two academic centers, we retrospectively included patients with biological hyperparathyroidism (HPT) and who had [18F]fluorocholine PET/CT. After a visual analysis, to measure the overall performance of [18F]fluorocholine PET/CT, a blind reading was carried out with standardized measurements of maximum standardized uptake value (SUVmax), liver ratio, thyroid ratio, and size ratio. We analyzed the quantitative criteria of [18F]fluorocholine PET/CT compared to the histological results, in particular to identify differences between adenomas and hyperplasias. We compared the performance of each quantitative criterion to the overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of [18F]fluorocholine PET/CT. The detection rate of hyperfunctioning parathyroid glands was calculated in subgroups of serum PTH level. Results The quantitative criteria in [18F]fluorocholine PET/CT were measured for 120 patients (135 lesions). The areas under the receiver operating characteristic (ROC) curve representing SUVmax and liver ratio were significantly increased. The optimal cut-off values represented by the maximum Youden index was >4.12 for SUVmax and >27.4 for liver ratio. Beyond certain threshold values of SUVmax (>4.12) or liver ratio (>38.1), all the lesions were histologically proven adenomas. SUVmax and liver ratio were significantly higher for adenomas than for hyperplasias and differential diagnosis (p = 0.0085 and p = 0.0002). The positivity of [18F]fluorocholine PET/CT was correlated with PTH level. Detection rates were 55.56, 75.56, and 87.5%, respectively, for serum PTH < 70, 70 to 120, and >120 ng/ml. Conclusion Semi-quantitative measurements (SUVmax and liver ratio) should be considered as additional tools in interpretation of [18F]fluorocholine PET/CT. These quantitative parameters have lower overall performance but higher specificity than overall visual analysis in identifying an adenoma. Above certain threshold values, all lesions are adenomas. [18F]fluorocholine PET/CT confirms excellent performance for the detection of hyperfunctional parathyroids. For serum PTH levels < 70 ng/ml, the detection rate of [18F]fluorocholine PET/CT is strongly decreased.
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Affiliation(s)
- Nicolas Jacquet-Francillon
- Department of Nuclear Medicine, Saint-Étienne University Hospital, University of Saint-Étienne, Saint-Étienne, France
- *Correspondence: Nicolas Jacquet-Francillon,
| | - Isabelle Morelec
- Department of Nuclear Medicine, Hospices Civils de Lyon, Lyon, France
| | - Natacha Germain
- Division of Endocrinology, Diabetes, Metabolism and Eating Disorders, Centre Hospitalo-Universitaire (CHU) de Saint-Étienne, Saint-Étienne, France
- Eating Disorders, Addictions and Extreme Bodyweight Research Group (TAPE) EA 7423, Université Jean Monnet, Saint-Étienne, France
| | - Jean-Michel Prades
- Department of Otorhinolaryngology, Head and Neck Surgery, Hospital Saint-Étienne, Saint-Étienne, France
- Laboratory of Human Anatomy, Faculty of Medicine, University of Saint-Étienne, Saint-Étienne, France
| | - Vincent Habouzit
- Department of Nuclear Medicine, Saint-Étienne University Hospital, University of Saint-Étienne, Saint-Étienne, France
| | - Christophe Mariat
- Department of Nephrology, Dialysis and Renal Transplantation, Hôpital Nord, Centre Hospitalo-Universitaire (CHU) de Saint-Étienne, Jean Monnet University, Université de Lyon, Saint-Étienne, France
- Groupe Immunité des Muqueuses et Agents Pathogènes GIMAP, EA 3065, University of Jean Monnet and Université de Lyon, Saint-Étienne, France
| | - Pierre-Benoit Bonnefoy
- Department of Nuclear Medicine, Saint-Étienne University Hospital, University of Saint-Étienne, Saint-Étienne, France
| | - Nathalie Prevot
- Department of Nuclear Medicine, Saint-Étienne University Hospital, University of Saint-Étienne, Saint-Étienne, France
- INSERM, U1059, SAINBIOSE, Univ Lyon, Univ Saint-Etienne, Saint-Etienne, France
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18
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Petranović Ovčariček P, Giovanella L, Hindie E, Huellner MW, Talbot JN, Verburg FA. An essential practice summary of the new EANM guidelines for parathyroid imaging. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2022; 66:93-103. [PMID: 35166093 DOI: 10.23736/s1824-4785.22.03427-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Parathyroid imaging is essential for the detection and localization of hyperfunctioning parathyroid tissue in patients with primary hyperparathyroidism (pHPT). Surgical treatment of pHPT mainly consists of minimally invasive parathyroidectomy (MIP), as a single adenoma represents the most common cause of this endocrine disorder. Successful surgery requires an experienced surgeon and relies on the correct preoperative detection and localization of hyperfunctioning parathyroid glands. Failure to preoperatively identify the culprit parathyroid gland by imaging may entail a more invasive surgical approach, including bilateral open neck exploration, with higher morbidity compared to minimally invasive parathyroidectomy. Parathyroid imaging may be also useful before surgery in case of secondary hyperparathyroidism (sHPT) or hereditary disorders (MEN 1, 2, 4) as it enables correct localization of typically located parathyroid glands, detection of ectopic as well as supernumerary glands. It is now accepted by most surgeons experienced in parathyroid surgery that preoperative imaging plays a key role in their patients' management. Recently, the European Association of Nuclear Medicine (EANM) issued an updated version of its Guidelines on parathyroid imaging. Its aim is to precise the role and the advantages and drawbacks of the various imaging modalities proposed or well established in the preoperative imaging strategy. It also aims to favor high performance in indicating, performing, and interpreting those examinations. The objective of the present article is to offer a summary of those recent EANM Guidelines and their originality among other Guidelines in this domain issued by societies of nuclear medicine physicians or other disciplines.
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Affiliation(s)
- Petra Petranović Ovčariček
- EANM Thyroid Committee, Vienna, Austria - .,Department of Oncology and Nuclear Medicine, University Hospital Center Sestre Milosrdnice, Zagreb, Croatia -
| | - Luca Giovanella
- EANM Thyroid Committee, Vienna, Austria.,Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland.,Clinic for Nuclear Medicine and Interdisciplinary Thyroid Center, University Hospital and University of Zurich, Zurich, Switzerland
| | - Elif Hindie
- Department of Nuclear Medicine, Bordeaux Hospital and University, Bordeaux, France
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Jean-Noël Talbot
- Nuclear Medicine, Hospital Tenon APHP and Sorbonne University, Paris, France
| | - Frederik A Verburg
- EANM Dosimetry Committee.,Erasmus MC, Department of Radiology and Nuclear Medicine, Rotterdam, the Netherlands
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19
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Huglo PD. Functional imaging for hyperparathyroidism. Presse Med 2022; 51:104120. [PMID: 35321847 DOI: 10.1016/j.lpm.2022.104120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 01/06/2022] [Accepted: 03/11/2022] [Indexed: 01/01/2023] Open
Abstract
Once hyperparathyroidism has been proven, the goal of parathyroid functional imaging is to identify one or more pathological glands in view of guiding a possibly targeted surgical procedure, while maximizing the chances for recovery. Currently, parathyroid radionuclide imaging is based on two techniques, parathyroid scintigraphy and 18F-fluorocholine - positron emission tomography (PET). The main radiopharmaceutical in scintigraphy is 99mTc-sestamibi, which can be used alone, in the dual-phase parathyroid scan, or in comparison with a thyroid radiotracer, pertechnetate (NaTcO4) or iodine 123 (dual-tracer method). The acquisitions can be planar and/or tomographic (SPECT). It is now recognized that the 99mTc-sestamibi - iodine 123 dual-tracer method is more efficient than the dual-phase scan, while SPECT-CT improves the sensitivity and specificity of the scintigraphy. This imaging and cervical ultrasonography are considered to be the two first-line reference techniques in preoperative assessment of hyperparathyroidism. More recently developed, 18F-fluorocholine detected by PET-CT has shown excellent performance, at least equal to that of scintigraphy. Initially considered as a second-line technique, its advantages over scintigraphy have prompted some authors to suggest it as the only examination to be performed in preoperative assessment of hyperparathyroidism. That said, due to a lack of specificity in 18F-fluorocholine uptake, which has been observed on inflammatory lesions and, particularly, in the mediastinal lymph nodes, and given the absence of simultaneous comparison of thyroid function, this strategy remains contested, and possibly reserved for patients without any associated thyroid pathology; large-scale evaluation would be justified.
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Affiliation(s)
- Pr Damien Huglo
- Univ Lille, Faculté de Médecine, 1 Place de Verdun, 5900 Lille, France; CHU Lille, Service de Médecine Nucléaire, Hôpital Huriez, rue Michel Polonovski, 59000 Lille, France; INSERM U1189 OncoTHAI, avenue Oscar Lambret, 59000 Lille, France.
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20
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Naik M, Khan SR, Owusu D, Alsafi A, Palazzo F, Jackson JE, Harvey CJ, Barwick TD. Contemporary Multimodality Imaging of Primary Hyperparathyroidism. Radiographics 2022; 42:841-860. [PMID: 35427174 DOI: 10.1148/rg.210170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Primary hyperparathyroidism (PHPT) is a disorder characterized by hypercalcemia and an elevated or inappropriately normal parathyroid hormone level. Classic features include bone pain, fractures, renal impairment, nephrolithiasis, and mental disturbance. However, most cases of PHPT are now asymptomatic at diagnosis or associated with nonspecific neurocognitive changes. The most frequent cause of PHPT is a solitary adenoma that secretes parathyroid hormone without the normal suppressive effect of serum calcium. A smaller number of cases can be attributed to multigland disease. Parathyroidectomy is curative and is considered for nearly all affected patients. Although PHPT is primarily a clinical and biochemical diagnosis, imaging is key to the localization of adenomas, which can lie in conventional locations adjacent to the thyroid gland or less commonly at ectopic sites in the neck and mediastinum. In addition, accurate localization facilitates the use of a minimally invasive or targeted surgical approach. Frequently used localization techniques include US, parathyroid scintigraphy, and four-dimensional CT. Second- and third-line modalities such as MRI, PET/CT, and selective venous sampling with or without parathyroid arteriography can increase confidence before surgery. These localization techniques, along with the associated technical aspects, relative advantages, and drawbacks, are described. Local expertise, patient factors, and surgeon preference are important considerations when determining the type and sequence of investigation. A multimodality approach is ultimately desirable, particularly in challenging scenarios such as multigland disease, localization of ectopic adenomas, and persistent or recurrent PHPT. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Mitesh Naik
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Sairah R Khan
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Desmond Owusu
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Ali Alsafi
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Fausto Palazzo
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - James E Jackson
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Chris J Harvey
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
| | - Tara D Barwick
- From the Department of Radiology (M.N., S.R.K., A.A., J.E.J., C.J.H., T.D.B.) and Department of Endocrine and Thyroid Surgery (F.P.), Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, England; Department of Radiology, Dartford and Gravesham NHS Trust, Kent, England (D.O.); and Department of Surgery and Cancer, Imperial College London, London, England (T.D.B.)
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21
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Morris MA, Saboury B, Ahlman M, Malayeri AA, Jones EC, Chen CC, Millo C. Parathyroid Imaging: Past, Present, and Future. Front Endocrinol (Lausanne) 2022; 12:760419. [PMID: 35283807 PMCID: PMC8914059 DOI: 10.3389/fendo.2021.760419] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/21/2021] [Indexed: 12/30/2022] Open
Abstract
The goal of parathyroid imaging is to identify all sources of excess parathyroid hormone secretion pre-operatively. A variety of imaging approaches have been evaluated and utilized over the years for this purpose. Ultrasound relies solely on structural features and is without radiation, however is limited to superficial evaluation. 4DCT and 4DMRI provide enhancement characteristics in addition to structural features and dynamic enhancement has been investigated as a way to better distinguish parathyroid from adjacent structures. It is important to recognize that 4DCT provides valuable information however results in much higher radiation dose to the thyroid gland than the other available examinations, and therefore the optimal number of phases is an area of controversy. Single-photon scintigraphy with 99mTc-Sestamibi, or dual tracer 99mTc-pertechnetate and 99mTc-sestamibi with or without SPECT or SPECT/CT is part of the standard of care in many centers with availability and expertise in nuclear medicine. This molecular imaging approach detects cellular physiology such as mitochondria content found in parathyroid adenomas. Combining structural imaging such as CT or MRI with molecular imaging in a hybrid approach allows the ability to obtain robust structural and functional information in one examination. Hybrid PET/CT is widely available and provides improved imaging and quantification over SPECT or SPECT/CT. Emerging PET imaging techniques, such as 18F-Fluorocholine, have the exciting potential to reinvent parathyroid imaging. PET/MRI may be particularly well suited to parathyroid imaging, where available, because of the ability to perform dynamic contrast-enhanced imaging and co-registered 18F-Fluorocholine PET imaging simultaneously with low radiation dose to the thyroid. A targeted agent specific for a parathyroid tissue biomarker remains to be identified.
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Affiliation(s)
| | | | | | | | | | - Clara C. Chen
- National Institutes of Health (NIH) Clinical Center, Department of Radiology and Imaging Sciences, Bethesda, MD, United States
| | - Corina Millo
- National Institutes of Health (NIH) Clinical Center, Department of Radiology and Imaging Sciences, Bethesda, MD, United States
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22
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Shao L, Wang X, Yu Y, Xie J. Comparative analysis of the efficacy and accuracy of magnetic resonance imaging (MRI) and contrast-enhanced CT for residual and new lesions after transcatheter arterial chemoembolization (TACE) in patients with primary liver cancer. Transl Cancer Res 2022; 10:3739-3747. [PMID: 35116674 PMCID: PMC8798762 DOI: 10.21037/tcr-21-831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 08/12/2021] [Indexed: 12/12/2022]
Abstract
Background The purpose of this study was to investigate the efficacy and accuracy of magnetic resonance imaging (MRI) and contrast-enhanced computed tomography (CECT) for residual and new lesions after transcatheter arterial chemoembolization (TACE) in patients with primary liver cancer (PHC). Methods Seventy-two PHC patients admitted to Linyi Central Hospital from May 2018 to May 2020 were selected as the study subjects, with a total of 92 lesions. All patients were treated with TACE, and were followed up at 6 months postoperatively. In addition, all patients underwent digital subtraction angiography (DSA), and with DSA results serving as the gold standard for diagnosis, the efficacy and accuracy of MRI and CECT for residual and new lesions after TACE in PHC patients were evaluated. Results There were no significant differences in the specificity between the two diagnostic methods (P>0.05), and the diagnostic accuracy and sensitivity of MRI were markedly higher than those of CECT (P<0.05). The number of residual and new lesions diagnosed by MRI was notably higher than that by multislice spiral computed tomography (MSCT) (P<0.05), and the detection rate of residual and new lesions after TACE in PHC patients with different types of iodized oil deposition by MRI was significantly higher than that by CECT (P<0.05). Also, the number of postoperative tumor capsules diagnosed by MRI was considerably higher than that by CECT (P<0.05). There were no significant differences between the two diagnostic methods in the score of residual enhancement appearances in the arterial phase after surgery (P>0.05). Furthermore, there were no notable differences between the two diagnostic methods in the diagnosis of portal vein tumorous emboli and the source of blood supply to lesions after surgery (P>0.05). Conclusions The diagnostic accuracy and sensitivity of MRI for residual and new lesions after TACE in PHC patients were higher than those of CECT. However, these two diagnostic methods were similar in diagnosing portal vein tumorous emboli, the source of blood supply to lesions, and the score of residual enhancement appearances in the arterial phase after surgery.
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Affiliation(s)
- Liang Shao
- Department of Radiology, Maternity and Child Health Care of Zaozhuang, Zaozhuang, China
| | - Xiaolei Wang
- Department of Radiology, Maternity and Child Health Care of Zaozhuang, Zaozhuang, China
| | - Yongtao Yu
- Department of Radiology, Linyi Central Hospital, Linyi, China
| | - Jiangwei Xie
- Department of Radiology, Linyi Central Hospital, Linyi, China
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23
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Liberini V, Morand GB, Rupp NJ, Orita E, Deandreis D, Broglie Däppen M, Hofbauer M, Maurer A, Husmann L, Mader CE, Grünig H, Alharbi AA, Messerli M, Huellner MW. Histopathological Features of Parathyroid Adenoma and 18F-Choline Uptake in PET/MR of Primary Hyperparathyroidism. Clin Nucl Med 2022; 47:101-107. [PMID: 35006103 DOI: 10.1097/rlu.0000000000003987] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The aim of this study was to assess the relationship between the histopathological properties of hyperfunctioning parathyroids and parathyroid 18F-choline uptake. PATIENTS AND METHODS A total of 31 parathyroid adenomas were retrospectively analyzed in patients with primary hyperparathyroidism and preoperative 18F-choline PET/MR. PET/MR parameters of parathyroid glands (SUVmax and target-to-background ratio in early-phase [EP] and late-phase [LP]), MRI volume, preoperative parathyroid hormone (PTH) serum concentration, and postoperative histopathology (predominant cell type and growth pattern of adenoma cells, location and size of adenoma) were assessed. The relationship of PET/MR parameters, PTH, and histological parameters was determined using linear regression, Spearman correlation and Kruskal-Wallis test. RESULTS The median volume of parathyroid adenoma was 421.78 ± 142.46 mm3 (46.39-4412.69). Adenomas were predominantly composed of chief, water-clear, and oncocytic/oxyphilic cells in 27/31, 2/31, and 2/31 cases, respectively. The growth pattern was predominantly solid, follicular, and trabecular in 18/31, 8/31, and 5/31, respectively. The SUVmax was 6.71 ± 3.39 in EP and 6.91 ± 3.97 in LP. Follicular growth pattern had slightly higher EP SUVmax (trabecular: 4.12 ± 0.56; solid: 6.62 ± 3.19; follicular: 8.56 ± 3.96; P = 0.046). Spearman correlation showed strong positive correlation between volume and both EP and LP SUVmax (0.626; P = 0.0001 and 0.576; P = 0.0001, respectively). Linear regression analysis revealed significant correlation between PTH level and EP and LP SUVmax (both P = 0.001); in contrast, no correlation was found between PTH level and both cell type and growth pattern. CONCLUSIONS Our findings suggest that 18F-choline uptake of parathyroid adenomas might be associated both with the histological growth pattern and adenoma volume, but not with a specific cell type.
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Affiliation(s)
| | | | | | | | - Désirée Deandreis
- Department of Medical Science, Nuclear Medicine Unit, University of Turin
| | | | - Marlena Hofbauer
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Alexander Maurer
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Lars Husmann
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Cäcilia E Mader
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Hannes Grünig
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Abdullah A Alharbi
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Michael Messerli
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
| | - Martin W Huellner
- From the Department of Nuclear Medicine, University Hospital Zürich, Zürich, Switzerland
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24
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Positron nuclear medicine imaging: Parathyroid diseases. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00046-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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18F-Fluorocholine PET and 4D-CT in Patients with Persistent and Recurrent Primary Hyperparathyroidism. Diagnostics (Basel) 2021; 11:diagnostics11122384. [PMID: 34943620 PMCID: PMC8700343 DOI: 10.3390/diagnostics11122384] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/09/2021] [Accepted: 12/14/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with primary hyperparathyroidism (pHPT) can develop persistent (P-pHPT) or recurrent (R-pHPT) disease after parathyroidectomy. Before recommending reoperation, recurrence must be accurately identified because of the high risk of complications. Our study evaluates 18F-fluorocholine (18F-FCH) PET/CT and 4D-CT integrated in PET/4D-CT in patients with P-pHPT/R-pHPT. Patients with P-pHPT/R-pHPT investigated by 18F-FCH PET/4D-CT between May 2018 and March 2021 were retrospectively included. Forty-two patients were included, 37 of whom underwent 4D-CT. The sensitivity and detection rate (DR%) were 95% and 88% for 18F-FCH PET/CT and 70% and 63% for 4D-CT, respectively. PET/CT and 4D-CT were concordant in 18/24 glands and concordant and positive in 15/24 (63%) glands. Discordant results were obtained for 6/24 glands. The surgical success rate was 65%. PET/CT showed significantly higher sensitivity than 4D-CT. Dynamic CT allowed the identification of no additional glands missed by PET/CT, and the combination of the 2 techniques did not improve the sensitivity or DR%. 18F-FCH PET/CT appears to be a valuable technique to accurately detect hyperfunctioning parathyroid tissue in patients with P-pHPT/R-pHPT and is better than 4D-CT. Except for cases with doubtful locations of PET targets that may require 4D-CT for surgical guidance, standard nonenhanced 18F-FCH PET/CT can be effectively recommended in patients with P-pHPT/R-pHPT before reoperation.
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26
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Foppiani L, Sola S, Pitto F, Ansaldo G, Piccardo A. A Collision Intrathyroidal Tumor Causing Primary Hyperparathyroidism: Evidence From an 18F-Choline PET/CT Study. Clin Nucl Med 2021; 46:924-926. [PMID: 33867452 DOI: 10.1097/rlu.0000000000003650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 67-year-old man was diagnosed with primary hyperparathyroidism and normofunctioning left nodular goiter. Fine-needle aspiration cytology showed thyroid (Thy) 4 (suspicious of malignancy). After first-line imaging proved negative, integrated 18F-choline PET/4D contrast-enhanced CT revealed uptake by the thyroid nodule and by 3 nodules of the left central compartment. Thyroidectomy and lymphadenectomy were performed. Histopathology revealed a collision tumor (ie, 2 histologically distinct tumors occurring at the same anatomic site) composed of both PTC (papillary thyroid carcinoma) and parathyroid carcinoma within the left thyroid nodule. Lymph nodes showed PTC metastases. Primary hyperparathyroidism and calcium levels normalized, and the patient underwent radioiodine therapy.
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27
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Piccardo A, Bottoni G, Boccalatte LA, Camponovo C, Musumeci M, Bacigalupo L, Collaud C, Ugolini M, Fiz F, Trimboli P. Head-to-head comparison among 18F-choline PET/CT, 4D contrast-enhanced CT, and 18F-choline PET/4D contrast-enhanced CT in the detection of hyperfunctioning parathyroid glands: a systematic review and meta-analysis. Endocrine 2021; 74:404-412. [PMID: 34173158 DOI: 10.1007/s12020-021-02798-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/07/2021] [Indexed: 12/28/2022]
Abstract
INTRODUCTION In primary hyperparathyroidism (PHPT), the localization of hyperfunctioning parathyroid gland (HPTG) allows tailored surgery. Although Four-Dimensional Contrast-enhanced Computed Tomography (4DCeCT) and 18F-choline Positron Emission Tomography/Computed Tomography (PET/CT) are reported to be promising second-line imaging procedures, no meta-analysis of their comparison exists. DESIGN we conducted a systematic review and meta-analysis to find original papers reporting the head-to-head comparison of 4DCeCT, 18F-choline PET/CT and integrated 18F-choline-PET/4DCeCT. METHODS this systematic review was conducted according to PRISMA. PubMed, CENTRAL, Scopus, and Web of Science were searched until January 2021. Studies comparing the ability of 4DCeCT, 18F-choline PET/CT and 18F-choline PET/4DCeCT to identify HPTG in patients with PHPT were selected. A per patient-based analysis of the three procedures was conducted in all patients (detection rate, DR) and in those with histologically confirmed HPTG (sensitivity). RESULTS Of the 78 records identified, five articles (153 PHPT patients) published between January the 1st, 2018 and January the 31st, 2021 were included. The pooled DR of 18F-choline PET/CT, 4DCeCT and 18F-choline PET/4DCeCT was 0.86, 0.69, and 0.86, respectively, while their pooled sensitivity was 0.89, 0.77 and 0.93, respectively. The analysis of pooled discrepancy showed that the sensitivity of 18F-choline PET/CT and 18F-choline PET/4DCeCT was higher than that of 4DCeCT by 0.11 and 0.13, respectively, the sensitivity of 18F-choline PET/4DCeCT being 0.06 higher than that of 18F-Choline PET/CT. CONCLUSIONS This meta-analysis suggests that the sensitivity of 18F-choline PET/CT and 18F-choline PET/4DCeCT is higher than that of 4DCeCT, while only a slight difference was observed between 18F-choline PET/CT and 18F-choline PET/4DCeCT.
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Affiliation(s)
- Arnoldo Piccardo
- Nuclear Medicine Department, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
| | - Gianluca Bottoni
- Nuclear Medicine Department, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
| | | | - Chiara Camponovo
- Clinic of Endocrinology and Diabetology, Lugano and Mendrisio Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Martina Musumeci
- Department of Endocrinology, Metabolism and Nuclear Medicine/PET-CT, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Lorenzo Bacigalupo
- Radiology Department, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
| | - Carlos Collaud
- Department of Endocrinology, Metabolism and Nuclear Medicine/PET-CT, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Martina Ugolini
- Nuclear Medicine Department, Ente Ospedaliero "Ospedali Galliera", Genoa, Italy
| | - Francesco Fiz
- Nuclear Medicine Department, Humanitas Research Hospital-IRCCS, Rozzano, Milan, Italy.
| | - Pierpaolo Trimboli
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), Lugano, Switzerland
- Clinic of Endocrinology and Diabetology, Lugano and Mendrisio Regional Hospital, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
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Knappe L, Paone G, Giovanella L. An ectopic, dysmorphic and atypical parathyroid adenoma. Endocrine 2021; 74:200-201. [PMID: 33765297 DOI: 10.1007/s12020-021-02699-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Luisa Knappe
- Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Gaetano Paone
- Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Luca Giovanella
- Imaging Institute of Southern Switzerland, Bellinzona, Switzerland.
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29
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Whitman J, Allen IE, Bergsland EK, Suh I, Hope TA. Assessment and Comparison of 18F-Fluorocholine PET and 99mTc-Sestamibi Scans in Identifying Parathyroid Adenomas: A Metaanalysis. J Nucl Med 2021; 62:1285-1291. [PMID: 33452040 PMCID: PMC8882892 DOI: 10.2967/jnumed.120.257303] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 01/03/2021] [Indexed: 01/24/2023] Open
Abstract
Hyperparathyroidism is an endocrine disorder caused by one or more hyperfunctioning parathyroid glands. Current imaging consisting of ultrasound and 99mTc-sestamibi is imprecise, making localization difficult. 18F-fluorocholine (18F-FCH) PET has recently shown promise in presurgical localization of parathyroid adenomas. The primary aim of this study was to summarize the sensitivities and specificities of studies using 18F-FCH PET to localize hyperparathyroidism. A secondary aim was to summarize a subset of studies in which 99mTc-sestamibi scans were also used and to compare the performance of the 2 modalities. Methods: We searched the MEDLINE and EMBASE databases following the PRISMA (Preferred Reporting Items for Systematic Review and Metaanalysis) statement. Quality was assessed using the QUADAS-2 tool (Quality Assessment of Diagnostic Accuracy Studies). Twenty studies were included for quantitative assessment in our metaanalysis. A random-effects model and a hierarchic summary receiver-operating-characteristic model was used to summarize the sensitivity of 18F-FCH PET in detecting abnormal parathyroid adenomas. We used the same methodology to assess sensitivity of 99mTc-sestamibi, as a comparison to 18F-FCH PET. Results:18F-FCH PET had a high sensitivity, 0.97 (range, 0.96-0.98), for the detection of abnormal parathyroid adenomas. In the subpopulation for which both 18F-FCH and 99mTc-sestamibi were reported, 18F-FCH also had a higher sensitivity, 0.96 (0.94-0.98), than the 0.54 (0.29-0.79) reported for 99mTc-sestamibi (P < 0.001). Conclusion:18F-FCH PET demonstrates high localization accuracy in patients with hyperparathyroidism. This metaanalysis supports the use of 18F-FCH over 99mTc-sestamibi in patients with hyperparathyroidism.
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Affiliation(s)
- Julia Whitman
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Isabel E Allen
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California
| | - Emily K Bergsland
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, San Francisco, California
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Thomas A Hope
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, California;
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California; and
- Department of Radiology, San Francisco VA Medical Center, San Francisco, California
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30
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de Jong MC, Jamal K, Morley S, Beale T, Chung T, Jawad S, Hurel S, Simpson H, Srirangalingam U, Baldeweg SE, Rozalén García V, Otero S, Shawky M, Abdel-Aziz TE, Kurzawinski TR. The use of computed tomography as a first-line imaging modality in patients with primary hyperparathyroidism. Hormones (Athens) 2021; 20:499-506. [PMID: 32405929 DOI: 10.1007/s42000-020-00205-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The success of minimally invasive parathyroidectomy (MIP) relies on accurate localization of the abnormal parathyroid glands. Concordant findings on ultrasound (US) and 99mTc-scintigraphy (sestamibi) are currently considered the 'gold standard'. Computed tomography (CT) has also recently been used in preoperative planning. We sought to assess the accuracy of CT for localization of abnormal parathyroid glands in such patients. METHODS An audit of 75 patients with primary hyperparathyroidism (PHPT) who underwent neck US and CT between 2017 and 2019 at our center as their first-line imaging. RESULTS All 75 patients underwent US and CT and 54 (72.0%) also had sestamibi. CT alone identified a potential target in all patients, of which the location was correct in 63 (84.0%). The overall combined sensitivity of US and CT was 88% (95% CI 78-94) and was higher than the combined sensitivity of US and sestamibi (65% [95% CI 53-76]; p < 0.001). Twenty-one patients (28.0%) had an ectopic gland, and the sensitivity of US and CT was 86% (95% CI 64-96) versus US and sestamibi (57% [95% CI 34-77]; p = 0.016). For adenomas < 1.0 g (n = 36; 48%), the accuracy of CT was 81% (95% CI 64-91) compared with 62% (95% CI 44-77) for US and sestamibi (p = 0.04). The correct preoperative diagnosis of multiglandular disease (n = 9; 12%) seemed to be the most difficult, with similar accuracy for US and sestamibi (40% [95% CI 14-73]) and US and CT (50% [95% CI 20-80]) (p > 0.99). CONCLUSION The combination of US and CT was able to correctly identify the location of the abnormal parathyroid in 88% of patients and, in comparison with US and sestamibi, had better diagnostic accuracy, especially for smaller and ectopic adenomas. This finding suggests that US and CT could be considered as a first-line imaging modality in patients with PHPT considered for MIP.
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Affiliation(s)
- Mechteld C de Jong
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK.
| | - K Jamal
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - S Morley
- Department of Radiology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - T Beale
- Department of Radiology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - T Chung
- Department of Endocrinology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - S Jawad
- Department of Radiology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - S Hurel
- Department of Endocrinology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - H Simpson
- Department of Endocrinology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - U Srirangalingam
- Department of Endocrinology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - S E Baldeweg
- Department of Endocrinology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - V Rozalén García
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - S Otero
- Department of Radiology, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - M Shawky
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - T E Abdel-Aziz
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
| | - T R Kurzawinski
- Centre for Endocrine Surgery, University College London Hospital, 235 Euston Road, London, NW1 2BU, UK
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Petranović Ovčariček P, Giovanella L, Carrió Gasset I, Hindié E, Huellner MW, Luster M, Piccardo A, Weber T, Talbot JN, Verburg FA. The EANM practice guidelines for parathyroid imaging. Eur J Nucl Med Mol Imaging 2021; 48:2801-2822. [PMID: 33839893 PMCID: PMC8263421 DOI: 10.1007/s00259-021-05334-y] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/23/2021] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Nuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration. METHODS Over a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT. CONCLUSION These guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.
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Affiliation(s)
- Petra Petranović Ovčariček
- EANM Thyroid Committee, Vienna, Austria
- Department of Oncology and Nuclear medicine, University Hospital Center "Sestre milosrdnice", Zagreb, Croatia
| | - Luca Giovanella
- EANM Thyroid Committee, Vienna, Austria
- Clinic for Nuclear Medicine and Competence Centre for Thyroid Diseases, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Clinic for Nuclear Medicine and Interdisciplinary Thyroid Centre, University Hospital and University of Zurich, Zurich, Switzerland
| | - Ignasi Carrió Gasset
- Department of Nuclear Medicine, Hospital Sant Pau and Autonomous University of Barcelona, Barcelona, Spain
| | - Elif Hindié
- Department of Nuclear Medicine, Bordeaux Hospital and University, Bordeaux, France
| | - Martin W Huellner
- Department of Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
| | - Markus Luster
- EANM Thyroid Committee, Vienna, Austria
- Department of Nuclear Medicine, University Hospital Marburg, Marburg, Germany
| | - Arnoldo Piccardo
- Department of Nuclear Medicine, E.O. Ospedali Galliera, Genoa, Italy
| | - Theresia Weber
- Department of Endocrine Surgery, Katholisches Klinikum Mainz, Mainz, Germany
| | - Jean-Noël Talbot
- Nuclear Medicine, Hospital Tenon APHP and Sorbonne University, Paris, France
| | - Frederik Anton Verburg
- EANM Thyroid Committee, Vienna, Austria.
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, The Netherlands.
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Lee SW, Shim SR, Jeong SY, Kim SJ. Direct Comparison of Preoperative Imaging Modalities for Localization of Primary Hyperparathyroidism: A Systematic Review and Network Meta-analysis. JAMA Otolaryngol Head Neck Surg 2021; 147:692-706. [PMID: 34081083 DOI: 10.1001/jamaoto.2021.0915] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Importance Accurate preoperative localization of primary hyperparathyroidism (pHPT) is an important and challenging issue for a successful parathyroidectomy. Although new imaging modalities have been introduced during the past decade, direct comparative studies on advanced imaging techniques are limited. Objective To compare the performance of different preoperative imaging modalities for the localization of pHPT by performing a network meta-analysis (NMA). Data Sources PubMed, Embase, and the Cochrane Library were searched from the earliest available indexing date through September 28, 2020. Study Selection The inclusion criteria were diagnostic tests with sensitivities of 2 or more different preoperative imaging modalities for the same indivduals. Data Extraction and Synthesis Two researchers independently reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension statement of health care intervention guidelines for network meta-analyses. Main Outcomes and Measures After classifying various imaging modalities into 8 representative imaging categories, the pooled estimation between the odds ratio and 95% credible intervals (CrIs) was calculated in the sensitivity for localization of pHPT. The surface under the cumulative ranking curve (SUCRA) values were obtained to calculate the probability of each imaging modality being the most effective diagnostic method. Results A total of 8495 patients from 119 direct comparative studies using 2 or more imaging modalities for localization of pHPT were included. The sensitivity of choline positron emission tomography and computed tomography (PET-CT) was significantly higher than that of technetium 99m sestamibi single-photon emission computed tomography (MIBI SPECT) in both patient-based and lesion-based analyses (patient-based analysis: odds ratio, 5.22; 95% CrI, 2.36-11.80; lesion-based analysis: odds ratio, 17.70; 95% CrI, 5.79-60.10). Among 8 representative imaging modality categories, choline PET-CT showed the highest SUCRA value in both patient-based and lesion-based analyses. In patient-based analysis after 2010, choline PET-CT showed the highest SUCRA value, followed by the CT category, although MIBI SPECT had the highest SUCRA value in analysis before 2009. Conclusions and Relevance The results from this network meta-analysis suggest that choline PET-CT showed the best performance in both patient-based and lesion-based analyses and that choline PET-CT would be the best preoperative imaging modality for localization of pHPT.
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Affiliation(s)
- Sang-Woo Lee
- Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu, South Korea
| | - Sung Ryul Shim
- Department of Preventive Medicine, Korea University College of Medicine, Seoul, South Korea
| | - Shin Young Jeong
- Department of Nuclear Medicine, School of Medicine and Chilgok Hospital, Kyungpook National University, Daegu, South Korea
| | - Seong-Jang Kim
- Department of Nuclear Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea.,Department of Nuclear Medicine, College of Medicine, Pusan National University, Yangsan, South Korea.,BioMedical Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
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Graves CE, Hope TA, Kim J, Pampaloni MH, Kluijfhout W, Seib CD, Gosnell JE, Shen WT, Roman SA, Sosa JA, Duh QY, Suh I. Superior sensitivity of 18F-fluorocholine: PET localization in primary hyperparathyroidism. Surgery 2021; 171:47-54. [PMID: 34301418 DOI: 10.1016/j.surg.2021.05.056] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. METHODS Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. RESULTS In 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). CONCLUSION Long-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.
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Affiliation(s)
- Claire E Graves
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, University of California Davis, Sacramento, CA, USA. https://twitter.com/clairegravesmd
| | - Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/thomashopemd
| | - Jina Kim
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, Inova Schar Cancer Institute, Fairfax, VA, USA
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Wouter Kluijfhout
- Department of Surgery, University of Utrecht, Utrecht, The Netherlands
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, CA, USA. https://twitter.com/daceyseib
| | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/wshen16
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/pheosurgeon
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/jasosamd
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA. https://twitter.com/endosurgsf
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA; Department of Surgery, NYU Langone Health, New York, NY, USA.
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Hindié E, Schwartz P, Avram AM, Imperiale A, Sebag F, Taïeb D. Primary Hyperparathyroidism: Defining the Appropriate Preoperative Imaging Algorithm. J Nucl Med 2021; 62:3S-12S. [PMID: 34230072 DOI: 10.2967/jnumed.120.245993] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 10/21/2020] [Indexed: 11/16/2022] Open
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 99mTc-sestamibi 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. Dual-tracer 99mTc-sestamibi/123I 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 18F-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 18F-fluorocholine PET/CT can be a way to improve accuracy. We also briefly discuss other localization procedures, including 11C-methionine PET/CT, MRI, ultrasound-guided fine-needle aspiration, and selective venous sampling for parathyroid hormone measurement.
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Affiliation(s)
- Elif Hindié
- Department of Nuclear Medicine, University Hospitals of Bordeaux, TRAIL, University of Bordeaux, Bordeaux, France;
| | - Paul Schwartz
- Department of Nuclear Medicine, University Hospitals of Bordeaux, TRAIL, University of Bordeaux, Bordeaux, France
| | - Anca M Avram
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Alessio Imperiale
- Nuclear Medicine and Molecular Imaging, ICANS, University Hospitals of Strasbourg, University of Strasbourg, IPHC, Strasbourg, France
| | - Frederic Sebag
- Endocrine Surgery, La Timone Hospital, Aix-Marseille University, Marseille, France; and
| | - David Taïeb
- Nuclear Medicine, La Timone Hospital, CERIMED, Aix-Marseille University, Marseille, France
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Dynamic 18F-fluorocholine PET/CT for parathyroid imaging in patients with primary hyperparathyroidism. Nucl Med Commun 2021; 41:776-782. [PMID: 32453204 DOI: 10.1097/mnm.0000000000001217] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In the past few years, F-fluorocholine PET/CT has been established as a promising imaging technique for preoperative localization of parathyroid adenomas, but the optimal time point to start PET/CT acquisition after tracer injection is yet unknown. The aim of the present study was to assess the optimal time frame to acquire the PET/CT images and to evaluate the ability of dynamic imaging to differentiate parathyroid adenomas from active lymph nodes, a common cause for false-positive scan results. PATIENTS AND METHODS Patients with primary hyperparathyroidism who had undergone a dynamic F-fluorocholine PET/CT positive for parathyroid disease and who subsequently underwent successful parathyroidectomy were retrospectively included in this study. On the 20 minutes dynamic images, standardized uptake value measurements were acquired per 1 minute frame for the parathyroid adenoma, the thyroid gland, blood pool activity, and, if present, lymph node activity. RESULTS A total of 101 patients were included in this study. Time-activity curves showed a decrease of activity in parathyroid and thyroid glands, with faster wash-out from the thyroid gland and on average a stable, lower activity in lymph nodes. Blood pool activity was particularly present in the first 2 minutes. Differentiation of a parathyroid adenoma from active lymph nodes was best before 5 minutes, but no definitive cutoff value could be determined. Differentiation of a parathyroid adenoma from the thyroid gland was best after 10 minutes. CONCLUSION Dynamic imaging starting at the early time point of 2 minutes after injection of F-fluorocholine is useful for characterization of hyperfunctioning parathyroid glands.
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Diagnostic Role of Four-Dimensional Computed Tomography for Preoperative Parathyroid Localization in Patients with Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis. Diagnostics (Basel) 2021; 11:diagnostics11040664. [PMID: 33917261 PMCID: PMC8068020 DOI: 10.3390/diagnostics11040664] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 11/22/2022] Open
Abstract
We sought to systematically evaluate diagnostic performance of four-dimensional computed tomography (4D-CT) in the localization of hyperfunctioning parathyroid glands (HPGs) in patients with primary hyperparathyroidism (pHPT). We calculated the pooled sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratios (DOR) of 4D-CT on a per-lesion level, as well as pooled sensitivity and positive predictive value (PPV) on a per-patient level with 95% confidence intervals (CIs). Additionally, we plotted summary receiver operating characteristic (SROC) curves and evaluated the areas under the curves (AUC). A total of 16 studies were included in the analysis. Their pooled sensitivity, specificity, PLR, NLR, and DOR of 4D-CT on per-lesion level were 75% (95%CI: 66–82%), 85% (95%CI: 50–97%), 4.9 (95%CI: 1.1–21.3), 0.30 (95%CI: 0.19–0.45), and 17 (95%CI: 3–100), respectively, with an AUC of 81% (95%CI: 77–84%). We also observed heterogeneity in sensitivity (I2 = 79%) and specificity (I2 = 94.7%), and obtained a pooled sensitivity of 81% (95%CI: 70–90%) with heterogeneity of 81.9% (p < 0.001) and PPV of 91% (95%CI: 82–98%) with heterogeneity of 80.8% (p < 0.001), based on a per-patient level. Overall, 4D-CT showed moderate sensitivity and specificity for preoperative localization of HPG(s) in patients with pHPT. The diagnostic performance may improve with 4D-CT’s promotion to first-line use on a lesion-based level, further research is needed to confirm the results.
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Tay D, Das JP, Yeh R. Preoperative Localization for Primary Hyperparathyroidism: A Clinical Review. Biomedicines 2021; 9:biomedicines9040390. [PMID: 33917470 PMCID: PMC8067482 DOI: 10.3390/biomedicines9040390] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 01/02/2023] Open
Abstract
With increasing use of minimally invasive parathyroidectomy (PTx) over traditional bilateral neck exploration in patients with primary hyperparathyroidism (PHPT), accurate preoperative localization has become more important to enable a successful surgical outcome. Traditional imaging techniques such as ultrasound (US) and sestamibi scintigraphy (MIBI) and newer techniques such as parathyroid four-dimension computed tomography (4D-CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) are available for the clinician to detect the diseased gland(s) in the preoperative workup. Invasive parathyroid venous sampling may be useful in certain circumstances such as persistent or recurrent PHPT. We review the diagnostic performance of these imaging modalities in preoperative localization and discuss the advantages and weaknesses of these techniques. US and MIBI are established techniques commonly utilized as first-line modalities. 4D-CT has excellent diagnostic performance and is increasingly performed in first-line setting and as an adjunct to US and MIBI. PET and MRI are emerging adjunct modalities when localization has been equivocal or failed. Since no evidence-based guidelines are yet available for the optimal imaging strategy, clinicians should be familiar with the range and advancement of these techniques. Choice of imaging modality should be individualized to the patient with consideration for efficacy, expertise, and availability of such techniques in clinical practice.
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Affiliation(s)
- Donovan Tay
- Department of Medicine, Sengkang General Hospital, 110 Sengkang E Way, Singapore 544886, Singapore;
| | - Jeeban P. Das
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
| | - Randy Yeh
- Department of Radiology, Molecular Imaging and Therapy Service, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA;
- Correspondence:
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[Asymptomatic primary hyperparathyroidism : Operation or observation?]. Internist (Berl) 2021; 62:496-504. [PMID: 33710361 DOI: 10.1007/s00108-021-00996-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND In many cases primary hyperparathyroidism (PHPT) remains asymptomatic for years and is only detected by abnormalities in routine diagnostics. While symptomatic disease almost always requires surgical treatment, in symptom-free patients the question of whether and in what form treatment should be carried out is particularly important. OBJECTIVE The aim of this review is to summarize the current recommendations regarding the diagnostics and treatment of asymptomatic PHPT, taking the existing evidence into account. RESULTS AND CONCLUSION The diagnostics of asymptomatic PHPT is the same as for symptomatic disease. The diagnosis is made in the presence of elevated parathyroid hormone and balanced vitamin D levels when a combination of hypercalcemia, hypophosphatemia and hypercalciuria is present. Borderline laboratory findings occur especially in asymptomatic PHPT and the differential diagnosis of familial hypocalciuric hypercalcemia must be considered. Once the diagnosis is made sonography, radiography or computed tomography (CT) is used to search for nephrolithiasis or nephrocalcinosis. Regarding bone mineral density (BMD) measurements, in addition to routine measurements at the lumbar spine and femur, measurement at the distal radius is important as it is the most sensitive site for detecting osteoporosis in PHPT. An indication for parathyroidectomy is confirmed in the case of hypercalcemia > 1.0 mg/dl (>0.25 mmol/l) above the upper limit of normal, hypercalciuria > 400 mg/day (>10 mmol/day), renal insufficiency, proven osteoporosis or age < 50 years. If none of these criteria are fulfilled and surgery is not desired by the patient, annual laboratory check-ups and assessment of BMD every 1-2 years are recommended.
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Ferrari C, Santo G, Mammucci P, Pisani AR, Sardaro A, Rubini G. Diagnostic Value of Choline PET in the Preoperative Localization of Hyperfunctioning Parathyroid Gland(s): A Comprehensive Overview. Biomedicines 2021; 9:biomedicines9030231. [PMID: 33669104 PMCID: PMC7996619 DOI: 10.3390/biomedicines9030231] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 02/13/2021] [Accepted: 02/18/2021] [Indexed: 12/03/2022] Open
Abstract
Hyperparathyroidism is a metabolic disorder characterized by the excessive production of the parathyroid hormone. The diagnosis is based on clinical and laboratory data. In most cases the only treatment is surgery and a correct preoperatory localization of the hyperfunctioning parathyroid gland(s) is essential. Currently, ultrasonography combined with [99mTc]Tc-MIBI parathyroid scintigraphy, optionally associated with single photon emission computed tomography/computed tomography (SPECT/CT), represent the standard preoperative imaging. In recent years, a number of studies have evaluated the potential role of choline positron emission tomography (PET) in hyperparathyroidism with promising results. Most of the recent evidence underlined its higher sensitivity and diagnostic accuracy in the localization of hyperfunctioning parathyroid glands. Choline PET has a higher spatial resolution that is useful for the detection of smaller parathyroid glands and it also has shorter examination times and favorable radiation exposure. These are just a few of the aspects that support it to overcome traditional imaging. Moreover, from the preliminary data, the choline uptake mechanism seems to also have an impact on its better performance. For these reasons, if first used as second level imaging in patients with negative or inconclusive traditional imaging results, several authors have supported its use as a first line investigation. This comprehensive overview aims to provide an accurate description of the preliminary results available in the literature about the use of choline PET/CT in hyperparathyroidism and to compare these results with the performance of traditional imaging methods.
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Affiliation(s)
- Cristina Ferrari
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Giulia Santo
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Paolo Mammucci
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Antonio Rosario Pisani
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
| | - Angela Sardaro
- Section of Radiology and Radiation Oncology, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy
- Correspondence:
| | - Giuseppe Rubini
- Nuclear Medicine Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Piazza Giulio Cesare 11, 70124 Bari, Italy; (C.F.); (G.S.); (P.M.); (A.R.P.); (G.R.)
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Giovanella L, Bacigalupo L, Treglia G, Piccardo A. Will 18F-fluorocholine PET/CT replace other methods of preoperative parathyroid imaging? Endocrine 2021; 71:285-297. [PMID: 32892309 DOI: 10.1007/s12020-020-02487-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/28/2020] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a common endocrine disorder usually due to hyperfunctioning parathyroid glands (HPs). Surgical removal of the HPs is the main treatment for PHPT, making the correct detection and localization of HPs crucial to guiding targeted and minimally invasive surgical treatment in patients with PHPT. To date, different imaging methods have been used to detect and localize HPs, including radiology, nuclear medicine, and hybrid techniques. METHODS The present work discusses the role and value of different imaging methods in PHPT and, particularly, evaluates the potential role of 18F-fluorcholine PET/CT as a "one-stop-shop" method for preoperative parathyroid localization in patients with PHPT. DISCUSSION Cervical ultrasound (US) and parathyroid scintigraphy using 99mTc-MIBI are the most commonly employed methods in clinical practice. More recently, four-dimensional computed tomography (4D CT) and positron emission tomography (PET) with radiolabeled choline have emerged as useful alternatives in cases of negative or discordant findings from first-line imaging methods. CONCLUSIONS Due to the excellent diagnostic performance of radiolabeled choline PET/CT and the low radiation burden, this technique seems to be an ideal candidate to substitute current imaging procedures including US, MIBI scintigraphy, 4D CT and MRI and perform a fast and reliable "one-stop-shop" preoperative localization of HP in patients with PHPT, including challenging cases of postoperative persistent/recurrent disease.
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Affiliation(s)
- Luca Giovanella
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland.
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland.
| | - Lorenzo Bacigalupo
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Ente Ospedaliero Galliera, Genova, Italy
| | - Giorgio Treglia
- Clinic for Nuclear Medicine and Molecular Imaging, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Research and Innovation Service, Academic Education, Research and Innovation Area, General Directorate, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arnoldo Piccardo
- Department of Diagnostic Imaging, Radiology and Nuclear Medicine, Ente Ospedaliero Galliera, Genova, Italy
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Mukhtar NN, Abouzied MEDM, Alqahtani MH, Hammami MM. Misleading localization by 18F-fluorocholine PET/CT in familial hypocalciuric hypercalcemia type-3: a case report. BMC Endocr Disord 2021; 21:20. [PMID: 33499837 PMCID: PMC7836468 DOI: 10.1186/s12902-021-00683-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 01/19/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Familial hypocalciuric hypercalcemia (FHH) is a heterogeneous autosomal-dominant disorder of calcium hemostasis that may be difficult to distinguish clinically from mild primary hyperparathyroidism. Loss-of-function mutations mainly involving Arg15 residue of the adaptor-related protein complex 2, sigma subunit 1 (AP2S1) cause a rarer, more recently recognized form of FHH, FFH type-3. Recently, 18F-fluorocholine positron emission tomography/computed tomography (FCH-PET/CT) showed superior sensitivity to conventional imaging in localizing parathyroid adenomas. We report a new FFH type-3 patient who underwent unnecessary parathyroidectomy in association with misleading FCH-PET/CT imaging. CASE PRESENTATION A 29-year old woman was initially evaluated for parathyroid hormone (PTH)-dependent hypercalcemia in 2013. Medical history was positive only for chronic constipation and malaise with no personal or family history of hypercalcemia, kidney stones, or neck surgery. Over seven years, serum calcium level was 2.51-2.89 mmol/L with concomitant PTH level of 58.7-94.8 mmol/L. Serum phosphate levels were in the low/low normal range. Serum creatinine and magnesium levels were normal. 25-hydroxy vitamin D level was 13 nmol/L. 24-hour urine calcium level was 1.92 mmol/day but increased to 6.99 mmol/day after treatment with cholecalciferol 1000 IU daily. Bone mineral density and renal ultrasound were normal. Parathyroid ultrasound showed two hypoechoic nodules inferior to the left and right thyroid lobes; however, 99mtechnitium-sestamibi scans (2013, 2016, 2018) were negative. FCH-PET/CT (2019) showed focal uptake co-localizing with the nodule inferior to the left thyroid lobe. The patient underwent left inferior parathyroidectomy and pathology was consistent with parathyroid hyperplasia. However, postoperatively, serum calcium and PTH levels remained elevated and FCH-PET/CT and ultrasound showed persistence of the uptake/nodule. Whole exome sequencing showed Arg15Cys mutation in the AP2S1 gene characteristic of FHH type-3. CONCLUSIONS In this new case of FHH type-3, FCH-PET/CT failed to localize to the hyperplastic parathyroid glands and localized instead to apparently a lymph node. This, together with increased urinary calcium after vitamin D supplementation, led to unnecessary parathyroidectomy. Given the increasingly lower cost of genetic testing and the cost of follow up and unnecessary surgery, it may prudent to include genetic testing for FHH early on in patients with mild PTH-dependent hypercalcemia.
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Affiliation(s)
- Noha N Mukhtar
- Department of Medicine , King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Mohammed H Alqahtani
- Department of Cyclotron and Radiopharmaceuticals, Alfaisal University, Riyadh, Saudi Arabia
| | - Muhammad M Hammami
- Department of Medicine , King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
- Department of Clinical Studies and Empirical Ethics, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), 11211 Riyadh, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
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Gök İ, Şahbaz NA, Akarsu C, Cem Dural A, Mert M, Erbahçeci Salık FA, Çil BE, Güzey D, Alış H. The role of selective venous sampling in patients with non-localized primary hyperparathyroidism. Turk J Surg 2020; 36:164-171. [PMID: 33015561 DOI: 10.5578/turkjsurg.4335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 05/01/2019] [Indexed: 11/15/2022]
Abstract
Objectives The aim of this observational clinical study was to evaluate the success of angiographic selective venous sampling (ASVS) in locating parathyroid adenoma in patients with primary hyperparathyroidism (PHPT), in whom the other imaging modalities have failed, and and to evaluate its possible contribution to the applicability of minimal invasive surgery. Material and Methods Fifty-five patients who were admitted to our hospital's General Surgery department between January 2012 and January 2015 for PHPT in whom ultrasound and sestamibi scintigraphy have failed to localize the diseased gland were included to the study. Patients were divided into two groups: those who underwent ASVS and those who did not. The outcomes of patients were reviewed retrospectively. Results Among 55 patients, 20 underwent ASVS. ASVS successfully lateralized the diseased gland in 17 (85%) patients, and minimally invasive parathyroidectomy could be performed in 14 (70%) patients. The cut-off value of parathormon gradient was considered 10% for lateralization and the accuracy of ASVS in lateralization was 94.1%. In 11 (59%) patients, the superior-inferior discrimination could be achieved in addition to lateralization. Conclusion ASVS has a high sensitivity in locating the diseased gland in patients with PHPT in whom ultrasound and sestamibi scan have failed, and thereby, rendering the performance of minimally invasive surgery possible. Further studies may reveal the role of ASVS in providing useful information about not only lateralization but also the superior-inferior discrimination.
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Affiliation(s)
- İlhan Gök
- Department of General Surgery, Buyukcekmece Mimar Sinan State Hospital, Istanbul, Turkey
| | - Nuri Alper Şahbaz
- Department of General Surgery, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Cevher Akarsu
- Department of General Surgery, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Ahmet Cem Dural
- Department of General Surgery, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Meral Mert
- Department of Endocrinology and Metabolism, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Fatma Aysun Erbahçeci Salık
- Department of Interventional Radiology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Barbaros Erhan Çil
- Department of Interventional Radiology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Deniz Güzey
- Department of General Surgery, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Halil Alış
- Department of General Surgery, İ.A.Ü. VM Medical Park Florya Hospital, Istanbul, Turkey
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Boccalatte L, Gómez N, Musumeci M, Galich A, Collaud C, Figari M. 18F-choline PET/4D CT in hyperparathyroidism: correlation between biochemical data and study parameters. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Evangelista L, Ravelli I, Magnani F, Iacobone M, Giraudo C, Camozzi V, Spimpolo A, Cecchin D. 18F-choline PET/CT and PET/MRI in primary and recurrent hyperparathyroidism: a systematic review of the literature. Ann Nucl Med 2020; 34:601-619. [PMID: 32767248 PMCID: PMC7438295 DOI: 10.1007/s12149-020-01507-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 07/26/2020] [Indexed: 12/12/2022]
Abstract
The aims of the present systematic review were to: (1) assess the role of 18F-fluorocholine (FCH) positron emission tomography (PET) with computed tomography (CT) and PET with magnetic resonance imaging (MRI) in patients with biochemically known hyperparathyroidism; (2) compare the diagnostic performance of FCH PET/CT or PET/MRI with conventional morphological and functional imaging. A literature search until December 2019 was performed in the PubMed, Scopus and Web of Science databases, using the terms “choline” AND “PET” AND “hyperparathyroidism”. The search was conducted with and without the addition of filters (e.g., language: English only; type of article: original article; subjects: humans only) and selecting only articles published in the last 5 years. Twenty-three articles and 1112 patients were considered. Different FCH PET/CT acquisition protocols were adopted across the studies, using dynamic, early or delayed scans. FCH PET/CT proved more accurate than ultrasonography (US) or 99mTc-sestamibi single-photon emission tomography (SPET). PET/MRI also seemed to be more accurate than MRI alone in detecting benign parathyroid lesions. FCH PET/CT is more accurate than conventional morphological and functional imaging modalities (US or SPET) for the detection of benign parathyroid lesions. It could, therefore, be a reliable tool in both primary and recurrent hyperparathyroidism.
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Affiliation(s)
- Laura Evangelista
- Nuclear Medicine Unit, Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
| | - Ilaria Ravelli
- Nuclear Medicine Unit, Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Fabio Magnani
- Nuclear Medicine Unit, Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - Maurizio Iacobone
- Surgery Unit, Department of Surgery, University of Padova, Padua, Italy
| | - Chiara Giraudo
- Radiology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Valentina Camozzi
- Endocrine Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Alessandro Spimpolo
- Nuclear Medicine Unit, Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy.,Surgery Unit, Department of Surgery, University of Padova, Padua, Italy.,Radiology Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy.,Endocrine Unit, Department of Medicine (DIMED), University of Padova, Padua, Italy.,International PhD Program in Arterial Hypertension and Vascular Biology (ARHYVAB), Department of Medicine (DIMED), University of Padova, Padua, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128, Padua, Italy
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18F-Fluorocholine PET and Multiphase CT Integrated in Dual Modality PET/4D-CT for Preoperative Evaluation of Primary Hyperparathyroidism. J Clin Med 2020; 9:jcm9062005. [PMID: 32604786 PMCID: PMC7356908 DOI: 10.3390/jcm9062005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/16/2020] [Accepted: 06/24/2020] [Indexed: 12/11/2022] Open
Abstract
The present retrospective study evaluates the diagnostic value of integrated 18F-Fluorocholine positron emission tomography/four-dimensional contrast-enhanced computed tomography (18F-FCH PET/4D-CT) as second-line imaging in preoperative work-up of primary hyperparathyroidism (pHPT), and compares 18F-FCH PET with 4D-CT. Patients with pHPT and negative/discordant first-line imaging addressed for integrated 18F-FCH PET/4D-CT were retrospectively selected. Sensitivity and detection rate (DR%) of 18F-FCH PET/CT, 4D-CT, and PET/4D-CT were calculated according to the per patient and per lesion analyses, and afterwards compared. Histology associated with a decrease more than 50% of perioperative parathyroid hormone (PTH) blood level was used as a gold standard. Persistent high serum PTH and calcium levels during a 6-month follow-up was considered as presence of pHPT in both operated and non-operated patients. 50 patients (55 glands) were included. 44/50 patients (88%) were surgically treated. On a per patient analysis, sensitivity was 93%, 80%, and 95%, and DR% was 82%, 68%, and 84%, respectively for PET/CT, 4D-CT, and PET/4D-CT. PET/CT was more sensitive than 4D-CT (p = 0.046). PET/4D-CT performed better than 4D-CT (p = 0.013) but was equivalent to PET/CT alone. On a per gland analysis, sensitivity PET/CT, 4D-CT, and PET/4D-CT was 88%, 66%, and 92%, and DR% was 79%, 57%, and 83%, respectively. PET/CT and PET/4D-CT were more sensitive than 4D-CT alone (p = 0.01, p < 0.001, respectively). However, PET/CT and PET/4D-CT performed similarly. In conclusion, 18F-FCH PET provides better identification of hyperfunctioning parathyroids than 4D-CT and the combination of both did not significantly improve diagnostic sensitivity. Further investigations involving larger populations are necessary to define the role of 18F-FCH PET/4D-CT as a “one-stop shop” second-line imaging in preoperative work-up of pHPT, especially considering the additional patient radiation exposure due to multi-phase CT.
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Boccalatte LA, Gómez NL, Musumeci M, Galich AM, Collaud C, Figari MF. 18F-choline PET/4D CT in hyperparathyroidism: correlation between biochemical data and study parameters. Rev Esp Med Nucl Imagen Mol 2020; 39:273-278. [PMID: 32540340 DOI: 10.1016/j.remn.2020.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hyperparathyroidism (HPT) is characterised by increased levels of parathyroid hormone (HPT), surgical excision being the only definitive curative option. After establishing the need for surgery, it is essential to identify the parathyroid glands in the preoperative period to use a minimally invasive approach. Negativity and / or discrepancy in first-line studies (ultrasound and Tc-99m MIBI parathyroid scintigraphy) require more accurate images to reduce the likelihood of bilateral cervical exploration or reintervention. OBJECTIVES a) To demonstrate the sensitivity of 18F-fluorocholine (18F-choline) positron emission tomography (PET)/4D computed tomography (4D CT) in HPT. b) To check whether there is a correlation between calcaemia and preoperative PTH versus size and early and late SUVmax (Standardized Uptake Value) of the gland, determined by 18F-choline PET/4D CT and c) to study the behaviour of parathyroid lesions with intravenous contrast (IV). MATERIAL AND METHODS A total of 28 patients were included between 2016 and 2019 in a single institution. Prospective observational cohort study. Correlations were analysed using Pearson's coefficient for variables with normal distribution and Spearman (rho) for those with non-normal distribution. Anatomopathological analysis was the benchmark standard to determine sensitivity was. A p<.05 was interpreted as significant. STATA 13 software was used. RESULTS Of the 28 patients who underwent 18F-choline PET/4D CT, 18 were operated. Of the 26 lesions diagnosed by 18F-choline PET/4D CT as suggestive of parathyroid lesions, 23 corresponded to glandular disease (adenoma or hyperplasia) establishing a sensitivity of 88.5%. There was a correlation between the patient's preoperative PTH and the maximum size of the gland on 18F-choline PET/4D CT. (Spearman=.66; p=.0014). The parathyroid lesions showed, in addition to IV contrast enhancement, distinctive behavioural characteristics identified as highly suggestive. CONCLUSIONS 18F-choline PET/CT 4D is an anatomical and functional study with high sensitivity in patients with HPT with negative or discrepant first-line studies. Preoperative PTH showed a correlation with maximum gland size on 18F-choline PET/CT 4D. Parathyroid lesions behave in a highly suggestive way and are enhanced by IV contrast.
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Affiliation(s)
- L A Boccalatte
- Sección Cirugía de Cabeza y Cuello, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - N L Gómez
- Sección Cirugía de Cabeza y Cuello, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M Musumeci
- Medicina Nuclear, Servicio de Diagnóstico por Imágenes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - A M Galich
- Sección Metabolismo Fosfocálcico, Servicio de Endocrinología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - C Collaud
- Medicina Nuclear, Servicio de Diagnóstico por Imágenes, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - M F Figari
- Sección Cirugía de Cabeza y Cuello, Servicio de Cirugía General, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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47
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Pre-operative Localisation of the Parathyroid Glands in Secondary Hyperparathyroidism: A Retrospective Cohort Study. Sci Rep 2019; 9:14634. [PMID: 31602011 PMCID: PMC6787184 DOI: 10.1038/s41598-019-51265-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 09/29/2019] [Indexed: 12/11/2022] Open
Abstract
Complete parathyroidectomy (PTx) is essential during total PTx for secondary hyperparathyroidism (SHPT) to prevent recurrent and persistent hyperparathyroidism. Pre-operative imaging evaluations, including computed tomography (CT), ultrasonography (US), and Tc-99m sestamibi (MIBI) scans, are commonly performed. Between June 2009 and January 2016, 291 patients underwent PTx for SHPT after pre-operative evaluations involving CT, US, and MIBI scans, and the diagnostic accuracies of these imaging modalities for identifying the parathyroid glands were evaluated in 177 patients whose intact parathyroid hormone (PTH) levels were <9 pg/mL after the initial PTx. Additional PTx procedures were performed on 7 of 114 patients whose intact PTH levels were >9 ng/mL after PTx, and the diagnostic validities of the imaging modalities for the remnant parathyroid glands were evaluated. A combination of CT, US, and MIBI scans achieved the highest diagnostic accuracy (75%) for locating bilateral upper and lower parathyroid glands before initial PTx. The accuracies of CT, US, and MIBI scans with respect to locating remnant parathyroid glands before additional PTx were 100%, 28.6%, and 100%, respectively. A combination of CT, US, and MIBI scans is useful for initial PTx for SHPT, and CT and MIBI scans are useful imaging modalities for additional PTx procedures.
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48
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Liu Y, Dang Y, Huo L, Hu Y, Wang O, Liu H, Chang X, Liu Y, Xing X, Li F, Liao Q, Hacker M, Li X, Kreissl MC. Preoperative Localization of Adenomas in Primary Hyperparathyroidism: The Value of 11C-Choline PET/CT in Patients with Negative or Discordant Findings on Ultrasonography and 99mTc-Sestamibi SPECT/CT. J Nucl Med 2019; 61:584-589. [PMID: 31601698 DOI: 10.2967/jnumed.119.233213] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We aimed to assess the value of 11C-choline PET in patients with primary hyperparathyroidism and negative or discordant results on 99mTc-sestamibi imaging and neck ultrasound. Methods: Eighty-seven such patients were assessed and subsequently underwent parathyroidectomy. PET/CT image data were analyzed semiquantitatively using SUVmax and SUV ratios (target to contralateral thyroid gland and carotid artery). A positive PET/CT result was defined as focal uptake significantly higher than regular thyroid tissue. Ectopic foci were also considered positive. Inconclusive PET/CT cases were defined as a lesion with uptake equal to normal thyroid tissue. If no prominent or ectopic uptake was detectable, the PET/CT result was considered negative. Results: When dichotomizing the 11C-choline PET/CT imaging results by defining lesions with both positive and inconclusive uptake as positive, we found 84 of 92 lesions (91.3%) to have true-positive uptake whereas 8 lesions (8.7%) had false-positive uptake. One lesion showed false-negative uptake; the sensitivity was 98.8%. The corresponding positive predictive value for lesions was 91.3%. The mean SUVmax was 6.15 ± 4.92 in 72 lesions with positive uptake (70 patients) and 2.96 ± 2.32 in 20 lesions with inconclusive uptake (18 patients). Conclusion: These results in a large group of patients indicate that 11C-choline PET/CT is a promising tool for parathyroid adenoma localization when ultrasound and 99mTc-sestamibi imaging yield negative or discordant results.
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Affiliation(s)
- Yimin Liu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China.,Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Yonghong Dang
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China.,Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China.,Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Ya Hu
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - Ou Wang
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - He Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - Xiaoyan Chang
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - Yu Liu
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China.,Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Xiaoping Xing
- Department of Endocrinology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - Fang Li
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China.,Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Beijing, China
| | - Quan Liao
- Department of Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Peking, China
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria; and
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria; and
| | - Michael C Kreissl
- Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Magdeburg, Germany
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Cuderman A, Senica K, Rep S, Hocevar M, Kocjan T, Sever MJ, Zaletel K, Lezaic L. 18F-Fluorocholine PET/CT in Primary Hyperparathyroidism: Superior Diagnostic Performance to Conventional Scintigraphic Imaging for Localization of Hyperfunctioning Parathyroid Glands. J Nucl Med 2019; 61:577-583. [DOI: 10.2967/jnumed.119.229914] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 08/12/2019] [Indexed: 12/22/2022] Open
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50
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Boccalatte LA, Higuera F, Gómez NL, de la Torre AY, Mazzaro EL, Galich AM, Collaud C, Figari MF. Usefulness of18F-Fluorocholine Positron Emission Tomography–Computed Tomography in Locating Lesions in Hyperparathyroidism. JAMA Otolaryngol Head Neck Surg 2019; 145:743-750. [DOI: 10.1001/jamaoto.2019.0574] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Felipe Higuera
- Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Natalia Lucía Gómez
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Eduardo Luis Mazzaro
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ana María Galich
- Department of Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Carlos Collaud
- Department of Nuclear Medicine, Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo Fernando Figari
- Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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