The Significance of 18F-Fluorocholine-PET/CT as Localizing Imaging Technique in Patients with Primary Hyperparathyroidism and Negative Conventional Imaging

Abstract

ObjectiveThe essential prerequisite for focused parathyroidectomy in patients with primary hyperparathyroidism (pHPT) is proper localization of all autonomic tissue. Sensitivity of conventional imaging modalities (ultrasound, 99mTc-sestamibi scintigraphy/SPECT/CT) is influenced by different factors (i.e., size/weight and position of autonomic tissue) and decreases in the presence of a multinodular goiter. Therefore, a considerable percentage of pHPT patients have negative or equivocal localization studies before surgery. The aim of this study is to evaluate the utility of FCH-PET/CT for preoperative localization in patients with pHPT and negative/equivocal 99mTc-sestamibi scintigraphy/SPECT/CT and/or ultrasound.Methods and measurementsBetween 2014 and 2017, a total of 39 patients with pHPT and negative/equivocal conventional imaging were referred for FCH-PET/CT. In the analysis, we included those (n = 23) who had surgery and a histopathologic workup of the lesions.Results19 of 23 patients demonstrated no tracer uptake with 99mTc-sestamibi scintigraphy/SPECT/CT, 6 patients had an equivocal sonographic lesion, and multinodular goiter was present in 43% (10/23). In 21 of 23 patients, hyperfunctioning parathyroid tissue was identified correctly by FCH-PET/CT [21 true positive, 1 false negative, and 1 false positive; per-patient sensitivity 95.5% (95% confidence interval {CI}, 77.2–99.9)]. 29 lesions were resected [21 true positives, 3 false negatives, 1 false positive, and 4 true negatives; per-lesion sensitivity 87.5% (95% CI, 67.6–97.3)]. All patients were classified as having surgical success according to a decrease of intraoperative parathyroid hormone of ≥50% and normalization of postoperative serum calcium levels.ConclusionDespite a high prevalence of multinodular goiter, diagnostic accuracy of FCH-PET/CT in our patient group was excellent. Therefore, FCH-PET/CT is a promising new imaging tool in patients with pHPT and negative/equivocal results by conventional imaging techniques.

18F-choline PET/CT and PET/MRI in primary and recurrent hyperparathyroidism: a systematic review of the literature

“…Only Rep et al [25] reported scanning patients 3 times, at 5, 60 and 120 min after FCH injection. The FCH dosage was fixed in 16 studies, in the range of 100-230 MBq [15,[19][20][21][22][23][24][25][26][27][28][31][32][33][34]; it was adjusted to the patient's body weight in 5 (1.5-3.2 MBq/kg) and not declared in two studies [12,16,17,29,30].…”

“…Comparisons between FCH PET/CT and 99mTc-MIBI SPET/CT with a dual-phase and/or subtraction protocol were reported in numerous studies (Table 2; [4,[12][13][14][15][16][17][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33][34]).…”

“…10 min (100 MBq) Comparison among integrated FCH-PET/4DCeCT and FCH-PET/CT and 4DCeCT detection rate and sensitivity 4DCeCT Integrated FCH-PET/4DCeCT has a performance superior to that of FCH-PET/CT and 4DCeCT, separately Zajickova et al [ 22 ] 2018 Czech Republic 13 P 114.6 (78.9–145) ng/mL PHPT Stat. 30 ± 20 min (180 MBq) FCH PET/CT was performed after inconclusive neck US and MIBI SPET scintigraphy in patients with PHPT to localize abnormal parathyroid glands before surgery US and MIBI scintigraphy FCH correctly identified PTA and hyperplastic glands in 92% patients with previously inconclusive conventional imaging Fischli et al [ 23 ] 2018 Switzerland 39 R 168.39 ± 110.69 ng/mL PHPT Stat. 45 min (160 MBq) To evaluate the sensitivity and specificity of FCH-PET/CT for preoperative localization in patients with pHPT and negative or equivocal 99mTc-sestamibi scintigraphy and/or ultrasound None FCH-PET/CT provides an excellent sensitivity of > 90% per-patient and of > 87% per lesion-based level Amadou et al [ 4 ] 2019 France 29 R 122.81 ± 50.78 ng/mL PHPT Stat.…”

“…In particular, Michaud et al [ 13 ] and Kluijhout et al [ 14 ] ran a single dynamic acquisition lasting 10 min and 40 min, respectively; and Michaud et al and Prabhu et al [ 12 , 15 ] performed a dynamic acquisition for 10-15 min followed by a static image 10 or 45 min after the injection. Static acquisitions were obtained in the other studies at a single point ranging from 10 to 60 min after the intravenous administration of FCH in 9/23 studies [ 4 , 16 , 17 , 19 – 23 , 34 ]; and twice, first after 2–60 min and then after 60–120 min, in 10/23 studies. Only Rep et al [ 25 ] reported scanning patients 3 times, at 5, 60 and 120 min after FCH injection.…”

Diagnostic Value of Choline PET in the Preoperative Localization of Hyperfunctioning Parathyroid Gland(s): A Comprehensive Overview

“…In addition, in patients with autoimmune thyroid disease such as Hashimoto thyroiditis or Graves' disease a diffuse choline uptake in the thyroid gland can mask a possible parathyroid adenoma resulting in a false negative finding [3,[55][56][57]. However, another study documented that the presence of autoimmune thyroid disease did not compromise the use of choline PET/CT from an accurate localization of parathyroid adenoma [15,58].…”