Usefulness of PET/CT with Carbon-11-Labeled Methionine in the Diagnosis of Tertiary Hyperparathyroidism

Abstract

Introduction: Tertiary hyperparathyroidism (tHP) may develop in patients treated with hemodialysis or peritoneal dialysis. Parathyroidectomy may result in a significant reduction in the severity of symptoms. For the effective surgical treatment of hyperparathyroidism, proper localization of the parathyroid glands prior to surgery is essential. The sensitivity of scintigraphy in the diagnosis of tHP is lower than in the diagnosis of primary hyperparathyroidism. In recent years, positron emission tomography (PET/CT) has been gaining importance, usually as a complementary technique. Aim: The aim of this study was to determine the usefulness of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tertiary hyperparathyroidism caused by chronic kidney disease, in whom first-line diagnostic methods did not allow the localization of pathologically parathyroid glands. Material and methods: The study was conducted in a group of 19 adult patients with severe tHP who were resistant or intolerant to non-invasive treatment, with negative results of scintigraphy and ultrasonography of the neck. The study protocol included measurement of the concentration of calcium, phosphorus, and PTH in the blood serum and performing PET/CT with [11C]MET. Results: A positive result of PET/CT was obtained in 89.5% of the patients (17/19). Parathyroidectomy was performed in 52.9% of the patients (9/17) with positive results of PET/CT with [11C]MET, which were fully consistent with the results of the histopathological examinations of the removed parathyroid glands. On this basis, the sensitivity of PET/CT with [11C]MET in the preoperative localization diagnosis of patients with tHP was found to be 100%. Multiple lesions were visualized in 57.9% of the patients (11/19). Ectopic lesions were visualized in 21.1% of the patients (4/19). Conclusions: PET/CT with [11C]MET is a sensitive technique for the second-line preoperative imaging of parathyroid glands in patients with tertiary hyperparathyroidism in whom first-line examinations, such as ultrasound and scintigraphy, has failed.

18F-Fluorocholine PET/CT Compared with Current Imaging Procedures for Preoperative Localization of Hyperfunctioning Parathyroids in Patients with Chronic Kidney Disease

“…In nine operated patients, the sensitivity of PET/CT with 11C-MET in the preoperative localization of patients with tHPT was 100%. Multiple lesions were visualized in 11 and ectopic lesions in four of the 19 studied patients [ 32 ].…”

Endocrinology application of molecular imaging: current role of PET/CT

“…In the past, the most widely used amino acid for PET tumor imaging was [ 11 C]methionine [4]. Although the precise method of uptake by tumor cells remains somewhat unclear, it likely involves the transport of substrates across the tumor cell membrane [19]. [ 11 C]methionine has been used primarily for the study of brain tumors, where the use of [ 18 F]FDG can be problematic due to physiologically high uptake in normal gray matter of the brain [4].…”

“…Precise preoperative identification of parathyroid adenomas is crucial because minimally invasive surgery reduces surgical complications and expedites patients' recovery therefore preoperative imaging for parathyroid adenomas is of great importance [18]. In secondary hyperparathyroidism (sHPT) surgery is not recommended, while patients with tertiary hyperparathyroidism (tHPT) often undergo total or subtotal parathyroidectomy, therefore the identification of adenomatous glands may be useful to assist surgical planning [19]. Furthermore, persistence or recurrence of HPT after parathyroidectomy occurs in approximately 5-10% of patients [20].…”

“…All in all, [ 18 F]F-choline PET/CT is now considered the imaging method of choice in patients with tHPT due to its superior detection capability, also in cases of multiglandular disease and a low rate of localization failure of parathyroid adenoma [8]. Excellent sensitivity values of [ 11 C]methionine PET/CT were also reported in the tertiary HPT setting, where multiple lesions were visualized in 57.9% of patients and ectopic lesions in 21.1% of patients [19]. According to Bijnens et al, [ 18 F]F-choline PET/CT has proven to be a highly accurate method and obviates the need for extensive exploration in most cases where ultrasound and scintigraphy results do not align or both show negative results [21].…”