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Review
May 30, 2019

Usefulness of 18F-Fluorocholine Positron Emission Tomography–Computed Tomography in Locating Lesions in Hyperparathyroidism: A Systematic Review

Author Affiliations
  • 1Department of Head and Neck Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
  • 2Department of General Surgery, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
  • 3Department of Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
  • 4Department of Nuclear Medicine, Endocrinology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
JAMA Otolaryngol Head Neck Surg. 2019;145(8):743-750. doi:10.1001/jamaoto.2019.0574
Key Points

Question  What is the practical use of 18F-fluorocholine positron emission tomography–computed tomography as an anatomic and functional test in hyperparathyroidism?

Findings  This systematic review of 16 studies found that 18F-fluorocholine positron emission tomography–computed tomography has high sensitivity, specificity, positive predictive value, and diagnostic accuracy compared with first-line tests, where concomitant thyroid disease or ectopic glands may decrease such indices. It is a second-line test when the results of ultrasonography and sestamibi scans are negative or discordant.

Meaning  18F-fluorocholine positron emission tomography–computed tomography could be useful when there is clinical suspicion of hyperplasia, multiple lesions, persistent or recurrent hyperparathyroidism, small or ectopic adenomas, or normocalcemic hyperparathyroidism.

Abstract

Importance  Identifying parathyroid glands correctly before a surgical procedure is essential to perform minimally invasive surgery. First-line tests with discordant or negative results underscore the need for more accurate imaging tests, thus decreasing the requirement for bilateral neck exploration or reintervention.

Objective  To review the available evidence to determine positive predictive value, negative predictive value, sensitivity, and specificity in clinical cases in which 18F-fluorocholine positron emission tomography–computed tomography (PET/CT) could be useful as a method to locate the lesions, and the benefits and controversial aspects of the method.

Evidence Review  A search was conducted using the PubMed Central and Cochrane Library databases for studies published in English from July 26, 2014, to November 30, 2018, using the search terms 18 choline, 18F choline, 18F-choline, 18 fluorocholine PET CT, hyperparathyroidism, primary hyperparathyroidism, secondary hyperparathyroidism, tertiary hyperparathyroidism, persistent hyperparathyroidism, recurrent hyperparathyroidism, ectopic hyperparathyroidism, and parathyroid adenoma. Other inclusion criteria were reporting at least 1 of the following measurements: negative or positive predictive value, sensitivity, and specificity of 18F-fluorocholine PET/CT in the diagnosis of hyperparathyroidism (HPT). Exclusion criteria were language other than English, use of a tracer other than 18F-fluorocholine, reports of a single case, and studies not related to HPT. The Oxford Centre classifications for levels of evidence were used.

Findings  Sixteen studies fulfilled the inclusion criteria, comprising a total of 619 patients. Selected studies included 10 prospective cohort studies, 5 retrospective cohort studies, and 1 case series. Of the subtypes of HPT diagnosed using 18F-fluorocholine PET/CT, 579 were primary HPT, 22 were secondary HPT, 1 was tertiary HPT, and 7 were associated with multiple endocrine neoplasia type I. Pathologically, the neoplasms comprised 459 adenomas, 59 hyperplasia, and 19 double adenomas.

Conclusions and Relevance  18F-fluorcholine PET/CT may be indicated when results of first-line tests are negative or discordant and in challenging clinical situations where locating the source of HPT is difficult.

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