Update on Preoperative Parathyroid Localization in Primary Hyperparathyroidism

Abstract

Parathyroidectomy is the treatment of choice for primary hyperparathyroidism when the clinical criteria are met. Although bilateral neck exploration is traditionally the standard method for surgery, minimally invasive parathyroidectomy (MIP), or focused parathyroidectomy, has been widely accepted with comparable curative outcomes. For successful MIP, accurate preoperative localization of parathyroid lesions is essential. However, no consensus exists on the optimal approach for localization. Currently, ultrasonography and technetium-99m-sestamibi-single photon emission computed tomography/computed tomography are widely accepted in most cases. However, exact localization cannot always be achieved, especially in cases with multiglandular disease, ectopic glands, recurrent disease, and normocalcemic primary hyperparathyroidism. Therefore, new modalities for preoperative localization have been developed and evaluated. Positron emission tomography/computed tomography and parathyroid venous sampling have demonstrated improvements in sensitivity and accuracy. Both anatomical and functional information can be obtained by combining these methods. As each approach has its advantages and disadvantages, the localization study should be deliberately chosen based on each patient's clinical profile, costs, radiation exposure, and the availability of experienced experts. In this review, we summarize various methods for the localization of hyperfunctioning parathyroid tissues in primary hyperparathyroidism.

Keywords: Four-dimensional computed tomography; Hyperparathyroidism, primary; Radionuclide imaging; Ultrasonography.

Fig. 1.

Possible preoperative localization process for primary hyperparathyroidism. Dashed lines (---): Choline-positron emission tomography (PET) could be preferred to ¹¹C-methionine (MET)-PET. Dot-dashed lines (─·─·): This process could be chosen with an experienced parathyroid surgeon. PHPT, primary hyperparathyroidism; SPECT/CT, single photon emission computed tomography/computed tomography; PVS, parathyroid venous sampling; 4D-CT, four-dimensional computed tomography; PET/CT, positron emission tomography/computed tomography. ^aWhen a patient is referred to a high-volume center, this process might be followed.