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. 2025 Jul 31;17(7):e89110.
doi: 10.7759/cureus.89110. eCollection 2025 Jul.

Diagnostic Accuracy of 4D CT in Detecting Parathyroid Adenoma Compared With Ultrasound and Sestamibi SPECT/CT in Primary Hyperparathyroidism: A Retrospective Study

Somdatta Giri  1   2 , Krishnan Nagarajan  3 , Balamourougan Krishnaraj  4 , Debasis Gochhait  5 , Madhusudhanan Ponnusamy  6 , Anitha Sebastian  1 , Baskararaj Sriviruthi  3 , Jayaprakash Sahoo  1 , Sadishkumar Kamalanathan  1 , Dukhabandhu Naik  1
Affiliations

Diagnostic Accuracy of 4D CT in Detecting Parathyroid Adenoma Compared With Ultrasound and Sestamibi SPECT/CT in Primary Hyperparathyroidism: A Retrospective Study

Somdatta Giri et al. Cureus. .

Abstract

Background The accurate preoperative localization of parathyroid adenomas is crucial for minimally invasive parathyroidectomy (MIP) in primary hyperparathyroidism (PHPT). This study assessed the diagnostic performance of four-dimensional computed tomography (4D CT) in detecting parathyroid adenomas, compared with ultrasound (USG) and technetium methoxy isobutyl isonitrile single photon emission computed tomography (99mTc-sestamibi SPECT/CT). Methods We retrospectively analyzed 53 patients with biochemically confirmed PHPT who underwent all three preoperative imaging modalities, followed by parathyroidectomy from January 2020 to January 2025. Imaging findings were validated against intraoperative localization, histopathology, and intraoperative parathyroid hormone (PTH) dynamics. Multi-gland diseases were excluded. Sensitivity, positive predictive value (PPV), and concordance were calculated. Percentage arterial enhancement (PAE) was analyzed as a radiological marker. Results The mean age was 42.7 ± 14.7 years, with 29 (54.7%) women. Forty-nine (88.7%) patients had typical adenomas, three (0.05%) had carcinoma, and one (0.01%) had an atypical adenoma. The majority of lesions (24, 45%) were located in the right inferior parathyroid gland, followed by the left inferior (16, 30%). Overall, preoperative imaging was able to localize 50/53 (94.3%) lesions correctly. 4D CT correctly localized 45 lesions, outperforming USG and 99mTc-sestamibi SPECT/CT by identifying eight and 12 additional lesions, respectively. Sensitivity was highest for 4D CT (88.2%), followed by 99mTc-sestamibi SPECT/CT (82.4%) and USG (72.6%), with all three modalities showing high PPV (>94%). Among small adenomas (<20 mm), 4D CT demonstrated superior detection (21/21, 100%) compared to USG (16/21, 76.2%) and 99mTc-sestamibi SPECT/CT (15/21, 71.4%). Dynamic enhancement patterns on 4D CT distinguished adenomas from mimickers. However, applying a fixed PAE cutoff (128.9%), as previously proposed, yielded limited sensitivity (75%) and specificity (31.6%). Conclusion 4D CT outperformed USG and 99mTc-sestamibi SPECT/CT in localizing parathyroid adenomas in PHPT and was particularly useful when USG or 99mTc-sestamibi SPECT/CT results were inconclusive. While all three modalities showed high positive predictive value, 4D CT localized additional lesions missed by others. Its dynamic contrast patterns effectively differentiated adenomas from mimics. However, the utility of a fixed PAE cutoff was limited by protocol-dependent variability, indicating a need for tailored thresholds.

Keywords: diagnostic accuracy; four-dimensional computed tomography (4d ct); hyperparathyroidism primary; parathyroid gland adenoma; percentage arterial enhancement; spect/ct; ultrasound (usg).

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Conflict of interest statement

Human subjects: Informed consent for treatment and open access publication was obtained or waived by all participants in this study. The Institutional Ethics Committee for Observational Studies of the Jawaharlal Institute of Postgraduate Medical Education and Research issued approval JIP/IEC-O5120241445. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Flow Diagram Showing Preoperative Localization by Imaging.
4D CT, four-dimensional computed tomography; USG, ultrasound; 99mTC-sestamibi SPECT/CT, technetium methoxy isobutyl isonitrile single photon emission computed tomography
Figure 2
Figure 2. Dynamic Contrast Enhancement Curve of the Parathyroid Adenoma, Thyroid, and Lymph Node.
Parathyroid adenomas exhibited low baseline attenuation, marked arterial-phase enhancement, and venous wash-out. Thyroid tissue showed higher baseline HU, moderate arterial enhancement, and persistent venous-phase enhancement. Lymph nodes demonstrated low baseline HU with progressive enhancement peaking in the venous phase. Differences between parathyroid lesions and both thyroid and lymph nodes across phases were statistically significant (p<0.05).
Figure 3
Figure 3. 4D CT Scan for Parathyroid Lesion in a 46-Year-Old Man.
4D CT scan depicting a left inferior parathyroid adenoma measuring 3.6×2.1×2.1 cm, visualized in the plain (A), arterial (B), and venous (C) phases. The lesion demonstrates attenuation values of 48 HU, 112 HU, and 72 HU, respectively, across these phases. The percentage arterial enhancement (PAE) of the lesion was calculated to be 147.6%. 4D CT, four-dimensional computed tomography; HU, Hounsfield units
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