title: Enabling minimal invasive parathyroidectomy for patients with primary hyperparathyroidism using Tc-99m-sestamibi SPECT-CT, ultrasound and first results of (18)F-fluorocholine PET-CT.
abstract: OBJECTIVE
  Assessment of the diagnostic value of ultrasound (US), single photon-emission computed tomography-computed tomography (SPECT-CT) and (18)F-fluorocholine (FCH) PET-CT for preoperative localization of hyper-functioning parathyroid(s) in order to create a more efficient diagnostic pathway and enable minimal invasive parathyroidectomy (MIP) in patients with biochemical proven non-familial primary hyperparathyroidism (pHPT).
  
  
  METHODS
  A single-institution retrospective study of 63 consecutive patients with a biochemical diagnosis of non-familial pHPT who received a Tc-99m-sestamibi SPECT-CT and neck ultrasound. Surgical findings were used in calculating the sensitivity and the positive predictive value (PPV) of both imaging modalities. Furthermore we present 5 cases who received additional FCH PET-CT.
  
  
  RESULTS
  A total of 42 (66.7%) patients underwent MIP. The PPV and sensitivity of SPECT-CT, 93.0% and 80.3%, were significantly higher than those of US with 78.3% and 63.2%, respectively. Adding US to SPECT-CT for initial pre-operative localization did not significantly increase sensitivity but did significantly decrease PPV. Performance of US was significantly better when performed after SPECT-CT. (18)F-fluorocholine PET-CT localized the hyper-functioning parathyroid gland in 4/5 cases with discordant conventional imaging, enabling MIP.
  
  
  CONCLUSIONS
  SPECT-CT is the imaging modality of choice for initial pre-operative localization of hyper-functioning parathyroid gland(s) in patients with biochemical pHPT. Ultrasound should be performed after SPECT-CT for confirmation of positive SPECT-CT findings and for pre-operative marking allowing MIP. In cases with negative or discordant imaging additional FCH PET-CT should be considered since this might enable the surgeon to perform MIP.
authors.affiliation: Department of Endocrine Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: WPKluijfhout@gmail.com.
authors.forename: Wouter P
authors.initials: WP
authors.lastname: Kluijfhout
authors.affiliation: Department of Endocrine Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: W.M.Vorselaars@umcutrecht.nl.
authors.forename: Wessel M C M
authors.initials: WM
authors.lastname: Vorselaars
authors.affiliation: Department of Endocrine Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: mvriens@umcutrecht.nl.
authors.forename: Menno R
authors.initials: MR
authors.lastname: Vriens
authors.affiliation: Department of Endocrine Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: I.H.M.BorelRinkes@umcutrecht.nl.
authors.forename: Inne H M
authors.initials: IH
authors.lastname: Borel Rinkes
authors.affiliation: Department of Endocrinology, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: G.D.Valk@umcutrecht.nl.
authors.forename: Gerlof D
authors.initials: GD
authors.lastname: Valk
authors.affiliation: Department of Nuclear Medicine and Radiology, University Medical Center Utrecht, Utrecht, The Netherlands. Electronic address: B.deKeizer@umcutrecht.nl.
authors.forename: Bart
authors.initials: B
authors.lastname: de Keizer
mesh_terms: D002794:Choline / Q000031:analogs & derivatives*; D003952:Diagnostic Imaging / Q000379:methods*; D005260:Female; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D064847:Multimodal Imaging; D010280:Parathyroid Glands / Q000000981:diagnostic imaging; D016105:Parathyroidectomy; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D012189:Retrospective Studies; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon; D014057:Tomography, X-Ray Computed; D014463:Ultrasonography
chemical_list: D019275:Radiopharmaceuticals; C514960:fluorocholine; D017256:Technetium Tc 99m Sestamibi; D002794:Choline
keywords: (18)F-fluorocholine; PET–CT; Primary hyperparathyroidism; SPECT–CT; Tc99m-sestamibi; Ultrasound