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Table of Contents
Year : 2016  |  Volume : 20  |  Issue : 6  |  Page : 888-890

Incremental role of 18F-fluorocholine PET/CT over technetium-99m-labeled MIBI scan in hyperparathyroidism

Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication24-Oct-2016

Correspondence Address:
Nishikant Avinash Damle
Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-8210.192897

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How to cite this article:
Behera A, Damle NA. Incremental role of 18F-fluorocholine PET/CT over technetium-99m-labeled MIBI scan in hyperparathyroidism. Indian J Endocr Metab 2016;20:888-90

How to cite this URL:
Behera A, Damle NA. Incremental role of 18F-fluorocholine PET/CT over technetium-99m-labeled MIBI scan in hyperparathyroidism. Indian J Endocr Metab [serial online] 2016 [cited 2021 Jul 26];20:888-90. Available from: https://www.ijem.in/text.asp?2016/20/6/888/192897


Primary hyperparathyroidism is a highly morbid condition and remains a disease curable by surgery in the vast majority of patients. Historically, bilateral neck exploration has been used as a method for surgical removal. However, since the Majority of patients have only one of the parathyroid glands enlarged, more focused minimally invasive parathyroidectomy is more commonly done.

This surgery requires very good presurgical parathyroid localization to be realized. Nuclear medicine studies have been at the forefront of parathyroid lesion localization for a very long time. Currently among the single-photon emission computed tomography (SPECT) tracers, the data supporting dual-phase technetium-99m (99m Tc)-sestamibi scintigraphy with early SPECT/CT is the most compelling. This technique has shown the highest sensitivity with good specificity and excellent histopathological correlation.[1],[2]

Various studies have reported the sensitivity of this technique between 77% and 89%.[3],[4] However, this technique also suffers from various shortcomings. These include a significant drop in sensitivity of the technique in very small parathyroid lesions, in postoperative patients, with thyroid adenomas and in certain adenomas with unusually fast sestamibi washout.[5],[6],[7]

Thus, In certain patients 99m Tc-Sestamibi dual phase with early SPECT/CT may be unable to localize parathyroid adenomas. Consequently, there has been a search for tracers which may potentially be able to improve upon the weaknesses of current investigations. Investigations such as 11 C-methionine positron emission tomography/CT (PET/CT) have shown good results.[8] In addition, radiological investigations such as ultrasonography and more recently four-dimensional computed tomography have been used for good effect in the preoperative localization of parathyroid lesions.

The most recent nuclear medicine technique to be used for this indication is 18 F-fluorocholine PET/CT. Initial studies with his tracer have yielded extremely promising results in research papers.[9],[10]

Even at our own institution, use of 18 F-fluorocholine PET/CT has been yielding encouraging results showing excellent correlation with final surgical histopathology findings.

A 58-year-old male patient with a nonsestamibi concentrating lesion on SPECT/CT and planar images underwent 18 F-fluorocholine PET/CT. On the PET images, the lesion was well localized and showed good radiotracer concentration. Subsequent surgical resection proved the lesion to be a parathyroid adenoma [Figure 1].
Figure 1: A 38-year-old patient of multiple endocrine neoplasia syndrome with two parathyroid lesions localized on technetium-99m-Sestamibi scan with early single-photon emission computed tomography/computed tomography. 18F-choline positron emission tomography/computed tomography of the same patient identified an additional parathyroid adenoma

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In addition, in another 38-year-old male patient with multiple endocrine neoplasia syndrome,99m Tc-sestamibi localized two parathyroid lesions and 18 F-fluorocholine PET/CT localized three lesions. Subsequent surgical pathology showed all three lesions to be parathyroid adenomas [Figure 2].
Figure 2: A 58-year-old male with suspected primary hyperparathyroidism underwent a technetium-99m-sestamibi scan with early single-photon emission computed tomography/computed tomography, with no definite localization of adenoma. 18F-choline positron emission tomography/computed tomography of the same patient localized the parathyroid adenoma

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These two cases exemplify the potential utility of this new investigation in primary hyperparathyroidism. This investigation may not just be useful in patients with the negative 99m Tc-sestamibi scan, but may even add regarding additional lesion detection in patients with already positive 99m Tc-sestamibi scans.

To conclude,18 F-fluorocholine PET/CT scans may have a potential role as a frontline investigation for localizing parathyroid adenomas and need further investigation in this role.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Lavely WC, Goetze S, Friedman KP, Leal JP, Zhang Z, Garret-Mayer E, et al. Comparison of SPECT/CT, SPECT, and planar imaging with single-and dual-phase (99m) Tc-sestamibi parathyroid scintigraphy. J Nucl Med 2007;48:1084-9.  Back to cited text no. 1
Slater A, Gleeson FV. Increased sensitivity and confidence of SPECT over planar imaging in dual-phase sestamibi for parathyroid adenoma detection. Clin Nucl Med 2005;30:1-3.  Back to cited text no. 2
Gayed IW, Kim EE, Broussard WF, Evans D, Lee J, Broemeling LD, et al. The value of 99mTc-sestamibi SPECT/CT over conventional SPECT in the evaluation of parathyroid adenomas or hyperplasia. J Nucl Med 2005;46:248-52.  Back to cited text no. 3
Shafiei B, Hoseinzadeh S, Fotouhi F, Malek H, Azizi F, Jahed A, et al. Preoperative 99 mTc-sestamibi scintigraphy in patients with primary hyperparathyroidism and concomitant nodular goiter: Comparison of SPECT-CT, SPECT, and planar imaging. Nucl Med Commun 2012;33:1070-6.  Back to cited text no. 4
Nichols KJ, Tomas MB, Tronco GG, Palestro CJ. Sestamibi parathyroid scintigraphy in multigland disease. Nucl Med Commun 2012;33:43-50.  Back to cited text no. 5
Witteveen JE, Kievit J, Stokkel MP, Morreau H, Romijn JA, Hamdy NA. Limitations of Tc99m-MIBI-SPECT imaging scans in persistent primary hyperparathyroidism. World J Surg 2011;35:128-39.  Back to cited text no. 6
Gupta Y, Ahmed R, Happerfield L, Pinder SE, Balan KK, Wishart GC. P-glycoprotein expression is associated with sestamibi washout in primary hyperparathyroidism. Br J Surg 2007;94:1491-5.  Back to cited text no. 7
Sundin A, Johansson C, Hellman P, Bergström M, Ahlström H, Jacobson GB, et al. PET and parathyroid L-[carbon-11]methionine accumulation in hyperparathyroidism. J Nucl Med 1996;37:1766-70.  Back to cited text no. 8
Michaud L, Balogova S, Burgess A, Ohnona J, Huchet V, Kerrou K, et al. A pilot comparison of 18F-fluorocholine PET/CT, ultrasonography and 123I/99mTc-sestaMIBI dual-phase dual-isotope scintigraphy in the preoperative localization of hyperfunctioning parathyroid glands in primary or secondary hyperparathyroidism: Influence of thyroid anomalies. Medicine (Baltimore) 2015;94:e1701.  Back to cited text no. 9
Lezaic L, Rep S, Sever MJ, Kocjan T, Hocevar M, Fettich J. 18 F-Fluorocholine PET/CT for localization of hyperfunctioning parathyroid tissue in primary hyperparathyroidism: A pilot study. Eur J Nucl Med Mol Imaging 2014;41:2083-9.  Back to cited text no. 10


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