Abstract
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Introduction: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder caused by hyperfunctioning of one or more parathyroid glands. Diagnosis of PHPT is based on biochemical tests showing elevated PTH levels and hypercalcemia. It is important to distinguish PHPT from malignancy, familial hypocalciuric hypercalcemia, side effects of drugs, such as lithium and thiazide diuretics and secondary hyperparathyroidism all of which can present similarly with elevated calcium and PTH levels. The role of parathyroid imaging is localization of the hyperfunctioning gland(s) for planning surgical resection. 18F-fluorocholine (FCH) positron emission tomography (PET) imaging using PET/MRI or PET/CT has demonstrated potential as an alternative modality for localization of parathyroid adenomas with superior performance as compared to cervical ultrasound or 99mTc-Sestamibi. The usefulness of FCH in parathyroid imaging was discovered incidentally while using the radiotracer to image prostate cancer, and the biochemical mechanism has not yet been fully elucidated. The current line of thought is that choline is a precursor for synthesis of the phospholipid component of cell membranes and cells with high proliferation/turnover rates have an increased uptake of choline due their increased metabolic demand. Choline can be labeled with radiotracer such as 18F allowing for imaging of tissues with high proliferation rates such as parathyroid adenomas/hyperplasias.
Objectives: The aim of this educational exhibit is to acquaint residents and clinicians with the fundamentals of FCH PET as well as review the radiotracer’s efficacy in detection of parathyroid lesions in the presence of primary hyperparathyroidism in comparison to other clinically available methods.
Methods: A scoping review of the literature was performed and instructive cases from the literature were selected to present a comprehensive review of FCH PET imaging for primary hyperparthyrodisim.
Results: In this review, we will discuss the current state of FCH PET imaging in localization of parathyroid adenomas with a major focus on: 1) the molecular biology basis of imaging parathyroid adenomas with FCH PET, 2) FCH PET imaging protocols, 3) comprehensive review of imaging features of lesions on FCH PET, 4) comparison of localization performance of parathyroid lesions on FCH PET with other imaging modalities, and 5) current limitations and future prospects of this imaging modality.
Conclusions: This review of FCH PET imaging of parathyroid lesions will provide the nuclear medicine community with a valuable resource to understand the fundamentals of this emerging imaging modality for guiding surgical treatment in patients with primary hyperparathyroidism.
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