Choline pet localisation and surgical outcomes in reoperative parathyroidectomy: a 20-year single-surgeon experience

Abstract Background A retrospective chart review at a high-volume endocrine surgery centre was undertaken to evaluate the diagnostic accuracy of 18F-fluorocholine PET/CT in localisation of hyperfunctioning parathyroid gland(s) and its impact on surgical outcomes in re-operative parathyroidectomy for persistent or recurrent primary hyperparathyroidism. Method Adult patients with biochemically confirmed persistent or recurrent primary hyperparathyroidism were included from 2005 to 2025, encompassing MEN1 and lithiumassociated hyperparathyroidism. Patient demographics, operative case, imaging, intraoperative parathyroid hormone (IOPTH) monitoring, and surgical outcomes were analysed. Imaging modalities included neck ultrasonography, Sestamibi SPECT, 4D-CT, venous sampling, Methionine PET and Choline PET. Results A total of 114 patients underwent 124 re-operations: 71.8% for persistent and 28.2% for recurrent hyperparathyroidism. 55.3% of cases were referred from external institutions. Choline PET demonstrated the highest detection rate (97.3%), followed by invasive venous sampling (94.1%). Focused or unilateral exploration was possible in 76.6% of cases, with sternotomy required in 10.5%. IOPTH monitoring showed an adequate decrease in 85.7% of cases, correlating with biochemical cure in 95.8%. Multi-glandular disease and missed singlegland adenomas in eutopic positions were the leading causes of initial surgical failure. Complications were infrequent, with vocal cord palsy in 0.8% and long-term hypoparathyroidism in 4% of re-operations. Conclusion 18F-fluorocholine PET/CT is a highly accurate localisation tool for re-operative parathyroid surgery, surpassing other imaging modalities. Its use enables targeted surgical approaches and, when paired with IOPTH monitoring, leads to high cure rates and minimal morbidity. These findings support the use of choline PET/CT as the first-line imaging modality in reoperative settings.