Intentional Imaging for Primary Hyperparathyroidism

Importance: Preoperative parathyroid localization has been a great advance in the success of surgery for patients with primary hyperparathyroidism (pHPT) over the past 40 years. Objective: To highlight the amount of radiation exposure from contemporary parathyroid imaging options and to suggest intentional imaging use in planning for parathyroidectomy. Evidence Review: Contemporary parathyroid imaging modalities and their respective radiation exposure were reviewed. The analysis focused on patients undergoing preoperative parathyroid imaging related to pHPT and persistent/recurrent pHPT. Exposure of patients to ionizing radiation from devices and radiotracers measured in mSv was reported. Findings: The parathyroid imaging recommendations include ultrasonography (0 mSv), technetium Tc 99m sestamibi single-photon emission computed tomography (SPECT) with or without computed tomography (CT) (8.6-12.1 mSv), and second-line/complex imaging for patients undergoing revision parathyroid surgery: 4-dimensional CT (9.3-20.2 mSv) or choline-based positron emission tomography (PET) with or without CT (6.7-11.8 mSv). Conclusions and Relevance: Imaging should be conducted only when the diagnosis is confirmed. When making decisions about imaging, consider radiation exposure, sensitivity/specificity for adenoma detection, local expertise in the imaging modality, and cost.