18F-Choline PET/CT Localization in a 20-Year Experience of Re-Operative Parathyroidectomy.

IMPORTANCE

Reoperative parathyroidectomy is necessary in up to 10% of patients with persistent or recurrent primary hyperparathyroidism. Accurate preoperative localization is critical for surgical success and minimizing complications. Conventional imaging methods often yield inconclusive or false-negative results in this challenging patient population.

OBJECTIVE

To evaluate the diagnostic accuracy and clinical utility of 18F-fluorocholine positron emission tomography/computed tomography imaging compared to traditional imaging modalities of neck ultrasonography and 99mTechnetium-sestamibi parathyroid scintigraphy in patients undergoing reoperative parathyroidectomy.

DESIGN

Retrospective cohort study of patients undergoing reoperative parathyroidectomy over a 20-year period (2005-2025). Localization imaging modalities, operative approaches, intraoperative parathyroid hormone monitoring, and surgical outcomes were analyzed.

SETTING

Single tertiary referral center specializing in endocrine surgery with a high-volume parathyroidectomy practice.

PARTICIPANTS

114 consecutive adult patients (aged ≥ 18 years) were included who underwent 124 reoperative parathyroidectomy operations for biochemically confirmed persistent or recurrent primary hyperparathyroidism. Patients were included if there was lithium-associated hyperparathyroidism or multiple endocrine neoplasia type 1 syndrome.

MAIN OUTCOMES AND MEASURES: Primary outcome included localization detection rates of imaging modalities performed. Secondary outcomes included type of surgical approach utilized, cause of failure from the primary operation, intraoperative parathyroid hormone monitoring response, biochemical cure rate, and surgical complications.

RESULTS

18F-fluorocholine positron emission tomography/computed tomography demonstrated a detection rate of 95.2%, outperforming 11C-methionine positron emission tomography/computed tomography (63.6%), fludeoxyglucose-positron emission tomography/computed tomography (50.0%), and neck ultrasonography (21.6%). In 90.5% of cases with negative or inconclusive conventional imaging, 18F-fluorocholine positron emission tomography/computed tomography accurately localized pathological parathyroid gland(s). A focused surgical approach (sternotomy or unilateral cervicotomy) was feasible in 87.1% of patients. Appropriate intraoperative parathyroid hormone monitoring decline was associated with a 95.8% biochemical cure rate. Complication rates were low, with vocal cord palsy in 0.8% and long-term hypoparathyroidism requiring calcium supplementation in 2.4%.

CONCLUSIONS AND RELEVANCE: 18F-fluorocholine positron emission tomography/computed tomography offers superior localization accuracy and a favorable radiation profile compared to conventional imaging options, supporting its use as a first-line modality in reoperative parathyroidectomy. Its application enables focused surgical interventions with high cure rates and low morbidity.