Preoperative identification of small parathyroid adenomas-better done by fluorocholine positron emission tomography/computed tomography.

Background: Preoperative localization imaging studies are crucial for safe and successful parathyroidectomy in patients with primary hyperparathyroidism (pHPT), especially in focused approaches. A common imaging sequence is ultrasound followed by scintigraphy. These techniques, but not 18F-fluorocholine positron emission tomography/computed tomography (PET/CT), show lower detection rates in multiglandular disease (MGD), which is associated with smaller adenomas. In this study, we evaluate the accuracy of these modalities in small parathyroid adenomas (PAs) and discuss the potential sequence of preoperative localization diagnostics. Methods: Patients undergoing parathyroidectomy for pHPT were retrospectively categorized into small adenoma (specimen diameter <10 mm) and large adenoma. The groups were compared for accuracy of preoperative imaging studies, short-term and long-term outcomes. Results: Among 147 patients retrospectively analyzed in this study, 38 small PAs were found. Preoperative correct quadrant prediction for small adenomas was significantly lower for ultrasound (P=0.03) and single-photon emission computed tomography/CT (SPECT/CT) (P<0.01) but not for choline PET/CT. While PET/CT was performed significantly more often in small PAs (P<0.01), it showed highly significant superiority over the other imaging modalities in accurate preoperative localization in both small (P<0.0001) and large PAs (P<0.01). There was no difference in calcium and parathyroid hormone (PTH) levels at latest follow-up with slightly more recurrences in small adenomas (P=0.08). Conclusions: Choline PET/CT showed a better diagnostic yield especially for small and multiple adenomas and was better in prediction of the correct localization. It could therefore serve as a second-line imaging modality.