Introduction
Materials and methods
Search strategy and study selection
Data extraction
Statistical analysis
Results
Authors, ref | Year pub | Country | N of pts | Study design | PTH level Median (range) Mean ± SD | Type of parathyroid disease | Protocol FCH PET (dosage) | End-point | Comparison with other modalities | Outcome |
---|---|---|---|---|---|---|---|---|---|---|
Dynamic studies | ||||||||||
Michaud et al. [12] | 2014 | France | 12 | P | 39.4 (4–176) ng/mL | PHPT and SHPT | Dyn.10 min + Stat. (3 MBq/kg) | To check if FCH uptake was a general feature of adenomatous or hyperplastic parathyroid glands | US and/or 123I/MIBI dual-phase scintigraphy | PTH decrease from 60 to 95%. |
Michaud et al. [13] | 2015 | France | 17 | P | 280 (61–1946) pg/mL | PHPT and SHPT | Dyn. 10 min (no activity data) | To compare FCH-PET/CT findings in pts with discordant or equivocal results at US and scintigraphy | US and/or I123 + MIBI scintigraphy | FCH-PET/CT sensitivity is better than that of US and not inferior to that of dual-phase I123 + sestaMIBI scintigraphy |
Kluijhout et al. [14] | 2017 | US | 10 | P | 86 ± 43 ng/mL | PHPT | Dyn. 40 min (no activity data) | To investigate the performance of FCH PET/MR imaging in patients with HP and non-localized disease who have negative or inconclusive results at US and MIBI scintigraphy | US, MIBI SPET/CT | FCH PET/MR imaging allowed localization of adenomas with high accuracy when conventional imaging results were inconclusive and provided detailed anatomic information. |
Prabhu et al. [15] | 2018 | India | 14 | P | NA | PHPT and PTA | Dyn. 15 min + Stat. 45-60 min (185-296 MBq) | To assess the utility of early dynamic FCH PET/CT in detecting parathyroid lesions and differentiating parathyroid lesions from cervical lymph nodes | None | Early dynamic FCH PET/CT can detect parathyroid adenomas in PHPT |
Static studies (single time point) | ||||||||||
Kluifhout et al. [16] | 2016 | The Netherlands | 44 | R | NA | HPT (MEN 1 and hyperpl.) | Stat. 30 min (2 MBq/Kg) | FCH PET/CT performance as second line imaging scan | None | FCH PET/CT is able to identify a HPT in case of inconclusive US and sestamibi |
Quak et al. [17] | 2017 | France | 25 | P | 94.8 ± 37.4 ng/mL | PHPT and PTA | Stat. 60 min (1.5 MBq/kg) | Evaluate the sensitivity of FCH PET/CT for PTA detection prior to surgery in patients with PHPT and negative or inconclusive cervical ultrasound and MIBI SPET/CT | US and MIBI SPET/CT | 88% patients were considered cured after surgery |
Grimaldi et al. [18] | 2018 | France | 27 | P | 102.5 (59.0-514.0) ng/mL | PHPT | Stat. 30 min (100 MBq) | To evaluate the added value of pre-surgical FCH-PET/CT in localizing hyperfunctioning parathyroid glands | US, MIBI + Tc SPET/CT | FCH-PET/CT is a promising modality in challenging pre-surgical localization |
Huber et al. [19] | 2018 | Switzerland | 26 | R | 110.8 (54.9-257.6) ng/mL | PHPT | Stat. 10 min (150 MBq) | FCH-PET/CT or MRI ability to pre-surgical localization of PT in case of negative or conflicting US and scintigraphy | US, I123 + Tetrofosmin SPET/CT | FCH-PET is a highly accurate method to detect PT adenomas even in case of failure of other imaging examinations |
Araz et al. [20] | 2018 | Turkey | 35 | P | 123.06 ± 34.82 ng/mL | PHPT | Stat. 45-60 min (100 MBq) | Comparison between FCH PET/CT and MIBI SPET/CT in hyperparathyroidism and the utility of SUVmax for the evaluation of disease severity | MIBI SPET/CT | FCH has a higher performance than MIBI SPECT/CT. SUV is correlated with PTH and bone mineral densitometry (BMD) scores |
Piccardo et al. [21] | 2018 | Italy | 44 | P | 120.7 (71.8–545) ng/mL | PHPT | Stat. 10 min (100 MBq) | Comparison among integrated FCH-PET/4DCeCT and FCH-PET/CT and 4DCeCT detection rate and sensitivity | 4DCeCT | Integrated FCH-PET/4DCeCT has a performance superior to that of FCH-PET/CT and 4DCeCT, separately |
Zajickova et al. [22] | 2018 | Czech Republic | 13 | P | 114.6 (78.9–145) ng/mL | PHPT | Stat. 30 ± 20 min (180 MBq) | FCH PET/CT was performed after inconclusive neck US and MIBI SPET scintigraphy in patients with PHPT to localize abnormal parathyroid glands before surgery | US and MIBI scintigraphy | FCH correctly identified PTA and hyperplastic glands in 92% patients with previously inconclusive conventional imaging |
Fischli et al. [23] | 2018 | Switzerland | 39 | R | 168.39 ± 110.69 ng/mL | PHPT | Stat. 45 min (160 MBq) | To evaluate the sensitivity and specificity of FCH-PET/CT for preoperative localization in patients with pHPT and negative or equivocal 99mTc-sestamibi scintigraphy and/or ultrasound | None | FCH-PET/CT provides an excellent sensitivity of > 90% per-patient and of > 87% per lesion-based level |
Amadou et al. [4] | 2019 | France | 29 | R | 122.81 ± 50.78 ng/mL | PHPT | Stat. 60 min (230 MBq) | To evaluate FCH-PET/CT and parathyroid 4D-CT as to guide surgery in patients with PHPT and prior neck surgery | US, MIBI scintigraphy and/or MIBI SPET/CT, 4D-CT | Superiority of FCH-PET/CT and 4D-CT compared to first-line imaging in re-operative patients |
Static studies (Dual Time Point): | ||||||||||
Lezaic et al. [24] | 2014 | Slovenia | 24 | P | NA | PHPT | Stat. 5 and 60 min (100 MBq) | Evaluate the usefulness of FCH PET/CT for preoperative localization of hyperfunctioning parathyroid tissue | MIBI SPET/CT, MIBI dual-phase and MIBI/Tc subtraction imaging | FCH PET/CT appears to be a promising, effective imaging method for localization of hyperfunctioning parathyroid tissue |
Rep et al. [25] | 2015 | Slovenia | 43 | P | 311.5 (70.6–2022) ng/mL | PHPT | Stat 5, 60 and 120 min (100 MBq) | To determine the optimal scan time, i.e., time between radiopharmaceutical administration and FCH PET/CT imaging in patients with a PHPT | Conventional MIBI scan | Optimal imaging time is one hour after the administration of FCH |
Hocevar et al. [26] | 2016 | Slovenia | 151 | R | NA | PTA | Stat. 5 and 60 min (100 MBq) | To analyze the results of FCH-PET/CT pre-surgical localization and the possibility to skip ioPTH testing in pts with single adenoma | US, MIBI SPECT/CT | FCH-PET/CT is a reliable test in pre-surgical localization and pts with single PTA on PET can safely undergo a focused parathyroidectomy |
Rep et al. [27] | 2018 | Slovenia | 36 | P | NA | PHPT | Stat. 5 and 60 min (100 MBq) | To measure the organ doses and the ED for conventional subtraction parathyroid imaging protocols, using dual-phase MIBI SPET/CT as a potential conventional imaging method of choice and FCH dual-phase PET/CT as a potential future imaging method of choice for localisation of HPGs | Parathyroid subtraction scintigraphy and dual-phase SPET/CT | In HPGs, SPET/CT and PET/CT have a superior diagnostic performance than conventional scintigraphy |
Alharbi et al. [28] | 2018 | Switzerland | 52 | R | 122.4 ± 49.9 ng/mL | PTA (only single adenomas) | Stat. 2 and 50 min (150 MBq) | To investigate the relationship between FCH-PET (MR and CT) results and PTH levels | None | FCH uptake in PTA is strongly correlated with preoperative PTH serum levels |
Beheshti et al. [29] | 2018 | Austria | 100 | P | 196.5 ± 236.4 pg/mL | PTA | Stat. 60 and 120 min (3.2 MBq/Kg) | To compare assessment of PHPT from FCH-PET/CT and MIBI or Tetrofosmin SPECT/CT | MIBI or Tetrofosmin SPECT/CT | FCH-PET/CT is clearly superior to MIBI/Tetrofosmin SPET/CT in detecting PTA, especially small ones |
Bossert et al. [30] | 2018 | Italy | 34 | P | 179.9 ± 123.1 ng/mL (Hypercalcemic) 158.4 ± 55.4 ng/mL (Normocalcemic) | PTA | Stat. 9 and 60 min (3.5 MBq/Kg MBq) | To compare diagnostic performance of FCH-PET/CT with MIBI + TC SPET/CT | US, MIBI + TC SPET/CT | FCH-PET/CT can be considered a first line imaging technique in pts with normo- or hypercalcemic PHTP |
Christakis et al. [31] | 2019 | UK | 12 | R | 19.1 ± 5.11 ng/mL | PHPT or recurrent PTA | Stat. 60 and 90 min (300 MBq) | To assess if FCH PET/CT is able to identify parathyroid adenomas, with a negative scan | None | FCH PET/CT is able to identify the presence of adenoma parathyroid also in case of negative conventional imaging |
Thanseer et al. [32] | 2019 | India | 54 | P | 165.5 (117–362.5) ng/mL in eutopic 302 (236–1264) ng/mL in ectopic | PHPT | Stat. 10-15 min + 60 min (150-185 MBq) | to compare pre-surgery localization in US, MIBI SPECT/CT and FCH PET | US, MIBI SPECT/CT | FCH PET/CT has higher sensitivity and specificity especially in patients with small and ectopic PHPT and low, slight PTH values |
Broos et al. [33] | 2019 | The Netherlands | 271 | R | 16.1 ± 11.3 ng/mL | PHPT | Stat. 5 and 60 min (150 MBq) | To evaluate FCH PET/CT as a first-line modality | None | High detection rates of FCH PET/CT in PHPT. FCH PET/CT can be used as a first-line imaging modality in preoperative planning of parathyroid surgery |
Authors, ref | Stand. of ref. | FCH PET/CT | Comparative imaging | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
SENS. | SPEC. | PPV | NPV | ACC. | SENS. | S SPEC. | PPV | NPV | ACC. | ||
Dynamic studies | |||||||||||
Michaud et al. [12] | Histology | 89% (PL) | 94% (PL) | ||||||||
Michaud et al. [13] | Histology | 94% (PP) 96% (PL) both in masked and open reading | PL: 88% (open) 56% (masked) | – | – | PL: 94% (open) 85% (masked) | US: 50% (PP) 50% (PL) I123 + SestaMIBI: 94% (PP) 83% (PL) both in masked and open reading | PL: 33% (US) 56% (I123 + SestaMIBI) both in masked and open reading | – | – | PL: 46% (US) 76%(I123 + SestaMIBI) both in masked and open reading |
Kluijhout et al. [14] | Histology | 90% | 100% | ||||||||
Prabhu et al. [15] | Histology | – | – | – | – | – | – | – | – | – | – |
Static studies (single time point) | |||||||||||
Klujfhout et al. [16] | Histology | 97.1% | – | 97.1% | – | 97.1% | – | – | – | – | – |
Quak et al. [17] | Histology | 91.3% (PL) 90.5% (PP) | – | 87.5% (PL) 86.4% (PP) | – | 80.7% (PL) | – | – | – | – | – |
Grimaldi et al. [18] | Histology and follow up | 81% (PP) 76% (PL) | – 91% (PL) | 94% (PP) 85% (PL) | – 86% (PL) | – – | – | – | – | – | – |
Huber et al. [19] | Histology and biochemistry | 96.2% (PP) | – | 100% (PL) | – | – | – | – | – | – | – |
Araz et al. [20] | Follow-up and histology | 96% | 100% | 100% | 93% | 97% | 78% | 100% | 100% | 70% | 86% |
Piccardo et al. [21] | Histology, biochemistry and follow up | 81% (PL) | – | – | – | – | PL: 54.5% (4DCeCT) 100% (PET + 4DCeCT) | – | – | – | – |
Zajickova et al. [22] | Histology | 92% | 100% | 92% | |||||||
Fischli et al. [23] | Histology | 95.5% (PP) 87.5% (PL) | – | – | – | – | – | – | – | – | – |
Amadou et al. [4] | Histology and follow up | 85.2% (PP) 95.8% (PL) | 12.5% (PL) | 76.7% (PL) | 50% (PL) | – | PL: 54.2% (US) 50% (MIBI) 75% (4D-CT) | PL: 75% (US) 75% (MIBI) 40 (4D-CT) | PL: 86.7% (US) 85.7% (MIBI) 80% (4D-CT) | PL: 35.3% (US) 33.3% (MIBI) 33.3% (4D-CT) | – |
Static studies (dual time point) | |||||||||||
Lezaic et al. [24] | Histology | 92% | 100% | 100% | 96% | 98% | 49% (MIBI SPET/CT) 46% (MIBI-Tc) 44% (MIBI dual-phase) | 100% (MIBI SPET/CT, MIBI-Tc and MIBI dual-phase) | 100% | 80% | 83% |
Rep et al. [25] | Histology | 90.5% (5 min) 93.6% (1 h) 93.6% (2 h) 95.3% (all) | 98.2% (5 min) 98.2% (1 h) 98.2% (2 h) 98.2% (all) | 96.6% (5 min) 96.7% (1 h) 96.7% (2 h) 96.8% (all) | 94.7% (5 min) 96.4% (1 h) 96.4% (2 h) 97.3% (all) | 94.1% (5 min) 96.5% (1 h) 96.5% (2 h) 97% (all) | – | – | – | – | – |
Hocevar et al. [26] | Histology and biochemistry | – | – | 95.2% (PL) 96.8% (per single PTA) | – | – | 61% (US per single PTA) 62% (MIBI-SPET/CT per single PTA) | – | – | – | – |
Rep et al. [27] | Histology | 97% | 99% | 46% (PSS), 64% (SPET/CT) | 98% (PSS), 96% (SPET/CT) | ||||||
Alharbi et al. [28] | PET positivity and histology | – | – | – | – | – | – | – | – | – | – |
Beheshti et al. [29] | Histology and follow up | 93.7% (PL) | 96% (PL) | 90.2% (PL) | 97.4% (PL) | 95.3% (PL) | 60.8% (PL) | 98.5% (PL) | 94.1% (PL) | 86.3% (PL) | 87.7% (PL) |
Bossert et al. [30] | Histology or citology/biochemistry | 88% | – | – | – | – | 82% (US) 17% (Tc + MIBI SPET/CT) | – | – | – | – |
Christakis et al. [31] | histology | 58.3% | – | – | 100% | 58.3% | – | – | – | – | – |
Thanseer et al. [32] | Histology | 100% (PP) 100% (PL) | – – | 96.3% (PP) 92.8% (PL) | – – | 96.3% (per pts) 92.8% (PL) | MIBI SPECT/CT 80.7% (PP) 76.4% (PL) US 69.3% (PP) 69.3% (PL) | MIBI SPECT/CT 100% (PP) 75% (PL) US 29% (PL) | MIBI SPECT/CT 97.7% (PP) 97.7% (PL) US 87.1% (PP) 87.1% (PL) | MIBI SPECT/CT 9% (PP) 23% (PL) US 12% (PL) | MIBI SPECT/CT 79.6% (PP) 80.4% (PL) US 62.9% (PP) 64.3% (PL) |
Broos et al. [33] | Histology | 96% (PP) 90% (PL) | 100% | 96% (PP) 90% (PL) |
Authors, ref | Year publ. | Patient-based analysis | Lesion-based analysis | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
N | TP | TN | FP | FN | N | TP | TN | FP | FN | ||
Michaud et al. [12] | 2014 | 12 | 11 | 0 | 0 | 1 | 20 | 17 | 0 | 1 | 2 |
Lezaic et al. [24] | 2014 | 24 | 23 | 0 | 0 | 1 | 39 | 36 | 0 | 0 | 3 |
Michaud et al. [13] | 2015 | 16 | 15 | 0 | 0 | 1 | 25 | 23 | 0 | 1 | 1 |
Klujfhout et al. [16] | 2016 | 33 | 30 | 0 | 1 | 2 | 35 | 33 | 1 | 1 | 0 |
Kluijhout et al. [[14] | 2017 | 10 | 9 | 0 | 0 | 1 | – | – | – | – | – |
Fischli et al. [23] | 2017 | 23 | 21 | 0 | 1 | 1 | 29 | 21 | 4 | 1 | 3 |
Hocevar et al. [26] | 2017 | 151 | 144 | 1 | 4 | 2 | – | – | – | – | – |
Thanseer et al. [32] | 2017 | 54 | 52 | 0 | 2 | 0 | 58 | 54 | 0 | 4 | 0 |
Quak et al. [17] | 2018 | 24 | 19 | 0 | 3 | 2 | 26 | 21 | 0 | 3 | 2 |
Grimaldi et al. [18] | 2018 | 21 | 17 | 0 | 1 | 3 | 76 | 22 | 43 | 4 | 7 |
Huber et al. [19] | 2018 | 26 | 25 | 0 | 0 | 1 | 28 | 27 | 0 | 0 | 1 |
Zajickova et al. [22] | 2018 | 13 | 11 | 0 | 1 | 1 | – | – | – | – | – |
Rep et al. [25] | 2018 | 144 | 39 | 103 | 1 | 1 | – | – | – | – | – |
Beheshti et al. [29] | 2018 | 82 | 76 | 3 | 0 | 3 | 277 | 74 | 190 | 8 | 5 |
Piccardo et al. [21] | 2019 | 31 | 25 | 0 | 0 | 6 | 31 | 31 | 0 | 0 | 0 |
Amadou et al. [4] | 2019 | 25 | 23 | 1 | 0 | 1 | 32 | 23 | 1 | 7 | 1 |
Bossert et al. [30] | 2019 | 17 | 15 | 0 | 0 | 2 | 17 | 15 | 0 | 0 | 2 |
Broos et al. [33] | 2019 | 137 | 131 | 0 | 0 | 6 | 148 | 133 | 0 | 0 | 15 |
Discussion
Authors, ref | Year of pub | Meta-analysis | N of included studies | Comparison with other imaging | Outcome |
---|---|---|---|---|---|
Kim et al. [38] | 2018 | Yes | 8 | No | 18F-Choline PET has a pooled sensitivity of 90% and a pooled specificity of 94% for the identification of HPT |
Treglia et al. [39] | 2019 | Yes | 18 | No | Radiolabeled Choline PET has a pooled sensitivity of 95% and a pooled PPV of 91% for the identification of HPT |
Boccalatte et al. [40] | 2019 | No | 15 | No | 18F-Choline PET provides a high accuracy, sensitivity and specificity for the identification of HPT |
Broos et al. [33] | 2019 | No | 11 | No | High detection rate of choline PET/CT in preoperative localization of hyperfunctioning parathyroid glands in patients with primary HPT |
Imaging technique | Pros | Cons |
---|---|---|
US | No radiation exposure Widely available, cost effective Doppler can assist in distinguishing parathyroid lesions from other surrounding structures: identification of polar arteries of parathyroid glands vs. hilar blood supply of lymph nodes Concurrent assessment of the thyroid and possibility of performing percutaneous biopsies | Operator dependent Accuracy can be limited in patients with elevated body mass index Visualization of low inferior glands can be particularly difficult in patients unable to extend their neck Difficult detection of ectopic glands located in the mediastinum |
MIBI SPECT | Widely available, cost effective Consolidated protocols described, including single-tracer double phase and dual-tracer single phase imaging Possibility of detecting ectopic lesions, particularly if in mediastinum | Thyroid nodules, thyroiditis and enlarged cervical lymph nodes may have delayed tracer washout and give the appearance of a thyroid adenoma Long acquisition time, compliance of patients is required Intermediate radiation dose (7–11 mSv) |
4D-ceCT | Characterization of lesion enhancement could offer insights into the benign/malignant nature of the parathyroid lesion/s Excellent anatomic detail and possibility of detecting ectopic lesions | High radiation dose (10–27 mSv) |
MRI | Characterization of lesion enhancement could offer insights into the benign/malignant nature of the parathyroid lesion/s Excellent anatomic detail and possibility of detecting ectopic lesions No radiation exposure | Long acquisition time, compliance of patients is required High costs and limited availability |
18F-Choline PET/CT and PET/MR | Greater spatial resolution than MIBI SPECT and shorter image acquisition time | Lack of protocol standardization (optimal imaging timing, dynamic acquisition, administered activity etc.) Currently not clinically approved High costs and limited availability |