Comparison of 4D Computed Tomography and F-18 Fluorocholine PET for Localisation of Parathyroid Lesions in Primary Hyperparathyroidism

A Systematic Review and Meta-Analysis

Dhrumil Deveshkumar Patel; Samiksha Bhattacharjee; Avaneesh Kumar Pandey; Chirag Rajkumar Kopp; Abhiram G. Ashwathanarayana; Himani Vinayak Patel; Rohit Barnabas; Sanjay Kumar Bhadada; Manjunath Havalappa Dodamani


Clin Endocrinol. 2023;99(3):262-271. 

In This Article

Abstract and Introduction


Minimally invasive parathyroidectomy (MIP) is the standard of care for primary hyperparathyroidism (PHPT). Four dimensional computed tomography(4DCT) and F-18 Fluorocholine positron emission tomography/computed tomography (FCH PET/CT) localize adenomas accurately to perform MIP. We aimed to conduct a systematic review and metanalysis to evaluate the diagnostic performance of 4DCT and FCH PET/CT scan for quadrant wise localisation in PHPT patients and to do head-to-head comparison between these two modalities.

Design, Patients and Measurement: After searching through PubMed and EMBASE databases, 46 studies (using histology as a gold standard) of 4DCT and FCH PET/CT were included.

Results: Total number of patients included were 1651 and 952 for 4DCT scan (studies n = 26) and FCH PET/CT scan (studies n = 24) respectively. In per patient analysis, FCH PET/CT and 4DCT had pooled sensitivities of 92% (88–94) and 85% (73–92) respectively and in per lesion analysis, 90% (86–93) and 79% (71–84), respectively. In the subgroup with negative conventional imaging/persistent PHPT, FCH PET/CT had comparable sensitivity to 4DCT (84% [74–90] vs. 72% [46–88]). As per patient wise analysis, FCH PET/CT had better detection rates than 4DCT ([92.4 vs. 76.85], odds ratio –3.89 [1.6–9.36] p = .0024) in the subpopulation where both FCH PET/CT and 4DCT were reported.

Conclusion: Both 4DCT and FCH PET/CT scan performed well in newly diagnosed patients, patients with persistent disease and in those with inconclusive conventional imaging results. FCH PET/CT scan had a higher pooled sensitivity than 4DCT in detecting patients with PHPT in head to head comparison.


Primary hyperparathyroidism (PHPT) is a common endocrine disorder due to autonomous hyperfunctioning parathyroid gland(s). It commonly occurs due to benign overgrowth of parathyroid tissue, in some cases due to hyperplasia, and very rarely due to parathyroid carcinoma.[1] It is biochemically characterized by hypercalcemia, hypophosphatemia, hypercalciuria accompanied by elevated parathyroid hormone levels.[2] If untreated, it leads to significant morbidity, including osteolytic lesions with pathological fracture, osteomalacia, nephrocalcinosis, renal calculi and chronic kidney disease.[3,4]

Abnormal parathyroid resection is curative treatment option for PHPT.[5] Minimally invasive parathyroidectomy (MIP) is the current standard of care for treating PHPT with equal cure rates compared to conventional bilateral neck exploration. The potential advantages of MIP include—procedure under local anaesthesia with a smaller incision, lower incidence and severity of hypocalcemia, decreased hospital stay with less medical cost, fewer complications, and favourable operative field in patients who require reoperation for recurrent disease.[6] Hence, it is crucial to have a modality with better sensitivity to localize abnormal parathyroid glands accurately. Neck ultrasonography (USG) and 99mTc-sestamibi imaging (either alone or combined with either single-photon emission computerized tomography [SPECT]) have an optimal detection ability in the majority of patients and are still the first-line imaging techniques in patients with PHPT. However, the performance of these modalities could be affected in patients with mild elevation of PTH and calcium, small adenomas, multiglandular disease, and concomitant thyroid abnormality. Several studies have shown promising results for both Four dimensional computed tomography (4DCT)[7] and F-18 Fluorocholine positron emission tomography/computed tomography (FCH PET/CT) scans,[8] but a systematic comparison of studies of these two techniques is still lacking.

The majority of all previous meta-analyses and systematic reviews of FCH PET/CT scan in PHPT have analysed per patient data. None of these studies clearly describe the performance of FCH PET/CT scan in previously operated patients with persistent disease, patients with inconclusive conventional imaging, and ectopic lesions. Hence, we conducted this meta-analysis to address the gaps in the literature. The primary objective of the present study was to compare the quadrant wise localising accuracy of FCH PET/CT scan and 4DCT at per patient and per lesion level in PHPT. Secondary objectives of the study were to compare these two modalities in homogenous populations of PHPT patients, to determine the sensitivity in patients with negative/inconclusive conventional scans/persistent disease requiring resurgery, newly diagnosed cases of PHPT, and those with ectopic lesions.