Preoperative Imaging Techniques in Primary Hyperparathyroidism: A Review.

Abstract

Successful minimally invasive parathyroidectomy requires confident and accurate preoperative localization. Several noninvasive imaging techniques are well established for preoperative localization, and others are emerging. Ultrasonography and sestamibi imaging are established preoperative localization techniques with good sensitivity and positive predictive value. Multiphase 4-dimensional computed tomography is a newer technique with arguably superior performance, particularly in the setting of negative or discordant ultrasonography and sestamibi imaging, residual or recurrent primary hyperparathyroidism following a previous surgical operation, and multiglandular disease. Emerging techniques that may further facilitate confident and accurate preoperative localization include ultrasonography, elastography, positron emission tomography, and 4-D magnetic resonance imaging. The optimal imaging localization algorithm for hyperparathyroidism remains undetermined, but a combination of techniques tailored to the specific scenario will likely yield the best outcomes. An algorithm is proposed that considers test performance, surgeon confidence, patient-specific factors, cost, local radiologic expertise, and patient radiation exposure.