Correlation Between ¹⁸F-Choline PET/CT and Surgical Outcomes in Primary Hyperparathyroidism With Negative or Inconclusive Imaging: A Retrospective Cohort of 70 Cases.

Abstract

Primary hyperparathyroidism (PHPT) is characterized by autonomous parathyroid hormone (PTH) secretion, leading to hypercalcemia and systemic complications. Most cases are caused by benign parathyroid tumors, and surgery remains the only curative treatment. Accurate preoperative localization of hyperfunctioning glands is critical for surgical success. When conventional imaging (ultrasound, SPECT/CT, CT) is negative or inconclusive, ¹⁸F-Choline PET/CT has emerged as a promising alternative. We conducted a retrospective cohort study of 70 patients with biochemically confirmed PHPT selected from 218 consecutive parathyroidectomies performed between 2021 and 2023 at the University Hospital Fundación Santa Fe de Bogotá. All patients included had negative or inconclusive findings on conventional imaging and underwent ¹⁸F-Choline PET/CT before surgery. Clinical, radiological, surgical, pathological, and follow-up data were retrieved from electronic medical records. Surgical success was defined as a ≥ 50% intraoperative PTH decrease with normalization of calcium and PTH at 6 months. All 70 patients (mean age, 63 years; 80% female) demonstrated at least one focal uptake on ¹⁸F-Choline PET/CT. Radiological-surgical-pathological concordance was 94.4%. Intraoperative PTH decreased by ≥ 50% in 94% of cases. At 6 months, 92% achieved normal calcium and PTH levels. Among 89 resected glands, 60.7% were adenomas, 25.8% showed adenomatous changes, 7.8% had hyperplasia, and 5.6% were histologically normal. In patients with multiple uptakes (n = 12), anatomical correlation was found in 88%, with pathological confirmation in 90%. ¹⁸F-Choline PET/CT demonstrated excellent performance in localizing parathyroid adenomas in PHPT with inconclusive conventional imaging. Its high diagnostic accuracy and strong agreement with intraoperative and long-term biochemical outcomes support its integration into preoperative planning, particularly in multiglandular disease and ectopic adenomas.