How has the diagnostic approach to parathyroid localization techniques evolved in the past decade? Insights from a single-center experience

Category	Detail
Condition	Primary hyperparathyroidism (pHPT), a common endocrine disorder causing hypercalcemia
Key Mechanisms	Autonomous parathyroid adenomas (85%), parathyroid hyperplasia (15%), rare carcinomas (1-2%) leading to elevated PTH and calcium
Target Population	Patients with biochemical evidence of pHPT, often asymptomatic or with symptoms like osteoporosis, nephrolithiasis, muscle weakness
Care Setting	Tertiary referral center for endocrine surgery with access to advanced imaging and surgical management

pHPT diagnosis relies on elevated serum calcium and PTH levels after excluding other causes
Parathyroidectomy is the only curative treatment, requiring precise preoperative gland localization
Multiple imaging modalities exist: neck ultrasound, 99mTc-sestamibi scintigraphy, 4D-CT, MRI, and 18F-fluorocholine PET/CT, each with distinct advantages and limitations

Confirm pHPT by biochemical testing showing elevated serum calcium and/or PTH
Exclude secondary causes of hyperparathyroidism and hypercalcemia
Use imaging modalities for preoperative localization, starting with neck ultrasound and MIBI scintigraphy

Parathyroidectomy is the definitive treatment for pHPT
Intraoperative PTH monitoring is recommended to confirm successful gland removal, defined as ≥50% drop from baseline within 15 minutes
Select imaging modality based on patient factors, prior surgery, and availability; consider advanced imaging (4D-CT, MRI, 18F-FCH PET/CT) for challenging cases

Measure intraoperative PTH at baseline, 5 and 15 minutes post-excision to guide surgical completeness
Postoperative serum calcium and PTH levels should be monitored to assess surgical success
Monitor for surgical complications within 30 days postoperatively

Radiation exposure with 4D-CT limits use in children and young adults
MIBI scintigraphy may miss small or multiglandular disease
Cost and availability may restrict use of 18F-FCH PET/CT
Incomplete resection risks persistent disease if intraoperative PTH does not drop adequately

Patients undergoing surgery for primary hyperparathyroidism at a tertiary endocrine surgery center

Intraoperative PTH monitoring is critical for confirming surgical success; imaging choice impacts localization accuracy and surgical planning

Use a combination of neck ultrasound and 99mTc-sestamibi scintigraphy as first-line imaging for preoperative localization
Reserve 4D-CT and MRI for cases with negative or inconclusive conventional imaging or reoperative surgery
Consider 18F-fluorocholine PET/CT for high-resolution localization, especially in difficult cases, balancing cost and availability
Perform intraoperative PTH assays at baseline, 5, and 15 minutes post-excision to ensure adequate gland removal
Exclude other causes of hyperparathyroidism before surgical intervention to avoid unnecessary procedures

Clinical Scorecard: The Advancement of Parathyroid Localization Diagnostic Techniques Over the Last Ten Years: A Single-Center Perspective