Head-to-head comparison of [11C]methionine PET, [11C]choline PET, and 4-dimensional CT as second-line scans for detection of parathyroid adenomas in primary hyperparathyroidism

Milou E Noltes; Schelto Kruijff; Auke P A Appelman; Liesbeth Jansen; Wouter T Zandee; Thera P Links; Bettien M van Hemel; Hugo M Schouw; Rudi A J O Dierckx; Anne Brecht Francken; Wendy Kelder; Anouk van der Hoorn; Adrienne H Brouwers

doi:10.1007/s00259-023-06488-7

Head-to-head comparison of [¹¹C]methionine PET, [¹¹C]choline PET, and 4-dimensional CT as second-line scans for detection of parathyroid adenomas in primary hyperparathyroidism

Eur J Nucl Med Mol Imaging. 2024 Mar;51(4):1050-1059. doi: 10.1007/s00259-023-06488-7. Epub 2023 Nov 17.

Authors

Milou E Noltes^{1

2

3}, Schelto Kruijff^{1

2

4}, Auke P A Appelman⁵, Liesbeth Jansen², Wouter T Zandee⁶, Thera P Links⁶, Bettien M van Hemel⁷, Hugo M Schouw^{1

2}, Rudi A J O Dierckx^{1

3}, Anne Brecht Francken⁸, Wendy Kelder³, Anouk van der Hoorn⁵, Adrienne H Brouwers⁹

Affiliations

¹ Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
² Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
³ Department of Surgery, Martini Hospital Groningen, Groningen, the Netherlands.
⁴ Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
⁵ Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁶ Division of Endocrinology, Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁷ Department of Pathology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.
⁸ Department of Surgical Oncology, Isala, Zwolle, the Netherlands.
⁹ Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands. a.h.brouwers@umcg.nl.

Abstract

Purpose: Accurate preoperative localization is imperative to guide surgery in primary hyperparathyroidism (pHPT). It remains unclear which second-line imaging technique is most effective after negative first-line imaging. In this study, we compare the diagnostic effectiveness of [¹¹C]methionine PET/CT, [¹¹C]choline PET/CT, and four dimensional (4D)-CT head-to-head in patients with pHPT, to explore which of these imaging techniques to use as a second-line scan.

Methods: We conducted a powered, prospective, blinded cohort study in patients with biochemically proven pHPT and prior negative or discordant first-line imaging consisting of ultrasonography and ^99mTc-sestamibi. All patients underwent [¹¹C]methionine PET/CT, [¹¹C]choline PET/CT, and 4D-CT. At first, all scans were interpreted by a nuclear medicine physician, and a radiologist who were blinded from patient data and all imaging results. Next, a non-blinded scan reading was performed. The scan results were correlated with surgical and histopathological findings. Serum calcium values at least 6 months after surgery were used as gold standard for curation of HPT.

Results: A total of 32 patients were included in the study. With blinded evaluation, [¹¹C]choline PET/CT was positive in 28 patients (88%), [¹¹C]methionine PET/CT in 23 (72%), and 4D-CT in 15 patients (47%), respectively. In total, 30 patients have undergone surgery and 32 parathyroid lesions were histologically confirmed as parathyroid adenomas. Based on the blinded evaluation, lesion-based sensitivity of [¹¹C]choline PET/CT, [¹¹C]methionine PET/CT, and 4D-CT was respectively 85%, 67%, and 39%. The sensitivity of [¹¹C]choline PET/CT differed significantly from that of [¹¹C]methionine PET/CT and 4D-CT (p = 0.031 and p < 0.0005, respectively).

Conclusion: In the setting of pHPT with negative first-line imaging, [¹¹C]choline PET/CT is superior to [¹¹C]methionine PET/CT and 4D-CT in localizing parathyroid adenomas, allowing correct localization in 85% of adenomas. Further studies are needed to determine cost-benefit and efficacy of these scans, including the timing of these scans as first- or second-line imaging techniques.

Keywords: Computed tomography (CT); Imaging; Parathyroid; Positron emission tomography (PET); Primary hyperparathyroidism; Sensitivity.

MeSH terms

Choline
Cohort Studies
Humans
Hyperparathyroidism, Primary* / diagnostic imaging
Hyperparathyroidism, Primary* / surgery
Methionine
Parathyroid Glands
Parathyroid Neoplasms* / complications
Parathyroid Neoplasms* / diagnostic imaging
Positron Emission Tomography Computed Tomography / methods
Prospective Studies
Racemethionine
Technetium Tc 99m Sestamibi

Substances

Methionine
Choline
Technetium Tc 99m Sestamibi
Racemethionine

Grants and funding

2019-51/Stichting De Cock-Hadders