The role of radionuclide imaging in the surgical management of primary hyperparathyroidism

Primary hyperparathyroidism is a frequent and potentially debilitating endocrine disorder for which surgery is the only curative treatment. The modalities of parathyroid surgery have changed over the last two decades, as conventional bilateral neck exploration is no longer the only surgical approach. Parathyroid scintigraphy plays a major role to define the surgical strategy, given its ability to orient a targeted (focused) parathyroidectomy and to recognize ectopic locations or multiglandular disease. This review, which represents a collaborative effort between nuclear physicians, endocrinologists and endocrine surgeons, emphasizes the importance of performing imaging prior to any surgery for primary hyperparathyroidism, even in case of conventional bilateral neck exploration. We discuss the advantages and drawbacks of targeted parathyroidectomy and the performance of various scintigraphic protocols to guide limited surgery. We also discuss the optimal strategy to localize the offending gland before reoperation for persistent or recurrent hyperparathyroidism. Finally, we describe the potential applications of novel PET tracers with special emphasis on 18F-fluorocholine.