Three-phase four-dimensional computed tomography as a first-line investigation in primary hyperparathyroidism

Area of Science:

• Radiology
• Endocrinology
• Surgical Oncology

Background:

• Four-dimensional computed tomography (4DCT) is a parathyroid localization technique introduced in 2006.
• Variable institutional adoption of 4DCT stems from inconsistent results and concerns about radiation dose compared to technetium-99 sestamibi scans (MIBI).
• Our institution has utilized 4DCT as the primary parathyroid localization method since 2013.

Purpose of the Study:

• To evaluate the accuracy and effectiveness of a three-phase 4DCT protocol for preoperative parathyroid localization in patients with primary hyperparathyroidism.
• To identify factors influencing the accuracy of 4DCT in parathyroid localization.

Main Methods:

• Retrospective analysis of 353 surgically managed patients with primary hyperparathyroidism who underwent preoperative 4DCT localization between 2013 and 2018.
• Assessment of 4DCT protocol performance metrics including positive predictive value (PPV), sensitivity, false-positive rate, and false-negative rate.
• Multivariable logistic regression analysis to determine predictors of 4DCT accuracy.

Main Results:

• The three-phase 4DCT protocol demonstrated a PPV of 93.3% and sensitivity of 85.2% when interpreted by a head and neck radiologist (HNR).
• The false-positive rate was 5.8%, and the false-negative rate was 13.9%.
• Experienced HNR reporting (P < 0.001) and parathyroid gland weight > 200 mg (P = 0.002) were significant predictors of higher accuracy.

Conclusions:

• A first-line three-phase 4DCT protocol is an accurate method for precise anatomical localization of abnormal parathyroid glands in primary hyperparathyroidism.
• Specialist HNR interpretation enhances 4DCT accuracy, offering superior localization for minimally invasive parathyroid surgery.
• This technique can potentially avoid the need for four-gland exploration in many patients.