Introduction and objective:

Radioguided surgery of hyperparathyroidism (HPT) has substantially evolved in recent years, due to the development of new intraoperative tools and the improvement of pre-operative techniques. The aim of this work is to perform a review of the role of choline PET-CT as a preoperative technique, as well as of the use of intraoperative tools, in the radioguided localization of parathyroid adenomas.

Synthesis:

Choline PET-CT is a pre-operative technique, alternative to the 99mTc-MIBI scintigraphy, for the pre-operative localization of HPT in cases where convencional techniques give negative or doubtful results. This technique has showed good results in two recently published meta-analysis. The radioguided localization by means of gamma probe is still the intraoperative technique of choice in cases where parathyroid glands show significant 99mTc-MIBI uptake. Hand-held gammacamera is an adjuvant tool to the probe, which allows performing an intraoperative imagine and ensuring the complete resection of the specimens. Free hand SPECT is already applied in parathyroid radioguided surgery, but its use is still not widespread, probably because the superiority of this technique over the probe and hand-held gammacamera has not been demonstrated. Radioguided occult lesion localization (ROLL) by means of 99mTc-MAA injection and 125I seed implantation are two successfully used alternatives for the radioguided localization of negative99mTc -MIBI parathyroid glands. Hybrid tracers are being used in the radioguided surgery of the sentinel node but have not been applied yet in hyperparathyroidism.

Conclusions:

Choline PET-CT is an increasingly used tool in preoperative HPT localization. Although gammadetector probe remains of choice in HPT surgery —both for its good results at low cost and for the great accumulated experience—; the combined use of the hand-held gammaprobe could be helpful for particular cases as well as to ensure the total excision of the specimens. On the other hand, the injection of 125I seeds and 99mTc-MAA, guided by means of sonography, are useful in 99mTc-MIBI negative cases. Lastly, more experience is required on the application of free hand SPECT and hybrid tracers to HPT surgery on order to demonstrate their possible advantages compared to other widespread tools.

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