Selective radioguided parathyroidectomy with indocyanine green prior to preoperative 18f-choline PET/CT location: a case report

A CASE REPORT

Abstract

Introduction

Most common cause of primary hyperparathyroidism (PHPT) is parathyroid adenoma, being surgery the only curative treatment. Nowadays, minimally invasive approach is preferred instead of cervical bilateral exploration, as implies an early recovery, lower rate of complications and cost-effective results. This surgical approach requires to know exactly preoperative location of the affected parathyroid, justifying the development of more accurate imaging techniques able to precise location even in small or ectopic adenomas, multiglandular disease, persistent or recurrent PHPT.

Presentation of the case

In the following case report, we present 83-year-old male diagnosed of PHPT during nephrologist follow-up due worsening of renal function associated with hypercalcemia 12 mg/dL and PTH 1218 pg/mL. As ^99mTc-MIBI scintigraphy showed difficulties to accurately localize the infracentimetric adenoma, ¹⁸F-choline PET/CT resolution allowed defining its location, suggesting the performance of a lower incision and exploration of deep planes in surgery. A selective radioguided parathyroidectomy was performed, guiding during surgery towards the pathological gland and ensuring the correct resection of the adenoma by exploring residual radioactivity of the surgical field. Intraoperative Indocyanine Green angiography also allowed to visualize the vascular pedicle. Postoperative was uneventful and follow up ensured curative results of surgery.

Conclusion

This case report describes the newest tools available to guarantee a minimally invasive surgical approach of the parathyroid glands, especially in those cases such as small or ectopic adenomas, multiglandular disease, persistent or recurrent PHPT where conventional tests are less sensitive. Further studies are needed to define the current place for these tools in the therapeutic algorithm of PHPT.