Use of dual energy computed tomography versus conventional techniques for preoperative localization in primary hyperparathyroidism: Effect of preoperative calcium and parathyroid hormone levels

Published:January 16, 2023DOI:


      • Sensitivity and accuracy of pre-operative localization of parathyroid glands is associated with Ca and PTH levels.
      • DECT had a higher sensitivity and accuracy than CT MIBI and US in all patient subgroups.
      • DECT had a salvage detection rate of 52.3% in patients for whom CT MIBI and US did not localize.
      • DECT can be utilized as a first-line or salvage test when CT-MIBI and US are non-localizing.



      We aimed to investigate the association of preoperative calcium and parathyroid hormone (PTH) levels with sensitivity and accuracy of dual energy computed tomography (DECT), single-photon emission CT with 99mTc-sestamibi (CT-MIBI), and ultrasound (US) for pre-operative localization primary hyperparathyroid (PHP) patients.


      Patients undergoing parathyroidectomy for PHP at a tertiary care facility who underwent DECT, CT-MIBI and US between 2012 and 2021 were stratified by preoperative calcium and PTH levels.


      Of 278 patients, those with high calcium and PTH levels had a higher sensitivity and accuracy with DECT (87.7%, 85.2%) compared to CT-MIBI (82.3%, 79.0%), and US (61.7%, 53.1%). DECT was more sensitive and accurate than other preoperative localization techniques in subgroups with normal PTH (DECT sensitivity 60.9%, accuracy 52.1%) and normal calcium levels (41.7%, 33.3%).


      Preoperative calcium and PTH were associated with sensitivity and accuracy of pre-operative localization in PHP. DECT was sensitive and accurate for preoperative localization compared to other first-line imaging techniques.

      Graphical abstract


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        • Wilhelm S.M.
        • Wang T.S.
        • Ruan D.T.
        • et al.
        The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism.
        JAMA Surg. 2016 Oct 1; 151: 959
        • Greene A.
        • Butler R.
        • McIntyre S.
        • Barbosa G.
        • Mitchell J.
        • Berber E.
        National trends in parathyroid surgery from 1998 to 2008: a decade of change.
        J Am Coll Surg. 2009; 209: 332-343
        • Cheung K.
        • Wang T.S.
        • Farrokhyar F.
        • Roman S.A.
        • Sosa J.A.
        A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism.
        Ann Surg Oncol. 2012 Feb; 19: 577-583
        • Roskies M.
        • Liu X.
        • Hier M.P.
        • et al.
        3-phase dual-energy CT scan as a feasible salvage imaging modality for the identification of non-localizing parathyroid adenomas: a prospective study.
        J Otolaryngol - Head Neck Surg. 2015 Dec; 44: 44
      1. Mahajan A, Starker L, Ghita M, Udelsman R, Brink J, Carling T. Parathyroid four-dimensional computed tomography: evaluation of radiation dose exposure during preoperative localization of parathyroid tumors in primary hyperparathyroidism. World J Surg. 36(6):1335–1339.

        • Seyednejad N.
        • Healy C.
        • Tiwari P.
        • et al.
        Dual-energy computed tomography: a promising novel preoperative localization study for treatment of primary hyperparathyroidism.
        Am J Surg. 2016 May; 211: 839-845
        • Hiebert J.
        • Hague C.
        • Hou S.
        • Wiseman S.M.
        Dual energy computed tomography should be a first line preoperative localization imaging test for primary hyperparathyroidism patients.
        Am J Surg. 2018 May; 215: 788-792
        • Kattar N.
        • Migneron M.
        • Debakey M.S.
        • Haidari M.
        • Pou A.M.
        • McCoul E.D.
        Advanced computed tomographic localization techniques for primary hyperparathyroidism: a systematic review and meta-analysis.
        JAMA Otolaryngol Neck Surg. 2022 May 1; 148: 448
        • Zhu M.
        • He Y.
        • Liu T.
        • et al.
        Factors that affect the sensitivity of imaging modalities in primary hyperparathyroidism.
        Internet J Endocrinol. 2021; (2021 Feb 20): 1-8
        • Berber E.
        • Parikh R.T.
        • Ballem N.
        • Garner C.N.
        • Milas M.
        • Siperstein A.E.
        Factors contributing to negative parathyroid localization: an analysis of 1000 patients.
        Surgery. 2008 Jul; 144: 74-79
        • Medas F.
        • Erdas E.
        • Longheu A.
        • et al.
        Retrospective evaluation of the pre- and postoperative factors influencing the sensitivity of localization studies in primary hyperparathyroidism.
        Int J Surg. 2016 Jan; 25: 82-87
        • Eichhorn-Wharry L.I.
        • Carlin A.M.
        • Talpos G.B.
        Mild hypercalcemia: an indication to select 4-dimensional computed tomography scan for preoperative localization of parathyroid adenomas.
        Am J Surg. 2011 Mar; 201: 334-338
        • Parikshak M.
        • Castillo E.
        • Conrad M.
        • Talpos G.
        Impact of hypercalcemia and parathyroid hormone level on the sensitivity of preoperative sestamibi scanning for primary hyperparathyroidism.
        Am Surg. 2003 May; 69: 393-398
        • Kebebew E.
        Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model.
        Arch Surg. 2006 Aug 1; 141: 777
        • Woisetschläger M.
        • Gimm O.
        • Johansson K.
        • Wallin G.
        • Albert-Garcia I.
        • Spångeus A.
        Dual energy 4D-CT of parathyroid adenomas not clearly localized by sestamibi scintigraphy and ultrasonography - a retrospective study.
        Eur J Radiol. 2020 Mar; 124108821
        • Sugg S.
        • Krzywda E.
        • Demeure M.
        • Wilson S.
        Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy.
        Surgery. 2004; 136: 1303-1309
        • Haciyanli M.
        • Lal G.
        • Morita E.
        • Duh Q.
        • Kebebew E.
        • Clark O.
        Accuracy of preoperative localization studies and intraoperative parathyroid hormone assay in patients with primary hyperparathyroidism and double adenoma.
        J Am Coll Surg. 2003; 197: 739-746
        • Jaskowiak N.
        • Norton H.
        • Alexander J.
        • et al.
        A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma.
        Ann Surg. 1996 Sep; 224: 308-320
        • Yen T.
        • Wang T.
        • Doffek K.
        • Krzywda E.
        • Wilson S.
        Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach.
        Surgery. 2008; 144: 611-621
        • Rodgers S.
        • Hunter G.
        • Hamber L.
        • et al.
        Improved preoperative planning for directed parathyroidectomy with 4-dimensional computed tomography.
        Surgery. 2006 Dec; 140: 932-940
        • Cordes M.
        • Dworak O.
        • Papadopoulos T.
        • Coerper S.
        • Kuwert T.
        MIBI scintigraphy of parathyroid adenomas: correlation with biochemical and histological markers.
        Endocr Res. 2018; 43: 141-148
        • Mihai R.
        • Gleeson F.
        • Buley I.
        • Roskell D.
        • Sadler G.
        Negative imaging studies for primary hyperparathyroidism are unavoidable: correlation of sestamibi and high-resolution ultrasound scanning with histological analysis in 150 patients.
        World J Surg. 2006; 30: 697-704
        • Siegel A.
        • Alvarado M.
        • Barth R.
        • Brady R.
        • Lewis J.
        Parameters in the prediction of the sensitivity of parathyroid scanning.
        Clin Nucl Med. 2006; 31: 679-682
        • Ciappuccini R.
        • Morera J.
        • Pascal P.
        • et al.
        Dualphase 99mTc sestamibi scintigraphy with neck and Thorax SPECT/CT in primary hyperparathyroidism.
        Clin Nucl Med. 2012; 37: 223-228
        • Arici C.
        • Cheah W.
        • Ituarte P.
        • et al.
        Can localization studies be used to direct focused parathyroid operations?.
        Surgery. 2001 Jun; 129: 720-729
        • Pons F.
        • Torregrosa J.
        • Fuster D.
        Biological factors influencing parathyroid localization.
        Nucl Med Commun. 2003; 24: 121-124
        • Kushchayeva Y.
        • Tella H.
        • Kushchayev S.
        • Van Nostrand D.
        • Kulkarni K.
        Comparison of hyperparathyroidism types and utility of dual radiopharmaceutical acquisition with Tc99m sestamibi and 123I for localization of rapid washout parathyroid adenomas.
        Osteoporos Int. 2019; 30: 1051-1057
        • Prekeges J.
        • Eisenberg B.
        Parathyroid scintigraphy.
        J Nucl Med Technol. 1997; 25: 59-65
        • Aygun N.
        • Uludag M.
        Intraoperative adjunct methods for localization in primary hyperparathyroidism.
        Sisli Etfal Hast Tip Bul. 2019; 53