Available online 15 October 2025

Teaching points:

[18F]fluorocholine (FCH) PET/CT demonstrate high diagnostic performance for localizing parathyroid adenomas, including lesions < 1 cm, when used as the initial imaging modality

This is one of the first studies to evaluate FCH-PET/CT in routine clinical practice, outside of controlled research settings.

Replacing SPECT/CT with first-line FCH-PET/CT reduces scan time by 82% and significantly lowers radiation exposure, enhancing efficiency and patient comfort.

Detection of hyperplasia and intrathyroidal parathyroid adenomas remains a diagnostic challenge.

For treatment of hyperparathyroidism(HPT), accurate detection of potential parathyroid adenomas(PPA) is crucial prior to surgical removal. [18F]fluorocholine(FCH) PET/CT has emerged as an alternative to previous imaging procedures, and literature shows superior diagnostic performance. This study aims to evaluate FCH-PET/CT as a first-line procedure for localizing PPAs in a real-world setting, and establish benefits and challenges of adopting this procedure.

Patients referred for HPT imaging had FCH-PET/CT performed as first-line procedure. The diagnostic performance was determined from histopathology on both per-patient and per-lesion level and 6-months biochemical follow-up. The radiation burden and acquisition duration was determined to evaluate patient benefits. Imaging descriptions and surgical reports were examined to uncover any challenges.

Fifty-eight patients were included, of which 39 had undergone parathyroidectomy at the time of data collection. Per-patient results were; sensitivity 97.4%, positive predictive value 100%. Per-lesion results were; sensitivity 82.6%, positive predictive value 97.4%. Compared to the previous imaging procedure, patients experienced a 43% reduction in radiation burden, and an 82% reduction in acquisition time. Histopathology revealed a superiority in detecting adenomas over hyperplasia. Additionally, detecting adenomas and hyperplasia located intrathyroidally was challenging.

FCH-PET/CT yields a high diagnostic performance in clinical practice, thus making it one of the reliable first-line imaging procedure. Despite several benefits, the procedure holds challenges in regards to hyperplasia detection and intrathyroidally located adenomas. These observations from an early adopting center should be in consideration for other sites, looking to implement FCH-PET/CT as a first-line imaging procedure in clinical practice.

hyperparathyroidism

PET/CT

fluorocholine

parathyroid adenoma

[18F]fluorocholine

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Acknowledgements: We would like to acknowledge Anne Arveschoug and Maria Balshøj at the Nuclear Medicine Department at Aarhus University Hospital, Denmark, for sharing their insights into FCH protocol specifications. We would also like to thank Stine Rosenkilde Larsen at the Department of Pathology at Odense University Hospital, Denmark, for her assistance in understanding the examination process of the removed parathyroid glands.

Competing Interests The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose nor any conflict of interests.

Sources of Support None.

Author Contributions All authors contributed to the study conception and design. All authors performed preliminary image assessment, data collection and analysis. All authors have read and approved the final manuscript.

Clinical Relevance: This is one of the first studies to assess FCH-PET/CT as a first-line nuclear imaging modality in real-world clinical practice outside a research setting. It shows high diagnostic performance and reduces scan time and radiation dose. Limited sensitivity for hyperplasia and intrathyroidal parathyroid adenomas should be considered in clinical use.

© 2025 Published by Elsevier Inc. on behalf of the AACE.