Letter to the Editor: 18 F-fluorocholine PET/CT in MEN1 Patients with Primary Hyperparathyroidism
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LETTER TO THE EDITOR
Letter to the Editor: 18F-fluorocholine PET/CT in MEN1 Patients with Primary Hyperparathyroidism Oscar R. Barnes1
Accepted: 31 October 2020 Ó Socie´te´ Internationale de Chirurgie 2020
Dear Editor, It was a pleasure to read the recent article by Gauthe´ et al., which describes the use of FCH PET/CT in a series of patients with MEN1 [1]. In this article, the authors find that FCH PET/CT outperforms sestaMIBI scintigraphy in identifying pathologic parathyroid glands. Developing more effective imaging techniques of the parathyroid glands is of huge importance in guiding better surgical intervention. At present, methods of detecting pathological glands are inadequate. For example, a study by Nilubol et al. in 2015 [2] found a clear disconnect between the results of preoperative localizing studies and later intraoperative findings. Previously, as noted in this article, preoperative parathyroid gland imaging has been controversial, partly because it underperformed but also in line with the preponderance for carrying out extensive neck exploration and total parathyroid resection. This was because in patients with MEN1, the parathyroid glands are essentially guaranteed to form adenomas. Therefore, surgery tended to remove all parathyroid tissue despite the inevitable hypoparathyroidism that would follow. We now understand that the parathyroid glands of those with MEN1 can become adenomatous at dramatically different times. It is not uncommon for a patient to present, for example, with adenomatous parathyroid glands on one side and normal anatomy on the other. This is much more likely in a younger patient or someone with mild disease on biochemical analysis, and so an understanding of their pretest probability of having limited disease is always important in interpreting preoperative investigations. In a
young patient with mild hypercalcemia, carrying out a less extensive intervention with the knowledge of inevitably having to operate later in their life is a sensible option, as it avoids unnecessarily rendering them hypoparathyroid for the many years in between. Often, a period of several years can be achieved before the next surgery is required, during which time retention of the remaining normal parathyroid tissue increases their quality of life. Furthermore, younger patients often have unilateral disease. This means that minimally invasive parathyroidectomy can be carried out on the affected side without causing any disruption to the other side [3]. If, later in life, primary hyperparathyroidism manifests again, surgery for this will be essentially a new operation as it is on the opposite of the body. As our understanding of MEN1-related hyperparathyroidism has improved, our surgical treatment is becoming more targeted and considerate and so the need for effective preoperative imaging has increased dramatically. It is exciting to see improvements in imaging such as FCH PET/CT, which should help us to offer the right treatment at the right time, alongside developments such as intraoperative parat
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