Parathyroid Imaging Should Follow Confirmed Diagnosis, Recommends JAMA Study
USA: A new JAMA Otolaryngology–Head & Neck Surgery analysis recommends performing parathyroid imaging only after primary hyperparathyroidism (pHPT) has been confirmed, with the authors emphasizing the importance of intentional imaging to minimize unnecessary radiation exposure. While ultrasound does not involve ionizing radiation, advanced localization techniques can expose patients to substantially higher radiation doses.
The Special Communication was published by Twyla B. Bartel, Global Advanced Imaging, PLLC, Little Rock, Arkansas, and colleagues. The authors reviewed contemporary imaging approaches used to localize abnormal parathyroid glands before surgery and highlighted the radiation burden associated with different modalities.
Preoperative localization has significantly improved the success of parathyroid surgery over the past four decades. However, the authors noted that imaging is intended to identify the location of abnormal parathyroid tissue rather than establish the diagnosis of pHPT. Therefore, imaging before biochemical confirmation may expose patients to radiation without providing appropriate clinical benefit.
The analysis evaluated commonly used parathyroid imaging modalities and quantified exposure to ionizing radiation in millisieverts (mSv). The review included imaging performed for patients with confirmed pHPT as well as those undergoing evaluation for persistent or recurrent disease after previous surgery.
The following were the key takeaways:
- Ultrasonography: 0 mSv radiation exposure; recommended as an initial imaging option.
- Technetium Tc 99m sestamibi SPECT ± CT: 8.6–12.1 mSv radiation exposure; used for further parathyroid localization.
- 4-dimensional CT: 9.3–20.2 mSv radiation exposure; considered for complex or revision parathyroid surgery.
- Choline-based PET ± CT: 6.7–11.8 mSv radiation exposure; another second-line option for complex or revision cases.
The authors stressed that the choice of imaging should not be based solely on the ability to locate a parathyroid adenoma. Clinicians should also consider the radiation dose, sensitivity and specificity for detecting adenomas, institutional expertise with the imaging technique, and associated costs.
The analysis particularly highlights the importance of avoiding unnecessary imaging before a diagnosis is established. Once pHPT has been confirmed, imaging can be used strategically to guide surgical planning and potentially improve operative outcomes.
Overall, the authors advocate an intentional, stepwise approach to parathyroid imaging, beginning with radiation-free ultrasound where appropriate and reserving higher-radiation techniques for situations in which additional localization is clinically justified. This approach may help balance the benefits of accurate preoperative localization with the need to reduce avoidable radiation exposure.
Reference:
Bartel TB, Yarbrough TL, Stack BC. Intentional Imaging for Primary Hyperparathyroidism. JAMA Otolaryngol Head Neck Surg. Published online August 20, 2026. doi:10.1001/jamaoto.2026.2316
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