Challenges and unmet needs of 18Ffluorocholine PET in hyperparathyroidism: A framework for refining current practice and advancing parathyroid imaging.

The advent of 18Ffluorocholine (FCH) positron emission tomography (PET)/computed tomography (CT) or magnetic resonance (MR) imaging has enhanced the diagnostic performance of preoperative imaging in patients with primary and renal hyperparathyroidism (HPT) during the past decade 1, 2. Numerous studies and meta-analyses have confirmed the excellent performance of FCH PET, including in complex cases (i.e., inconclusive or negative results on parathyroid scintigraphy, recurrence, renal hyperparathyroidism (HPT), multiple endocrine neoplasia type 1 (MEN1)-related pHPT), with diagnostic accuracy consistently exceeding 95% in larger studies 3-11. As a result, when available, FCH PET is a widely accepted first-line modality for primary and renal HPT 10. Moreover, FCH PET offers several advantages over parathyroid scintigraphy, such as a lower radiation dose burden (especially if PET/MR is used) 12, 13, shorter acquisition times, and sustained cost-effectiveness 14-17. Despite these advantages, there are several unmet needs that remain to be addressed. This editorial explores the remaining challenges associated with the use of FCH PET and underscores the need for close interdisciplinary collaboration among nuclear medicine physicians, endocrinologists, and surgeons to further optimize diagnostic and therapeutic strategies and address existing clinical gaps.