{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T22:06:15Z","timestamp":1791324375446,"version":"4.3.1"},"reference-count":45,"publisher":"MDPI AG","issue":"15","license":[{"start":{"date-parts":[[2025,8,4]],"date-time":"2025-08-04T00:00:00Z","timestamp":1754265600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Introduction: Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by excessive parathyroid hormone production, typically due to adenomas, hyperplasia, or carcinoma. Preoperative imaging plays a critical role in guiding surgical planning, particularly in selecting patients for minimally invasive procedures. While first-line imaging techniques, such as ultrasound and 99mTc-sestamibi scintigraphy, are standard, advanced second-line imaging modalities like 18F-fluorocholine PET\/CT (FCH-PET) and four-dimensional computed tomography (4D-CT) have emerged as valuable tools when initial diagnostics are inconclusive. Methods: This article provides an updated review and recommendations of the role of these advanced imaging techniques in localizing parathyroid adenomas. Results: FCH-PET has shown exceptional sensitivity (94% per patient, 96% per lesion) and is particularly useful in detecting small or ectopic adenomas. Despite its higher sensitivity, it can yield false positives, particularly in the presence of thyroid disease. On the other hand, 4D-CT offers detailed anatomical imaging, aiding in the identification of parathyroids in challenging cases, including recurrent disease and ectopic glands. Studies suggest that FCH-PET and 4D-CT exhibit similar diagnostic performance and could be complementary in preoperative planning of most difficult situations. Conclusions: This article also emphasizes a multimodal approach, where initial imaging is followed by advanced techniques only in cases of uncertainty. Although 18F-fluorocholine PET\/CT is favored as a second-line option, 4D-CT remains invaluable for its high spatial resolution and ability to guide surgery in complex cases. Despite limitations in evidence, these imaging modalities significantly enhance the accuracy of parathyroid localization, contributing to more targeted and minimally invasive surgery.<\/jats:p>","DOI":"10.3390\/jcm14155468","type":"journal-article","created":{"date-parts":[[2025,8,5]],"date-time":"2025-08-05T08:46:55Z","timestamp":1754383615000},"page":"5468","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":11,"title":["Primary Hyperparathyroidism: 18F-Fluorocholine PET\/CT vs. 4D-CT for Parathyroid Identification: Toward a Comprehensive Diagnostic Framework\u2014An Updated Review and Recommendations"],"prefix":"10.3390","volume":"14","author":[{"given":"Gregorio","family":"Scerrino","sequence":"first","affiliation":[{"name":"Unit of Endocrine Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0222-9736","authenticated-orcid":false,"given":"Nunzia Cinzia","family":"Paladino","sequence":"additional","affiliation":[{"name":"Department of General and Endocrine Surgery, Conception Hospital, Aix-Marseille University, 147 Boulevard Baille, 13005 Marseille, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppa","family":"Graceffa","sequence":"additional","affiliation":[{"name":"Unit of General and Oncology Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppina","family":"Melfa","sequence":"additional","affiliation":[{"name":"Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppina","family":"Orlando","sequence":"additional","affiliation":[{"name":"Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2524-8691","authenticated-orcid":false,"given":"Renato","family":"Di Vuolo","sequence":"additional","affiliation":[{"name":"Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0187-524X","authenticated-orcid":false,"given":"Chiara","family":"Lo Cicero","sequence":"additional","affiliation":[{"name":"Unit of General and Emergency Surgery, Department of Surgical Oncological and Oral Sciences, Policlinico \u201cP. Giaccone\u201d, University of Palermo, Via Liborio Giuffr\u00e9 5, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alessandra","family":"Murabito","sequence":"additional","affiliation":[{"name":"Unit of Nuclear Medicine, Biomedical Department of Internal and Specialist Medicine, Policlinico \u201cP. Giaccone\u201d, University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stefano","family":"Radellini","sequence":"additional","affiliation":[{"name":"Section of Endocrinology, Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pierina","family":"Richiusa","sequence":"additional","affiliation":[{"name":"Section of Endocrinology, Department of Health Promotion Sciences Maternal and Infantile Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Lo Casto","sequence":"additional","affiliation":[{"name":"Section of Radiology, Department of Biomedicine, Neuroscience and Advanced Diagnostics (BIND), Policlinico \u201cP. Giaccone\u201d, University of Palermo, 90127 Palermo, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"168","DOI":"10.1016\/S0140-6736(17)31430-7","article-title":"Hyperparathyroidism","volume":"391","author":"Bilezikian","year":"2018","journal-title":"Lancet"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1007\/s13304-017-0477-1","article-title":"Updates in Primary Hyperparathyroidism","volume":"69","author":"Gasparri","year":"2017","journal-title":"Updates Surg."},{"key":"ref_3","doi-asserted-by":"crossref","unstructured":"Gurrado, A., Pasculli, A., Avenia, N., Bellantone, R., Boniardi, M., Merante Boschin, I., Cal\u00f2, P.G., Camandona, M., Cavallaro, G., and Cianchi, F. (2023). 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