Direct Comparison of Preoperative Imaging Modalities for Localization of Primary Hyperparathyroidism: A Systematic Review and Network Meta-analysis

Abstract

Importance: Accurate preoperative localization of primary hyperparathyroidism (pHPT) is an important and challenging issue for a successful parathyroidectomy. Although new imaging modalities have been introduced during the past decade, direct comparative studies on advanced imaging techniques are limited.

Objective: To compare the performance of different preoperative imaging modalities for the localization of pHPT by performing a network meta-analysis (NMA).

Data sources: PubMed, Embase, and the Cochrane Library were searched from the earliest available indexing date through September 28, 2020.

Study selection: The inclusion criteria were diagnostic tests with sensitivities of 2 or more different preoperative imaging modalities for the same indivduals.

Data extraction and synthesis: Two researchers independently reviewed the literature according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses extension statement of health care intervention guidelines for network meta-analyses.

Main outcomes and measures: After classifying various imaging modalities into 8 representative imaging categories, the pooled estimation between the odds ratio and 95% credible intervals (CrIs) was calculated in the sensitivity for localization of pHPT. The surface under the cumulative ranking curve (SUCRA) values were obtained to calculate the probability of each imaging modality being the most effective diagnostic method.

Results: A total of 8495 patients from 119 direct comparative studies using 2 or more imaging modalities for localization of pHPT were included. The sensitivity of choline positron emission tomography and computed tomography (PET-CT) was significantly higher than that of technetium 99m sestamibi single-photon emission computed tomography (MIBI SPECT) in both patient-based and lesion-based analyses (patient-based analysis: odds ratio, 5.22; 95% CrI, 2.36-11.80; lesion-based analysis: odds ratio, 17.70; 95% CrI, 5.79-60.10). Among 8 representative imaging modality categories, choline PET-CT showed the highest SUCRA value in both patient-based and lesion-based analyses. In patient-based analysis after 2010, choline PET-CT showed the highest SUCRA value, followed by the CT category, although MIBI SPECT had the highest SUCRA value in analysis before 2009.

Conclusions and relevance: The results from this network meta-analysis suggest that choline PET-CT showed the best performance in both patient-based and lesion-based analyses and that choline PET-CT would be the best preoperative imaging modality for localization of pHPT.

Figure 1.. Flowchart of the Literature Search

Databases were searched for eligible direct comparison studies on the performance of 2 or more noninvasive preoperative imaging modalities for localization of primary parahyperthyroidism.

Figure 2.. Forest Plots of the Sensitivity of 8 Representative Categories of Imaging Modalities for Localization of Primary Parahyperthyroidism

All modalities are compared with the technetium 99m sestamibi (MIBI) single-photon emission computed tomography (SPECT) category. 95% CrI indicates 95% credible interval; CT, computed tomography; MET, carbon 11–labeled methionine; MRI, magnetic resonance imaging; PET, positron emission tomography; and US, ultrasonography.