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. 2022 Mar 31;148(5):448–456. doi: 10.1001/jamaoto.2022.0271

Advanced Computed Tomographic Localization Techniques for Primary Hyperparathyroidism

A Systematic Review and Meta-analysis

Nrusheel Kattar 1, Matthew Migneron 2, Michael S Debakey 2, Muhib Haidari 2, Anna M Pou 1, Edward D McCoul 1,2,3,✉
PMCID: PMC8972149  PMID: 35357400

Key Points

Question

What is the diagnostic performance of advanced computed tomographic (CT) techniques compared with current imaging standards for the localization of primary hyperparathyroidism?

Findings

This meta-analysis of 23 studies revealed a sensitivity that was greater with 4-dimensional (4D)-CT compared with the current first-line modality of sestamibi–single-photon emission CT (SPECT/CT).

Meaning

The 4D-CT may have superior diagnostic performance than the sestamibi-SPECT/CT in localizing primary hyperparathyroidism.

This systematic review with meta-analysis evaluates the diagnostic performance of advanced computed tomographic imaging techniques compared with current imaging standards for the localization of primary hyperparathyroidism.

Abstract

Importance

Emerging computed tomographic (CT) imaging techniques for the localization of primary hyperparathyroidism (PHPT) may be superior to the current imaging standard, thus necessitating a critical review and pooling of available evidence.

Objective

Primary hyperparathyroidism requires accurate imaging to guide definitive surgical management. Advanced techniques including 4-dimensional computed tomographic (4D-CT) scan have been investigated over the past decade. We sought to evaluate the efficacy of these emerging imaging techniques through pooled analysis of the existing evidence.

Data Sources

PubMed, Embase, and Web of Science databases were queried for original English articles without any restrictions on date.

Study Selection

We included comparative observational studies but excluded animal studies, case reports, and case series. Overall, 353 abstracts were screened independently by 2 investigators along with a third reviewer to resolve conflicts. A total of 26 full-text articles were included in this review.

Data Extraction and Synthesis

This review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines. Data was independently extracted by 2 investigators and subsequently pooled into a meta-analysis using a random-effects model.

Main Outcomes and Measures

Measures of imaging diagnostic performance such as sensitivity, specificity, positive predictive value, and negative predictive value were the primary outcomes of interest.

Results

Overall, of 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Of the 26 studies included, there were 5845 patients, of which 4176 were women (79.2%). The average of mean ages reported in 23 studies was 60.9 years. Meta-analysis in all patients with PHPT revealed pooled sensitivity that was greater with 4D-CT (81%; 95% CI, 77%-84%; I2 = 88%) compared with the current first-line modality of sestamibi–single-photon emission CT (SPECT/CT) (65%; 95% CI, 59%-70%; I2 = 93%). For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I2 = 93%) in contrast to 53% (95% CI, 35%-71%; I2 = 81%) for sestamibi-SPECT/CT. The overall quality of the 26 studies was moderate with a median (range) Methodological Index for Nonrandomized Studies score for all included studies of 15.5 (13-19).

Conclusions and Relevance

The findings of this systematic review and with meta-analyses of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed to determine the clinical significance of this improvement in localization.

Introduction

Primary hyperparathyroidism (PHPT) is a common endocrine disorder with an incidence of 21.6 per 100 000-person years.1 Definitive treatment requires surgical exploration of the anterior neck. Preoperative localization has traditionally been accomplished through imaging modalities such as ultrasonography and technetium-99m sestamibi with or without single-positron emission computed tomography (SPECT).2,3 Historically, these modalities have been used in conjunction with a single-phase, contrast-enhanced CT to assist with surgical anatomy and operative planning, hence the combined term “sestamibi-SPECT/CT.”

An important advance occurred in 2006 with the introduction of 4-dimensional computed tomography (4D-CT), which is a multiphase CT used to localize hyperactive parathyroid tissue.4 This imaging protocol scans from the mandible to the upper mediastinum, in a 4-image acquisition series at specific time intervals: before intravenous contrast, and in arterial, venous, and delayed contrast-enhanced phases.4

Dual-energy computed tomography (DECT) is an alternative imaging modality that has been recently described as a localization tool for PHPT. Dual-energy computed tomography essentially evaluates tissues at 2 different x-ray energies and then uses sophisticated computer algorithms to generate virtual postprocessing images, which eliminates the need for the additional image acquisitions and extra radiation that comes with the 4D-CT scan.5 Theoretically, the reduced radiation risk with the DECT and comparable sensitivity with the 4D-CT could make it a potentially useful modality in younger patients where the increased radiation associated with the 4D-CT is not acceptable.

A 2012 systematic review of preoperative localization techniques by Cheung et al6 included 4 studies on 4D-CT and authors concluded that further investigation was necessary. The use of 4D-CT has since expanded over the past decade, as evidenced by the 24 studies in our review, which investigated 4D-CT. Furthermore, the inclusion of studies for DECT and positron emission tomography PET/CT as PHPT localization tools is unique to this systematic review. In this systematic review, both qualitatively and quantitatively compared emerging CT localization techniques for patients with PHPT. The diagnostic performance of these techniques were contrasted with the current first-line standard of sestamibi-SPECT/CT.

Methods

A systematic review and meta-analysis were conducted consistent with the updated 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting standard.7

Protocol and Registration

The protocol for this review was accepted to the PROSPERO registry on February 27, 2021 (registration number: CRD42021232114).

Study Selection and Eligibility Criteria

We included comparative observational studies that investigated advanced CT localization techniques for PHPT but excluded studies that investigated non-CT imaging as well as studies that focused on patients with secondary/tertiary hyperparathyroidism, parathyroid carcinoma, or thyroid pathologic disease.

Overall, 353 abstracts were reviewed independently by 2 reviewers (M.H. and M.S.D.). Subsequently, 34 full-text articles underwent further screening (M.H. and M.S.D.) to determine eligibility for inclusion. Following full-text review, a total of 26 studies were deemed to meet inclusion criteria for this review. A PRISMA flow diagram of this process is presented in Figure 1.

Figure 1. PRISMA Flow Diagram of Systematic Review of Advanced CT Localization Techniques for Patients With Primary Hyperparathyroidism.

Figure 1.

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CT Indicates computed tomography.

Information Sources and Search Strategy

A comprehensive search of PubMed, Embase, and Web of Science databases was performed on January 26, 2021, for original English articles with no filters or date by Laura Wright, MLIS, MPH, our research support librarian. Keywords pertaining to the purpose of this review included: primary hyperparathyroidism, four-dimensional computed tomography, 4D-CT, 4D computed tomography, DECT, dual energy CT, dual energy CT scan, dual energy computed tomography. Various combinations of keywords were used in searches with “AND/OR” as connecting terms to refine results. The comprehensive search strategy used to query the PubMed database is outlined in the Table.8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33

Table. Study Characteristics in Systematic Review of Advanced CT Localization Techniques for Patients With Primary Hyperparathyroidism.

Source Study design No. of patients Patient age, mean (SD), y Patient sex
Female Male
Abbott et al, 20128 Retrospective cohort 535 Mean, 60.1 NA NA
Amadou et al, 20199 Retrospective cohort 29 63 (16) 25 4
Bahl et al, 201910 Retrospective cohort 604 58.8 (13.1) 471 133
Binks et al, 201911 Retrospective cohort 165 Mean, 66 132 33
Broome et al, 202112 Retrospective cohort 1485 65.6 (12.2) 1188 297
Brown et al, 201513 Retrospective cohort 100 Mean (range), 62 (15-85) 78 22
Cunha-Bezerra et al, 201814 Prospective cohort 18 55.1 (14.4) 15 3
DeGregorio et al, 201615 Retrospective cohort 504 60.6 (12.3) 397 107
Eichhorn-Wharry et al, 201116 Retrospective cohort 135 59.2 (13) 109 26
Eller et al, 202117 Retrospective cohort 100 61.1 (10.3) 80 20
Hamidi et al, 201818 Retrospective cohort 58 59.4 (13.9) 48 10
Hiebert et al, 201819 Retrospective cohort 97 Mean (range), 64 (29-84) 65 32
Hinson et al, 201520 Retrospective cohort 19 66.4 (11.9) 16 3
Jategaonkar et al, 202121 Retrospective cohort 42 Mean (range), 60.0 (24-76) 35 7
Kedarisetty et al, 201922 Retrospective cohort 58 Mean (range), 58.8 (28-80) 45 13
Krakauer et al, 201523 Prospective cohort 91 Median (range), 66.0 (28-85) 67 24
Kukar et al, 201524 Prospective cohort 200 Mean, 58.0 154 46
Mortensen et al, 200825 Prospective cohort 45 Median (range), 65 (28.6-84.5) 39 6
Piccin et al, 202126 Retrospective cohort 336 Mean (SD) [range], 58.9 (12.76) [11-84] 277 59
Pretet et al, 202027 Retrospective cohort 50 Mean (range), 62 (28-79) 39 11
Rodgers et al, 200628 Prospective cohort 75 Median (range), 60 (27-83) 163 2
Seyednejad et al, 201629 Retrospective cohort 24 Mean (range), 64 (35-82) 21 3
Starker et al, 201130 Prospective cohort 87 59.1 (1.49) 67 20
Suh et al, 201531 Prospective cohort 38 55.8 (13.2) 27 11
Tian et al, 201832 Retrospective cohort 510 Mean (range), 62.2 (16-93) 399 111
Yeh et al, 201933 Retrospective cohort 400 61 (14) 319 81
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Abbreviation: CT, computed tomography.

Data Collection

Two reviewers (N.K. and M.M.) each independently transferred results to a secure data sheet and were blinded to each other’s extractions.

Data Items

Data extracted from each study included (1) study characteristics; (2) disease characteristics; and (3) outcomes of imaging accuracy. Study characteristics included study design, age, sex, and number of patients, whereas, disease characteristics included preoperative and postoperative serum PTH levels and preoperative and postoperative serum calcium levels. Outcomes sought from each study for imaging accuracy were true positive results (TP), false positive results (FP), true negative results (TN), false negative results (FN), sensitivity (TP/TP+FN), specificity (TN/TN+FP), positive predictive value (PPV), and negative predictive value (NPV). In all studies, a TP was defined as a positive imaging result that was subsequently histopathologically confirmed after surgery to be parathyroid tissue. These measures were chosen as data items based on clinical judgement and experience with diagnostic studies.

Risk of Bias Assessment

Risk of bias for nonrandomized studies was assessed through the validated Methodological Index of Nonrandomized Studies (MINORS) criteria.34 26 articles were reviewed by 2 authors (N.K. and M.D.) and scored out of a total of 16 or 24 (if the study was comparative). Each item was scored as 0 for not reported, 1 for reported but inadequate, and 2 for adequate. The final score was an average of the total scores of both reviewers.

Synthesis Methods

Meta-analyses included imaging results to calculate summary estimates of sensitivities and specificities for 4D-CT and sestamibi-SPECT/CT in patients with PHPT as well as subgroups of patients with SGD/MGD or reoperative parathyroid disease. Analyses performed with RevMan software (version 5.3.5; Cochrane Group). Forest plots were generated using random-effects models with inverse variance for the statistical method. The random-effects model was used over a fixed-effects model owing to slight variations in design among the studies included in the analysis.

For each imaging modality, the heterogeneity measure used was the I2 test, which is used to quantify the inconsistency in results between studies leading to heterogeneity. Z was used as the test for overall effect to determine the statistical significance of the pooled estimate for both imaging modalities.

Results

Study Selection

Of articles initially reviewed by title and/or abstract, we identified 34 for full-text screening. Of these 34 articles screened, 26 met criteria for qualitative synthesis, and 23 of these were appropriate for meta-analysis. Common reasons for exclusion included: conference abstract, lack of data on 4D-CT, wrong study design, and lack of comparison groups. All studies that were available were included.

Study Characteristics

The 26 diagnostic studies (eTable 1 in the Supplement) were all delayed-type cross-sectional studies consisting of 5845 total patients.8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33 Of 26 studies, 25 reported on sex distribution with a total of 4176 women (79.2%) compared with 1094 men (20.8%). The average of mean ages reported in 23 studies was 60.9 years. The range of median ages reported in 3 studies was 60 to 66 years. A total of 23 studies investigated PHPT patient populations before initial parathyroid surgery.8,10,11,12,13,14,15,16,17,19,20,21,22,23,24,26,27,28,29,30,31,32,33 However, 3 studies reported specifically on patients with PHPT with recurrent/reoperative disease.9,25,28 Characteristics of parathyroid disease are summarized in eTable 2 in the Supplement.

Risk of Bias in Studies

The MINORS criteria items to assess risk of bias are presented in eTable 3 in the Supplement. Overall quality was moderate and included 26 studies. The median (range) MINORS score for all included studies was 15.5 (13-19). Common potential sources of bias in these studies were a lack of reporting of the loss of patients to follow-up, a lack of prospective calculation of sample size, and minimal blinding of observers and patients.

Qualitative Analysis

Measures of efficacy of each imaging modality organized by study are shown in eTables 4, 5, 6, 7, and 8 in the Supplement. Results based on imaging modality are described as follows.

4D-CT

Of 24 studies investigating 4D-CT as a first-line localization modality, 19 reported sensitivity values for all patients with PHPT, which ranged from as low as 58% to as high as 92%. Values for specificity, PPV, and NPV were similarly variable. The mean values for 4D-CT localization were 87.7% accuracy, 79.93% sensitivity, 84.45% specificity, 88.41% PPV, and 71.74% NPV.

Sensitivity of 4D-CT localization in reoperative PHPT patients as reported in 3 studies was variable, ranging from 60% to 100%.9,18,25 The variability in the results for these preoperative patients could be attributed to the complexity of their PHPT disease, which had already been unsuccessfully managed with a prior surgery.

In subsets of patients with single-gland parathyroid disease (SGD), sensitivity of 4D-CT localization ranged from 58% to 92%, contrasted with 43% to 67% in patients with multigland parathyroid disease (MGD).10,12,17,23,32,33

DECT & PET/CT

Only 5 studies investigated the relatively novel application of DECT and PET/CT for PHPT patients. The mean values for DECT localization were 77.5% accuracy, 87.0% sensitivity, and 88.5% PPV.19,29 The mean sensitivity for localization by PET-CT was 83.8%.9,26,27

Sestamibi-SPECT/CT

Of 26 studies, 18 reported imaging data for all eligible patients with PHPT, with a very wide range of sensitivities from the lowest value of 50.0% to as high as 90.0%. Averages for sestamibi-SPECT/CT localization were: 70.55% accuracy, 64.0% sensitivity, 78.9% specificity, 84.9% PPV, and 65.5% NPV.

Sensitivity of sestamibi-SPECT/CT localization in reoperative PHPT patients ranged from 39% to 89%.10,14,19,26,33 In patients with SGD, sensitivity ranged from 53% to 80%, contrasted with 4% to 41% in patients with MGD.10,12,17,23,32,33,35,36

Ultrasonography

Of all imaging modalities included in this review, ultrasonography had the lowest and most variable sensitivity values as a first-line tool for identifying PHPT, ranging from 19% to 84%. Average values for ultrasound localization were: 57.4% accuracy, 55.3% sensitivity, 85.0% specificity, 85.2% PPV, and 61.1% NPV.

Meta-analysis

Meta-analyses included 23 studies in this review.8,9,10,11,12,13,16,17,18,19,20,21,22,23,25,26,27,28,29,30,31,32,33 As seen in Figure 2, the pooled sensitivity for 4D-CT in the localization of PHPT in 4695 patients was 81% (95% CI, 77%-84%; I2, 88%). In contrast, the pooled sensitivity for sestamibi-SPECT/CT in 4791 patients was 65% (95% CI, 59%-70%; I2, 93%).

Figure 2. Forest Plot of Meta-analysis of Pooled Sensitivity in Systematic Review of Advanced CT Localization Techniques for Patients With Primary Hyperparathyroidism.

Figure 2.

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Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI.

Meta-analysis of pooled specificity (Figure 3) revealed a summary estimate of 89% (95% CI, 84%-94%; I2, 98%) for 4D-CT compared with 80% (95% CI, 70%-90%; I2, 99%) for sestamibi-SPECT/CT.

Figure 3. Forest Plot of Meta-analysis of Pooled Specificity in Systematic Review of Advanced CT Localization Techniques for Patients With Primary Hyperparathyroidism.

Figure 3.

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Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI.

For patients with recurrent PHPT requiring reoperation, 4D-CT pooled sensitivity was 81% (95% CI, 64%-98%; I2, 93%) in contrast to 53% (95% CI, 35%-71%; I2, 81%) for sestamibi-SPECT/CT (Figure 4).

Figure 4. Forest Plot of Meta-analysis of Pooled Sensitivity for Reoperative Patients in Systematic Review of Advanced CT Localization Techniques for Patients With Primary Hyperparathyroidism.

Figure 4.

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Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI.

In PHPT patients with SGD, 4D-CT imaging had a pooled sensitivity of 82% (95% CI, 74%-89%; I2, 89%) compared with 69% (95% CI, 63%-75%; I2, 88%) for sestamibi-SPECT/CT (eFigure 1 in the Supplement). Predictably, pooled sensitivity values dropped for the localization of multiple lesions in patients with MGD, with 60% (95% CI, 53%-68%; I2, 27%) sensitivity for 4D-CT and 25% (95% CI, 8%-42%; I2, 94%) for sestamibi-SPECT/CT (eFigure 2 in the Supplement).

DECT and PET/CT sensitivity/specificity values were not included in the meta-analysis since only two studies investigated each of these modalities as a first-line tool for PHPT patients. In addition, ultrasound imaging results were also not included since it is rarely used as a sole first-line localization tool for PHPT.

Results from Kukar et al24 were not included in the meta-analysis owing to missing data. Sensitivity values from Cunha-Bezerra14 were not included in the analysis because they were only reported in the context of hypercalcemia or normocalcemia, which is heterogenous to the other studies that were meta-analyzed.

Discussion

To our knowledge, this review is the first to summarize the evidence for the use of 4D-CT as well as novel applications of DECT and PET/CT as localization studies for the identification of PHPT.

In the past decade, numerous studies have investigated the utility of 4D-CT for single parathyroid gland localization, with reported sensitivities of 86% to 88% for 4D-CT, 40% to 65% for Tc99m-sestamibi, and 48% to 58% for ultrasonography.35 In 2013, Madorin et al36 determined the difference in charges for 4D-CT ($1296) and sestamibi scans ($1112) to be negligible, but noted that the 4D-CT scan only took an average of 5 minutes to complete compared with 306 minutes for the sestamibi.

The most commonly cited drawback to the 4D-CT scan is the theoretical increase in radiation dose compared with sestamibi scintigraphy (0.52% vs 0.19% lifetime risk).37 Hoang et al37 suggest that these increased risks are negligible in older populations but must be closely considered in younger patients.

Meta-analysis in all patients with PHPT revealed statistically significant pooled sensitivity and specificity values, which were greater with 4D-CT compared with the current first-line modality of sestamibi-SPECT/CT. Even in cohorts of patients with SGD, MGD, and reoperative PHPT, sensitivity values were greater in 4D-CT over sestamibi-SPECT/CT.

Although heterogeneity values were high through the meta-analyses, this could be attributed both to minor differences in study design as well as institution-dependent variations in imaging protocols leading to inconsistent identification of lesions by radiologists.

The clinical significance of improved preoperative localization technique as suggested by our meta-analyses is difficult to assess owing to a lack of data comparing long-term cure outcomes in patients with PHPT having a 4D-CT scan compared with those having a sestamibi-SPECT/CT. For instance, all the studies included in this review ask which imaging modality best localizes a PHPT lesion without contrasting how different imaging modalities affect cure rates in patients with PHPT.

Though there is limited data in the literature regarding differences in coverage/cost of 4D-CT compared with sestamibi-SPECT/CT with private insurance, adding 4D-CT to sestamibi-SPECT/CT and ultrasonography can result in a cost increase of $266 based on Medicare reimbursement.8 A cost-utility analysis of these imaging modalities for PHPT using Medicare reimbursement determined that the current imaging protocol that is most often used (sestamibi-SPECT/CT + ultrasound) was found to have an estimated total cost of $7371 and 29.8 quality-adjusted life-years (QALY) whereas 4D-CT alone had an estimated total cost of $6773 and 29.8 QALY.38 Although further study is necessary, it appears it may be beneficial economically to use the 4D-CT alone for preoperative PHPT localization as opposed to sestamibi-SPECT/CT plus ultrasound.

Limitations

Limitations of this study include subtle variations in imaging sequence protocols, as well as heterogeneity in practice for the radiologists performing and interpreting these imaging studies. The variation in 4D-CT imaging protocols appears to stem from its primary drawback of significant radiation exposure. Subtle protocol adjustments may be employed by different institutions in an effort to minimize radiation exposure, which may involve decreasing the number of imaging acquisitions or the strength of the radiation itself. This inconsistency across institutions is not well characterized in the literature and may be considered an inherent limitation to interpreting studies of diagnostic sensitivity optimization.

Another limitation was the inconsistency in the reported blinding of radiologists, which varied from study to study. In addition, the overlap of sestamibi-SPECT/CT and 4D/CT being performed in the same patients is inherent to all the studies in this review, which precludes any analysis of long-term differences in PHPT cure rates between these imaging modalities.

To effectively contrast PHPT cure outcomes based on imaging modality, future studies could be designed with matched cohorts of patients (to minimize confounders) who have similar levels of biochemical parathyroid disease undergoing only 1 type of imaging per cohort. Subsequent long-term follow-up could then possibly distinguish which imaging modality is associated with the highest rate of cure from PHPT.

Conclusions

Four-dimensional CT, DECT, and PET/CT are emerging advanced localization techniques for patients with PHPT. Although DECT and PET/CT need further study to confirm promising initial results, the findings of this systematic review and meta-analysis of numerous studies from the past decade suggest that the 4D-CT can be more sensitive and specific than sestamibi-SPECT/CT in localizing PHPT. More research is needed, ideally with standardized imaging protocols, to determine the clinical significance of this improvement in localization. The decision to use 4D-CT as a first-line tool over sestamibi-SPECT/CT remains one of surgeon preference in concordance with availability, insurance reimbursement considerations, and institutional policy.

Supplement.

eTable 1. Search Strategy in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 2. Disease Characteristics in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 3. Diagnostic Performance of Four-Dimensional Computed Tomography (4D-CT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 4. Diagnostic Performance of Dual-Energy Computed Tomography (DECT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 5. Diagnostic Performance of Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 6. Diagnostic Performance of Positron-Emission Tomography with Computed Tomography (PET-CT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 7. Diagnostic Performance of Ultrasound in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 8. Methodological Index of Nonrandomized Studies (MINORS) Criteria Scores for Assessment of Risk of Bias of Observational Studies in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eFigure 1. Forest Plot of Meta-Analysis of Pooled Sensitivity for Single-Gland Disease in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism. Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI

eFigure 2. Forest Plot of Meta-Analysis of Pooled Sensitivity for Multi-Gland Disease in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism. Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI

Click here for additional data file. (736.1KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eTable 1. Search Strategy in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 2. Disease Characteristics in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 3. Diagnostic Performance of Four-Dimensional Computed Tomography (4D-CT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 4. Diagnostic Performance of Dual-Energy Computed Tomography (DECT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 5. Diagnostic Performance of Sestamibi Single-Photon Emission Computed Tomography (SPECT)/CT in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 6. Diagnostic Performance of Positron-Emission Tomography with Computed Tomography (PET-CT) in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 7. Diagnostic Performance of Ultrasound in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eTable 8. Methodological Index of Nonrandomized Studies (MINORS) Criteria Scores for Assessment of Risk of Bias of Observational Studies in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism

eFigure 1. Forest Plot of Meta-Analysis of Pooled Sensitivity for Single-Gland Disease in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism. Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI

eFigure 2. Forest Plot of Meta-Analysis of Pooled Sensitivity for Multi-Gland Disease in Systematic Review of Advanced CT Localization Techniques for Patients with Primary Hyperparathyroidism. Diamond, overall effect estimates; square, point estimate of the study; black line, 95% CI

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