Parathyroid adenoma is responsible for 85% of primary hyperparathyroidism (PHPT). Target (minimally invasive) surgery is the gold standard, for which preoperative imaging localization is essential.

A male patient, 68 years old, with osteoporosis, was diagnosed with primary hyperparathyroidism (PHPT). Aiming at target surgery, an ultrasound, and a Tc-99m sesta MIBI scintigraphy were performed to locate the abnormal parathyroid tissue.

Ultrasonography was negative. Additionally, no hyperfuncional parathyroid tissue was found in the MIBI. A cervical and thoracic CT was negative for eutopic and ectopic parathyroids. Before proceeding to a cervical exploration, an 11C-Choline PET/CT was performed. A 9 mm nodule posterior to the inferior pole of the right thyroid lobe suggestive of a parathyroid adenoma was found. A right PIII target parathyroidectomy through a backdoor approach was conducted. The surgery was uneventful. Pathology confirmed the diagnosis of a PIII adenoma.

In PHPT, failure to preoperatively identify the diseased parathyroid gland(s) requires bilateral cervical exploration, associated with greater morbidity. PET-Choline is superior to MIBI in the preoperative identification of parathyroid tissue. The clinical case supports how PET-Choline can be essential for surgical planning by avoiding cervical exploration and promoting a target parathyroidectomy, reducing operative risks.