Safety and efficiency of microwave ablation for recurrent and persistent secondary hyperparathyroidism after parathyroidectomy: A retrospective pilot study

Background: Recurrent and persistent secondary hyperparathyroidism (SHPT) nodules have an incidence of 10–70% after surgery. The treatment of recurrent and persistent SHPT nodules is a challenge, and surgical resection of difficult-to-reach or post-operative adhesions often fails. Purpose: The aim of this research was to study the safety and effectiveness of microwave ablation (MWA) for recurrent and persistent SHPT. Materials and methods: This was a retrospective study of 11 patients enrolled with a total of 16 nodules, and MWA was employed to manage SHPT. The laboratory test results, including the intact parathyroid hormone (iPTH), serum calcium, phosphorus and alkaline phosphatase (ALP) levels, improvement of SHPT-related symptoms after ablation, and complications during and after MWA were recorded and analysed. Results: After ablation the value of iPTH was markedly decreased from 1570?±?1765?pg/mL to 287?±?239?pg/mL 1 day after MWA (p?<?0.05). The levels of serum calcium and phosphorus decreased from 2.51?±?0.23?mmol/L to 2.06?±?0.27?mmol/L (p?<?0.001) and 1.80?±?0.43?mmol/L to 1.48?±?0.32?mmol/L (p?<?0.05), respectively, 1 day after MWA. There was no significant difference in the ALP value before and after MWA (p?>?0.05). The clinical symptoms, including ostalgia, pruritus, disability, and restless legs, improved after MWA. Minor complications and side effects encountered during or after MWA include haematoma (1/11, 9%), transient hoarseness (2/11, 18.2%), hypocalcemia (6/11, 54.5%). No major complication occurred. Conclusion: MWA may be safe and effective to manage recurrent and persistent SHPT nodules; a definite conclusion needs to expand the sample size with a longer follow-up time.     

Microwave ablation: an effective treatment for mild-to-moderate secondary hyperparathyroidism in patients undergoing haemodialysis

Abstract

Background: Microwave ablation (MWA) is an effective treatment for severe secondary hyperparathyroidism (SHPT), but it can also be used for mild-to-moderate secondary hyperparathyroidism (SHPT). In this randomised, controlled study, the efficacy of MWA in the treatment of mild-to-moderate hyperparathyroidism is investigated.

Materials and methods: We assessed outcomes 12?months after the randomisation of 28 patients with mild-to-moderate SHPT. The subjects received either MWA plus calcitriol or calcitriol alone. The primary end-points were the rate of achieving target levels of intact parathyroid hormone (iPTH), changes in iPTH levels and the rate of patients developing severe SHPT.

Results: Primary end points: the overall rates of achieving target levels of iPTH were comparable between the MWA and calcitriol alone groups (24% vs. 22%, p?=?0.85). However, the rate of iPTH <150?pg/mL (lower limit of the target range) in the MWA group was higher than that in the calcitriol alone group (23% vs. 8%, p?=?0.02). The mean iPTH level in the MWA group after MWA was lower than that in the calcitriol alone group (373.09?±?322.31 vs. 552.28?±?361.87?pg/mL, p?<?0.001). There was a significant difference in the change in iPTH levels over time within the MWA group (p?<?0.001) but not in the calcitriol alone group. Only one patient developed severe SHPT in the MWA group, while six patients in the calcitriol alone group developed severe SHPT (p?=?0.04).

Conclusions: Compared with calcitriol alone, MWA plus calcitriol decreases iPTH levels and prevents the progression of mild-to-moderate SHPT.     

Parathyroid carcinoma,atypical parathyroid adenoma,or parathyromatosis?

BACKGROUND: Parathyroid carcinoma, atypical parathyroid adenoma, and parathyromatosis can be differentiated relatively easily from typical parathyroid adenomas, but distinguishing them from each other is more difficult. METHODS: A retrospective study of 28 consecutive patients with parathyroid carcinoma, 7 patients with atypical parathyroid adenoma, and 13 patients with parathyromatosis who were treated at the University of California at San Francisco Medical Center between 1966 and 2005 was performed. Patient demographics and clinical characteristics, indication for surgery, intraoperative findings, histopathologic characteristics, disease recurrence or persistence, site of invasion/metastases, and survival were compared in the 3 groups. RESULTS: Parathyroid carcinoma (19 of 28 patients) and atypical adenoma (4 of 7 patients) were significantly more common in men, whereas parathyromatosis was more common in women (10 of 13 patients) (P = .02). A palpable neck mass and hoarseness were almost exclusively present in patients with parathyroid carcinoma. Prior to the first parathyroid surgery, patients with parathyroid carcinoma were found to have higher blood calcium levels (>/=14 mg/dL in 16 of 26 patients [62%]), whereas only 1 of 6 patients with atypical adenoma (17%) and no patients with parathyromatosis were found to have profound hypercalcemia (P < .01). Intraoperatively, patients with parathyroid carcinoma and atypical adenoma presented with single lesions, whereas patients with parathyromatosis had multiple small lesions. Histopathologic findings were well defined in parathyroid carcinoma, but some findings overlapped in the 3 tumors studied. CONCLUSIONS: Patients with parathyroid carcinoma often differ from those with atypical parathyroid adenoma or parathyromatosis at the time of presentation because patients with parathyroid carcinoma have more profound hypercalcemia as well as invasive tumors. However, at times it is difficult to distinguish between these conditions both clinically and by final histologic examination.     

异位甲状旁腺肿瘤合并原发性甲状旁腺功能亢进症的研究进展

甲状旁腺肿瘤是引起原发性甲状旁腺亢进症的主要因素。异位甲状旁腺肿瘤较为少见,多数肿瘤无典型的临床症状,隐匿性高而在临床中易被忽视。对异位性肿瘤的定性、定位是目前临床诊治难点,99Tcm-MIBI闪烁扫描术是诊断甲状旁腺肿瘤的金标准,通常与其他影像方法联合应用。手术治疗是最有效也是唯一可以治愈的方式。     

Efficacy and its predictor in microwave ablation for severe secondary hyperparathyroidism in patients undergoing haemodialysis

Background: Microwave ablation (MWA) can be used to treat severe secondary hyperparathyroidism; however, its efficacy and the predictor of its efficacy are unclear. In this retrospective study we determined the predictor of efficacy of MWA and compared the efficacy of MWA and parathyroidectomy.

Materials and methods: Patients with severe secondary hyperparathyroidism who had received MWA or parathyroidectomy were enrolled in the study. Participants with MWA were divided into response and no response groups based on efficacy. Possible predictors were analysed using logistic regression to determine efficacy predictors. The participants were divided into MWA and parathyroidectomy groups, and the efficacy (including rates of achieving recommended goals for intact parathyroid hormone (iPTH), calcium, and phosphorus levels) were compared between the two groups.

Results: Thirty-one participants were enrolled for predictor analysis. Only baseline iPTH level predicted efficacy (OR 0.997, P?=?0.018). The optimal threshold value of iPTH for predicting efficacy was 1493.5?pg/mL. To compare efficacy, 30 patients were enrolled in MWA (18/30) and parathyroidectomy (12/30) groups. The rates of achieving recommended goals for iPTH levels varied between 0 and 60%; a significant difference was found between the groups at 5 months (P?=?0.01). However, in the parathyroidectomy group, the iPTH level and rate of iPTH <124?pg/mL (lower limit of target range) were significantly lower than in the MWA group after treatment (40–75% versus 0–16.7%).

Conclusion: Baseline iPTH level is a good predictor of MWA efficacy for severe secondary hyperparathyroidism; parathyroidectomy is more effective for severe secondary hyperparathyroidism than MWA.     

Up-to-date on parathyroid carcinoma: analysis of an experience of 19 cases

BACKGROUND AND OBJECTIVES: Parathyroid carcinoma (PC) is a rare disease; experience with its management is limited. The aim of this retrospective study was to evaluate a relatively large series of patients suffering from PC. METHODS: Since 1980, PC was diagnosed in the 4.7% of cases of primary hyperparathyroidism (HPT) (19 patients). Clinical and biochemical features, and surgical outcome were analyzed. RESULTS: In patients with PC, the mean serum calcium was 3.34 mmol/L; the tumor size 30.5 mm. Malignancy was never diagnosed preoperatively. Thirty-two operations were performed; six patients underwent repeated surgery. Recurrence of HPT was observed in 100% of patients. The median disease-free interval was 15 months (range 2-74 months). Fifteen patients died because of the disease; median survival was 29 months (range 20-146 months). A significant correlation was found between late recurrences and prolonged survival; less advanced age and higher preoperative calcium levels predicted early recurrences. CONCLUSIONS: Preoperative diagnosis of PC is difficult. Preoperative severe hypercalcemia should alert the surgeon. En bloc resection of the PC and the adjacent structures is the treatment of choice. Unfortunately, recurrences are common and long-term survival rate is low.     

Focused parathyroidectomy without intraoperative parathormone testing is safe after pre-operative localization with 18F-Fluorocholine PET/CT

A focused surgical approach based on pre-operative localization replaced the classical four-gland exploration in patients with primary hyperparathyroidism (PHP). Sestamibi scanning and ultrasound are most often used localization modalities with reported sensitivity of 54–100% for identification of single gland disease.The aim of this study was to analyze the results of pre-operative localization with ¹⁸F-Fluorocholine PET/CT (FCh-PET) in patients with PHP.A retrospective review of 151 patients with PHP who underwent surgery after pre-operative localization with FCh-PET was performed. Only a focused parathyroidectomy without ioPTH testing had been done in patients with single adenoma on FCh-PET. Primary outcome was operative failure, defined as persistent PHP.According to pre-operative FCh-PET 126 (83,4%) patients had single adenoma, 22 (14,5%) multiglandular disease and the test was negative in only two patients. Intraoperative failure experienced 4/126 patients (3,3%) with single adenoma. Removed parathyroid glands were normal in three and hyperplastic in one patient with intraoperative failure. A limited bilateral neck exploration with ioPTH testing was used in 14/22 patients with double adenoma and a classical four-gland exploration without ioPTH testing was used in 8/22 patients with more than two pathological glands according to pre-operative FCh-PET. Intraoperative failure experienced 2/22 patients (9,1%). In two patients with negative FCh-PET a classical four-gland exploration without ioPTH testing was used and one experienced intraoperative failure.A preoperative localization with FCh-PET is a reliable test in patients with PHP. Patients with a single adenoma on FCh-PET can safely undergo a focused parathyroidectomy without ioPTH testing.     

甲状旁腺增生手术治疗分析

目的:总结甲状旁腺增生致甲状旁腺功能亢进症的外科治疗经验.方法:回顾性分析2000年-2012年在广西医科大学第一附属医院胃肠腺体外科行外科手术治疗的10例甲状旁腺增生致功能亢进症患者的临床资料.全组病例均行甲状旁腺切除术,其中5例曾在外院行1~3枚甲状旁腺切除,5例在本院初次手术.结果:10例患者中骨、关节病变6例(骨棕色瘤2例),泌尿系结石病变4例,骨和泌尿系结石病变3例,病理性骨折1例.全组血钙均升高,在2.81~7.37mmol/L之间,平均3.57mmol/L.10例患者术前测定甲状旁腺激素升高在153~296ng/L之间,平均206ng/L.术后全组均随访6~18个月,术后患者临床症状缓解,骨质疏松改善,骨折愈合,有3例患者出现短期低血钙,出现面部、手足麻木,1例出现手足抽搐;术后有7例患者血钙正常,低血钙者经钙剂和骨化三醇治疗1~4周均可改善,血钙恢复正常.术后9例患者甲状旁腺激素均在1个半月内恢复到正常,1例略高于正常值.结论:甲状旁腺切除术是治疗甲状旁腺增生致甲状旁腺功能亢进症的有效方法.而手术切除增生的甲状旁腺范围是手术疗效的关键.     

Trends in the incidence and treatment of parathyroid cancer in the United States

BACKGROUND: Parathyroid cancer is a rare cause of hyperparathyroidism. The objectives of this study were to determine the patterns of disease, treatment trends, and outcomes among patients with parathyroid cancer by using a population-based data source. METHODS: Surveillance, Epidemiology, and End Results (SEER) cancer registry data were used to identify patients who were diagnosed with parathyroid cancer from 1988 through 2003. To assess whether the incidence rate, treatment, tumor size, and cancer stage changed over time, the Cochrane-Armitage trend test was used, and Cox proportional-hazards modeling was used to identify the factors associated with an improved overall survival rate. RESULTS: From 1988 through 2003, 224 patients with parathyroid cancer were reported in the SEER data. Over that 16-year study period, the incidence of parathyroid cancer increased by 60% (1988-1991, 3.58 per 10,000,000 population; 2000-2003, 5.73 per 10,000,000 population). Most patients (96%) underwent surgery (parathyroidectomy, 78.6% of patients; en bloc resection, 12.5% of patients; other, 4.9% of patients). The rate of surgical treatment increased significantly during the study period. The 10-year all-cause mortality rate was 33.2%, and the 10-year cancer-related mortality rate was 12.4%. Patient age (P<.0001), sex (P=.0106), the presence of distant metastases at diagnosis (P=.0004), and the year of diagnosis (P=.0287) were associated significantly with the overall survival rate. Tumor size, lymph node status, and type of surgery were not associated significantly with the overall survival rate. CONCLUSIONS: Although parathyroid cancer is rare, the incidence increased significantly in the United States from 1988 through 2003. Young age, female gender, recent year of diagnosis, and absence of distant metastases were associated significantly with an improved survival rate.     

Hyperparathyroidism and subsequent incidence of breast cancer

Preliminary data are available on the coexistence of primary hyperparathyroidism and breast carcinoma. To further understand the association between hyperparathyroidism and breast cancer, we conducted a record-linkage study in Sweden using the Swedish Cancer Registry from 1958-1997. A total of 9,835 women who underwent surgery for primary parathyroid adenoma were followed to evaluate the hypothesis that a history of primary hyperparathyroidism increases the risk of subsequent breast cancer. During 99,929 person-years of follow-up, 331 cases of newly diagnosed breast cancer were reported. The number of expected breast cancers in this population was 260.0. This resulted in a standardized incidence ratio of 1.27 (95% confidence interval [CI] = 1.14-1.41). The relation persisted over time after the surgical removal of the parathyroid adenoma. Possible explanations for the observed association are a shared etiology including genetic and environmental factors such as early life radiation, and hypercalcemia after the overproduction of parathyroid hormone, which may increase breast cancer incidence.     

甲状旁腺功能亢进并发颌骨瘤样变的治疗

目的：探讨甲状旁腺功能亢进引起颌骨瘤样病变的治疗方法。方法：回顾分析我院2000年-2009年收治的由甲状旁腺功能亢进引起颌骨瘤样病变患者的临床资料,总结其临床特点及治疗方法。结果：所有患者行甲状旁腺肿瘤切除,对局灶型的颌骨瘤样病变采取保守治疗,经观察,均自行恢复。结论对甲状旁腺功能亢进引起的颌骨瘤样病变,仅对甲状旁腺肿瘤手术切除,颌骨病灶采取保守治疗的方法是一种有效的治疗方法。     

甲状旁腺功能亢进并发颌骨瘤样变的治疗

目的:探讨甲状旁腺功能亢进引起颌骨瘤样病变的治疗方法。方法:回顾分析我院2000年-2009年收治的由甲状旁腺功能亢进引起颌骨瘤样病变患者的临床资料,总结其临床特点及治疗方法。结果:所有患者行甲状旁腺肿瘤切除,对局灶型的颌骨瘤样病变采取保守治疗,经观察,均自行恢复。结论对甲状旁腺功能亢进引起的颌骨瘤样病变,仅对甲状旁腺肿瘤手术切除,颌骨病灶采取保守治疗的方法是一种有效的治疗方法。     

甲状腺手术中甲状旁腺显影的临床应用进展

摘 要：术中识别甲状旁腺是甲状腺癌手术中重要的外科技术。裸眼识别依靠外科医师的经验。正显影识别主要包括5-氨基乙酰丙酸、吲哚菁绿、亚甲蓝,通过全身静脉注射,副反应严重,临床未广泛应用。目前临床主要应用纳米碳、米托蒽醌两类负显影识别,但纳米碳不可降解,米托蒽醌有细胞毒性,有待优化性能。新近甲状旁腺自体荧光显影技术兴起,研究结论尚不一致,无靶向性,存在一定假阳性。未来基于荧光技术,研发特异性的甲状旁腺正显影是发展的重要趋势。     

甲状旁腺腺瘤并多器官功能不全一例报告并文献复习

甲状旁腺是重要的内分泌腺体,主要调节人体钙磷代谢[1],甲状旁腺腺瘤是一种少见的原发于甲状旁腺的良性肿瘤,由甲状旁腺腺瘤引发的甲状旁腺功能亢进症约占90%左右,是原发性甲状旁腺功能亢进的最主要原因[2]。近年来随着甲状腺体检普及而发病率略有提高,手术切除是甲状旁腺腺瘤最主要的治疗方法[3]。本研究对收治的1例甲状旁腺腺瘤并多器官功能不全患者的资料进行分析,结果报道如下。     

Sestamibi scan-directed unilateral neck exploration for primary hyperparathyroidism due to a solitary adenoma

AIM: To evaluate the accuracy of Tc-99m sestamibi scintography in pre-operative localization of a single parathyroid adenoma and to determine if neck exploration can be limited to the side of the adenoma. METHODS: Over a period of 4 years, 30 patients with primary hyperparathyroid disease underwent surgical treatment in the form of unilateral neck exploration after localization by Tc-99m sestamibi scintigraphy. The scan findings were interpreted by one radiologist with a special interest in parathyroid imaging and the operative findings were correlated with scan findings. RESULTS: Tc-99 sestamibi scan localized a single parathyroid adenoma in 29 patients. There was doubtful uptake of isotope in one patient. Unilateral cervical exploration confirmed isotope scan findings in 29 patients with a positive scan, and these were subsequently proven by histology. In the patient with doubtful sestamibi scan, bilateral neck exploration was undertaken and three enlarged glands were excised. All the three glands were reported to be abnormal, consistent with either adenomas or hyperplasia. All the patients were normocalcaemic after 6 months follow-up. CONCLUSIONS: Our results demonstrate that Tc-99m sestamibi scintigraphy is highly accurate in pre-operative localization of a single parathyroid adenoma when performed by an experienced radiologist. Unilateral cervical exploration, as directed by a positive Tc-99m sestamibi scintigram, seems to be a logical approach for the patients with primary hyperparathyroid disease due to solitary adenoma.     

Microwave ablation is as effective as radiofrequency ablation for very-early-stage hepatocellular carcinoma

Background: Percutaneous radiofrequency ablation (RFA) is a first-line treatment for very-early-stage hepatocellular carcinoma (HCC), whereas the efficacy of percutaneous microwave ablation (MWA) for very-early-stage HCC remains unclear. The purpose of this study was to clarify this issue by comparing the safety and efficacy of percutaneous MWA with percutaneous RFA in treating very-early-stage HCC. Methods: Clinical data of 460 patients who were diagnosed with very-early-stage HCC and treated with percutane-ous MWA or RFA between January 2007 and July 2012 at the Eastern Hepatobiliary Surgery Hospital, The Second Mili-tary Medical University, in Shanghai, China were retrospectively analyzed. Of these 460 patients, 159 received RFA, 301 received MWA. Overall survival (OS), recurrence-free survival (RFS), local tumor progression (LTP), complete ablation, and complication occurrence rates were compared between the two groups, and the prognostic factors associated with survival were analyzed. Results: No significant differences were observed between the two groups in terms of the 1-, 3-, or 5-year OS rates (99.3%, 90.4%, and 78.3% for MWA vs. 98.7%, 86.8%, and 73.3% for RFA, respectively;P= 0.331). Furthermore, no signif-icant differences were observed between the two groups in terms of the corresponding RFS rates (94.4%, 71.8%, and 46.9% for MWA vs. 89.9%, 67.3%, and 54.9% for RFA, respectively;P= 0.309), the LTP rates (9.6% vs. 10.1%,P= 0.883), the complete ablation rates (98.3% vs. 98.1%,P= 0.860), or the occurrence rates of major complications (0.7% vs. 0.6%,P= 0.691). By multivariate analysis, LTP, antiviral therapy, and treatment of recurrence were independent risk fac-tors for OS (P < 0.001), and the alpha-fetoprotein level was an independent prognostic factor for RFS (P= 0.002). Conclusions: MWA is as safe and effective as RFA in treating very-early-stage HCC, supporting MWA as a first-line treatment option for this disease.     

微波消融与手术切除治疗原发性小肝癌对癌细胞播散入血的影响

目的 对比研究微波消融与手术切除治疗原发性小肝癌（PHC）对癌细胞播散入血及外周血细胞免疫功能的影响。方法 将符合条件的40例患者,分为微波组19例,手术组21例,于治疗前、治疗后30min、1d及7d采静脉血,实时定量巢式RT-PCR检测外周血甲胎蛋白（AFP）mRNA,并检测CD3、CD4、CD8、CD4／CD8及肝功能。结果 手术组和微波组患者术后血清ALT及AST均升高,手术组升高较微波组显著;与术前相比,微波组患者术后7d内CD3、CD4、CD8和CD4／CD8无明显变化（P〉0．05）,手术组CD3、CD4和CD4／CD8较术前降低;实时定量巢式RT-PCR检测两组患者外周血标本,治疗前67．5％（27／40）患者可检测出AFP mRNA拷贝数,治疗后表达量增高,两组之间比较,差异无统计学意义。随访患者1～16个月,其外周血中AFP mRNA持续表达者,复发转移的可能性大。结论 微波消融或手术切除原发性小肝癌,可造成患者外周血中脱落肝癌细胞增多,患者外周血细胞免疫功能手术后降低,而微波消融后得以很好保护,微波消融对肝功能的损伤较小,此方法治疗PHC有一定的临床应用价值。     

Defining a molecular phenotype for benign and malignant parathyroid tumors

BACKGROUND:

It is frequently difficult to establish histologically whether a parathyroid tumor is a parathyroid carcinoma, parathyromatosis, or an atypical adenoma. The authors asked whether these tumors have a distinctive molecular profile, whether benign tumors could be distinguished from malignant tumors, and whether parathyromatosis is a low‐grade parathyroid carcinoma or is benign tissue that can invade other organs.

METHODS:

Samples of parathyroid carcinoma, atypical adenoma, parathyromatosis, parathyroid adenoma, and hyperplasia were obtained for tissue microarray studies. The molecular expression of genes involved in parathyroid tumor progression (HRPT2 [“parafibromin”], galectin‐3, Ki‐67, Rb, p27, and mdm‐2) was investigated by immunohistochemistry.

RESULTS:

Complete loss of parafibromin expression was seen in 5 of 16 (31.3%) parathyroid carcinomas; all parathyromatosis, atypical adenomas, adenomas, and hyperplasia stained positive for parafibromin. Loss of Rb expression was seen in 5 (33.3%) of 15 parathyroid carcinomas and 1 (7.1%) of 14 parathyroid hyperplasias; all parathyromatosis, atypical adenomas, and adenomas stained positive. Galectin‐3 stained strongly positive in 14 (93.3%) of 15 parathyroid carcinomas, and positive in 3 (18.7%) of 16 cases of parathyromatosis, 2 (100%) of 2 atypical adenomas, 1 (5.6%) of 18 adenomas, and 2 (14.3%) of 14 hyperplasias. The Ki‐67 proliferative index was high in 9 (60%) of 15 parathyroid carcinomas, 1 (6.7%) of 15 cases of parathyromatosis, 1 (5.6%) of 18 adenomas, and no atypical adenomas or hyperplasia. P27 and mdm‐2 protein expression did not differ appreciably among the tumor types.

CONCLUSIONS:

No single diagnostic marker currently determines whether a parathyroid tumor is a parathyroid carcinoma, but loss of parafibromin and Rb expression, and overexpression of galectin‐3, generally distinguish parathyroid carcinoma from other parathyroid tumors. Parathyromatosis does not appear to be a low‐grade parathyroid carcinoma. Cancer 2009. © 2009 American Cancer Society.