术前双时相 99mTc-MIBI 闪烁显像和 IO-PTH 测定在治疗继发性和三发性甲状旁腺功能亢进中的作用。

The usefulness of preoperative dual-phase 99mTc MIBI-scintigraphy and IO-PTH assay in the treatment of secondary and tertiary hyperparathyroidism.

机构信息

III degrees General and Esophageal Surgical Unit, Saint John Baptist Hospital, University of Turin, Turin, Italy.

出版信息

Ann Surg. 2009 Dec;250(6):868-71. doi: 10.1097/SLA.0b013e3181b0c7f4.

DOI:10.1097/SLA.0b013e3181b0c7f4

PMID:19855263

Abstract

BACKGROUND

Persistent secondary or tertiary hyperparathyroidism (HPT) results from failure to remove enough hyperfunctioning parathyroid tissue. Ectopically situated parathyroid glands and supernumerary glands make failure more likely. Recurrent HPT after subtotal Ptx is usually due to regrowth of the remaining parathyroid tissue. Recurrence may also develop from a hyperplastic supernumerary gland or rarely from parathyromatosis. Recurrent HPT after total Ptx with autotransplantation is usually due to overgrowth of the autograft or for the previously mentioned reasons.

METHODS

Since 1995, 464 patients with SHPT or THPT were treated surgically; intraoperative parathormone (PTH) was measured in 277 patients. Sixty-eight patients also had a preoperative MIBI scan. We compared the preoperative MIBI scan results with intraoperative findings, parathyroid gland weight and histology. We questioned whether MIBI uptake corresponded to parathyroid gland size and weight. We also correlated the number of Ki67 nuclear positive cells with MIBI uptake. For SHPT in group I with 145 patients, neither intraoperative PTH (IO-PTH) assay nor MIBI scanning was done. In group II with 163 patients IO-PTH was used and in group III with 48 patients both IO-PTH and MIBI scanning was used. For THPT in group I with 42 patients, neither IO-PTH assay nor MIBI scanning was done. In group II with 46 patients IO-PTH was used and in group III with 20 patients both IO-PTH and MIBI scanning was used.

RESULTS

Parathyroid weight correlated directly with MIBI uptake. No correlation, however, occurred between MIBI uptake and parathyroid histology or between Ki67 staining and MIBI scanning. For SHPT in group I the persistence rate was 6.2% and recurrence rate 11%; in group II the persistence rate was 4.9% and recurrence rate 4.9%; in group III the persistence rate was 2%, and recurrence 4.2% (P < 0.05 between group I and III for persistence and recurrence). We obtained similar results in THPT, but recurrence was 0 in groups II and III, also when only 3 glands were removed, probably due to asymmetric hyperplasia commonly seen in this particular population (P < 0.05 regarding recurrence between group I and II-III, no difference between group II and III).

CONCLUSION

In conclusion our findings support that the surgeon experience is a very important factor for good results in patients with SHPT and THPT. Preoperative MIBI scanning and IO-PTH are helpful but not essential except in reoperations.

摘要

背景

持续性继发性或 tertiary 甲状旁腺功能亢进症（HPT）是由于未能切除足够的功能亢进甲状旁腺组织所致。异位甲状旁腺和多余的腺体使手术失败的可能性更大。全甲状腺切除术后复发 HPT 通常是由于剩余甲状旁腺组织的再生。复发也可能来自增生性多余腺体，或罕见地来自甲状旁腺瘤病。全甲状腺切除术后自体移植后复发 HPT 通常是由于自体移植物过度生长或由于之前提到的原因。

方法

自 1995 年以来，464 例 SHPT 或 THPT 患者接受了手术治疗；在 277 例患者中测量了术中甲状旁腺激素（PTH）。68 例患者还进行了术前 MIBI 扫描。我们比较了术前 MIBI 扫描结果与术中发现、甲状旁腺重量和组织学结果。我们质疑 MIBI 摄取是否与甲状旁腺大小和重量相对应。我们还将 Ki67 核阳性细胞的数量与 MIBI 摄取相关联。对于 I 组 145 例 SHPT 患者，均未进行术中 PTH（IO-PTH）测定或 MIBI 扫描。在 II 组 163 例患者中使用了 IO-PTH，在 III 组 48 例患者中同时使用了 IO-PTH 和 MIBI 扫描。对于 I 组 42 例 THPT 患者，均未进行 IO-PTH 测定或 MIBI 扫描。在 II 组 46 例患者中使用了 IO-PTH，在 III 组 20 例患者中同时使用了 IO-PTH 和 MIBI 扫描。

结果

甲状旁腺重量与 MIBI 摄取直接相关。然而，MIBI 摄取与甲状旁腺组织学之间或 Ki67 染色与 MIBI 扫描之间没有相关性。对于 I 组 SHPT，持续率为 6.2%，复发率为 11%；在 II 组中，持续率为 4.9%，复发率为 4.9%；在 III 组中，持续率为 2%，复发率为 4.2%（I 组和 III 组之间的持续率和复发率差异有统计学意义（P<0.05）。我们在 THPT 中也得到了类似的结果，但在 II 组和 III 组中复发率为 0，这可能是由于该特定人群中常见的不对称性增生（I 组和 II-III 组之间的复发差异有统计学意义（P<0.05），II 组和 III 组之间没有差异）。