Uludag Mehmet, Unlu Mehmet Taner, Kostek Mehmet, Caliskan Ozan, Aygun Nurcihan, Isgor Adnan
Division of Endocrine Surgery, Department of General Surgery, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye.
Deparment of General Surgery, Sisli Memorial Hospital, Istanbul, Türkiye.
Sisli Etfal Hastan Tip Bul. 2023 Mar 21;57(1):1-17. doi: 10.14744/SEMB.2023.39260. eCollection 2023.
Primary hyperparathyroidism (pHPT) is the most common cause of hypercalcemia and currently the only definitive treatment is surgery. Although the success rate of parathyroidectomy is over 95% in experienced centers, surgical failure is the most common complication today. Persistent HPT (perHPT) is defined as persistence of hypercalcemia after parathyroidectomy or recurrence of hypercalcemia within the first 6 months, and recurrence of hypercalcemia after a normocalcemic period of more than 6 months is defined as recurrent HPT (recHPT). In the literature, perHPT is reported to be 2-22%, and the rate of recHPT is 1-15%. perHPT is often associated with misdiagnosed pathology or inadequate resection of hyperfunctioning parathyroid tissue, recHPT is associated with newly developing pathology from potentially pathologically natural tissue left in situ at the initial surgery. In the pre-operative evaluation, the initial diagnosis of pHPT and the diagnosis of perHPT or rec HPT should be confirmed in patients who are evaluated with a pre-diagnosis (suspect) of perHPT and recHPT. Surgery is recommended if it meets any of the recommendations in surgical guidelines, as in patients with pHPT, and there are no surgical contraindications. The first preoperative localization studies, surgical notes, operation drawings, if any, intraoperative PTH results, pathological results, and post-operative biochemical results of these patients should be examined. Localization studies with preoperative imaging methods should be performed in all patients with perHPT and recHPT with a confirmed diagnosis and surgical indication. The first-stage imaging methods are ultrasonography and Tc99m sestamibi single photon tomography Tc99mMIBI SPECT or hybrid imaging method, which is combined with both single-photon emission computed tomography and computed tomography (SPECT/CT). The combination of USG and sestamibi scintigraphy increases the localization of the pathological gland. In the secondary stage, Four-Dimensional computer tomography (4D-CT) or dynamic 4-dimensional Magnetic Resonance Imaging (4D-MRI) can be applied. It is focused on as a secondary stage imaging method, especially when the lesion cannot be detected by conventional methods. Positron Emission Tomography (PET) and PET/CT examinations with 11C-choline or 18F-fluorocholine are promising imaging modalities. Invasive examinations can rarely be performed in patients in whom suspicious, incompatible or pathological lesion cannot be detected in noninvasive imaging methods. Bilateral jugular vein sampling, selective venous sampling, parathyroid arteriography, imaging-guided fine-needle aspiration biopsy, and parathormone washout are invasive methods.
原发性甲状旁腺功能亢进症（pHPT）是高钙血症最常见的病因，目前唯一的确定性治疗方法是手术。尽管在经验丰富的中心，甲状旁腺切除术的成功率超过95%，但手术失败是目前最常见的并发症。持续性甲状旁腺功能亢进症（perHPT）定义为甲状旁腺切除术后高钙血症持续存在或在术后6个月内高钙血症复发，而在血钙正常超过6个月后高钙血症复发则定义为复发性甲状旁腺功能亢进症（recHPT）。据文献报道，perHPT的发生率为2% - 22%，recHPT的发生率为1% - 15%。perHPT通常与病理误诊或功能亢进的甲状旁腺组织切除不充分有关，recHPT则与初次手术时原位留存的潜在病理自然组织新出现的病变有关。在术前评估中，对于术前诊断为perHPT和recHPT（疑似）的患者，应确认pHPT的初始诊断以及perHPT或recHPT的诊断。如果符合手术指南中的任何建议，如pHPT患者且无手术禁忌证，则建议进行手术。应检查这些患者的首次术前定位研究、手术记录、手术图（如有）、术中甲状旁腺激素（PTH）结果、病理结果及术后生化结果。对于所有确诊且有手术指征的perHPT和recHPT患者，均应采用术前成像方法进行定位研究。第一阶段的成像方法是超声检查和锝99m甲氧基异丁基异腈单光子断层扫描（Tc99mMIBI SPECT）或单光子发射计算机断层扫描与计算机断层扫描相结合的混合成像方法（SPECT/CT）。超声检查（USG）和甲氧基异丁基异腈闪烁扫描相结合可提高病变甲状旁腺的定位。在第二阶段，可应用四维计算机断层扫描（4D - CT）或动态四维磁共振成像（4D - MRI）。尤其是在常规方法无法检测到病变时，它作为第二阶段成像方法受到关注。使用11C - 胆碱或18F - 氟胆碱的正电子发射断层扫描（PET）和PET/CT检查是很有前景的成像方式。对于在非侵入性成像方法中无法检测到可疑、不相符或病理性病变的患者，很少进行侵入性检查。双侧颈静脉采血、选择性静脉采血、甲状旁腺动脉造影、成像引导下细针穿刺活检和甲状旁腺激素洗脱是侵入性方法。
