Peeler B B, Martin W H, Sandler M P, Goldstein R E
Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA.
Am Surg. 1997 Jan;63(1):37-46.
For patients with previous thyroid or parathyroid surgery and for those with significant comorbid conditions, noninvasive and invasive modalities exist for the preoperative localization of pathologic parathyroid tissue. Formal localization at our institution involves obtaining two studies that are independently positive for the same location. The studies utilized have included ultrasound, CT scans, MRI, technetium-99m/thallium-201 (Tc-Tl) imaging, and more recently, (99m)Tc-sestamibi (20-25 mCi) (MIBI) scans. These were followed by arteriography and/or venous sampling if necessary. From January 1992 through October 1995, 25 patients underwent preoperative parathyroid localization (10 reoperation, 3 grave hypercalcemia, 2 concurrent goiter, 2 cerebral vascular accident, 1 bleeding disorder, and 1 malignant ventricular arrhythmia) and were evaluated prospectively during the changeover from Tc-Tl to MIBI scanning at our institution. A total of 92 studies were obtained. All 25 patients were operated on by a single surgeon, and in each case the parathyroid adenoma was successfully resected with minimal morbidity (1 permanent hypoparathyroid and 1 temporary recurrent laryngeal nerve injury). True positives interpreted preoperatively: MIBI, 14 of 19 (74%); CT scan, 13 of 19 (68%); Tc-Tl, 4 of 8 (50%), ultrasound, 9 of 20 (45%); MRI, 8 of 14 (57%); arteriography, 3 of 7 (43%); venous sampling, 3 of 4 (75%); and positron emission tomography, 0 of 1. There were no false-positive MIBI scans. These results suggest that when formal parathyroid localization is needed in reoperative/complicated patients, 1) MIBI appears to be the most sensitive and specific study, and 2) the MIBI scan should be the initial study in any situation in which preoperative localization is needed. Ultrasound can be useful for patients with significant comorbidities who have not been previously explored. CT or MRI should then be used if further evaluation is needed. If the use of these noninvasive modalities does not produce positive gland localization, selective venous sampling should be utilized as the definitive procedure.
对于既往有甲状腺或甲状旁腺手术史的患者以及有严重合并症的患者，存在多种非侵入性和侵入性方法用于术前定位病理性甲状旁腺组织。在我们机构，正式的定位需要获得两项针对同一部位均独立呈阳性的检查结果。所采用的检查包括超声、CT扫描、MRI、锝-99m/铊-201（Tc-Tl）显像，以及最近的（99m）Tc-甲氧基异丁基异腈（20 - 25 mCi）（MIBI）扫描。如有必要，随后会进行动脉造影和/或静脉采血。从1992年1月至1995年10月，25例患者接受了术前甲状旁腺定位检查（10例再次手术、3例重度高钙血症、2例合并甲状腺肿、2例脑血管意外、1例出血性疾病和1例恶性室性心律失常），并在我们机构从Tc-Tl扫描转换为MIBI扫描的过程中进行了前瞻性评估。共获得92项检查结果。所有25例患者均由同一位外科医生进行手术，每例患者的甲状旁腺腺瘤均成功切除，且并发症发生率极低（1例永久性甲状旁腺功能减退和1例暂时性喉返神经损伤）。术前判定的真阳性结果：MIBI，19例中有14例（74%）；CT扫描，19例中有13例（68%）；Tc-Tl，8例中有4例（50%），超声，20例中有9例（45%）；MRI，14例中有8例（57%）；动脉造影，7例中有3例（43%）；静脉采血，4例中有3例（75%）；正电子发射断层扫描，1例中0例。MIBI扫描无假阳性结果。这些结果表明，当再次手术/复杂患者需要进行正式的甲状旁腺定位时，1）MIBI似乎是最敏感和特异的检查，2）在任何需要术前定位的情况下，MIBI扫描都应作为初始检查。对于既往未接受过探查且有严重合并症的患者，超声可能有用。如果需要进一步评估，则应使用CT或MRI。如果这些非侵入性方法未能实现阳性腺体定位，则应采用选择性静脉采血作为确定性检查。
