微波消融治疗前臂甲状旁腺移植组织功能亢进2例并文献复习
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摘要
目的探讨超声引导下微波消融治疗前臂甲状旁腺移植组织功能亢进的效果及技术安全性。方法 2例曾行甲状旁腺全切除联合自体组织移植术(PTX+AT)并行维持性血液透析的患者,因血清全段甲状旁腺激素(iPTH)水平显著升高及伴发症状加重,确诊为前臂甲状旁腺移植组织功能亢进。对移植物进行多模态高频超声检查并行超声引导下经皮微波消融术治疗,观察患者术后疗效和临床症状。结果超声检查清晰显示2例患者前臂甲状旁腺移植组织的位置、数量、大小、血流灌注状态。测定2例患者各移植组织内iPTH水平后,保留测定值最低的1枚,其余均实施微波消融术,消融治疗均获技术成功。2例患者共消融前臂甲状旁腺移植组织分别为5枚和4枚,最大者分别为15 mm×6 mm和13 mm×5 mm。2例患者微波消融术后1 d移植侧、非移植侧前臂静脉血iPTH水平分别为87.3 ng/L、79.6 ng/L和66.3 ng/L、65.2 ng/L。术后1年随访期间患者钙、磷、碱性磷酸酶水平均下降并持续稳定,骨和关节痛明显缓解,且未出现移植侧前臂皮肤感觉麻木以及指、腕关节的屈伸活动异常。结论 PTX+AT后前臂甲状旁腺移植组织可发生功能亢进,微波消融可有效治疗移植组织功能亢进,其操作简便且安全性高。
Objective To explore the treatment effect and technical safety of ultrasound-guided microwave ablation for hyperparathyroidism of forearm transplanted autograft. Methods Two patients who had undergone parathyroidectomy with autotransplantation(PTX+AT) and maintenance hemodialysis were diagnosed as having hyperparathyroidism of forearm transplanted autograft based on the increased serum intact parathyroid hormone(iPTH) and aggravated accompanying symptoms. The multimodal high frequency ultrasound was performed to examine the autografts, and ultrasound-guided percutaneous microwave ablation was used to treat the hyperparathyroidism of the patients. Curative effect and symptoms of the patients were observed after treatment. Results Ultrasonography clearly showed the location, number, size and blood perfusion of the parathyroid gland autografts in the forearm of the two patients. After measuring the levels of iPTH in the transplanted tissues of the two patients, one with the lowest iPTH level was retained and the others were treated with microwave ablation, and the ablation treatment was technically successful. In the two patients, 5 and 4 parathyroid gland autografts were ablated and the largest ones were 15 mm×6 mm and 13 mm×5 mm, respectively. The levels of iPTH on the graft side and non-graft side were 87.3 ng/L and 79.6 ng/L, and 66.3 ng/L and 65.2 ng/L after 1 day of microwave ablation, respectively. During the follow-up period of 1 year after microwave ablation, calcium, phosphorus and alkaline phosphatase levels of the two patients were decreased and remained stable, bone and joint pains were relieved, and no numbness or abnormal movement of fingers and wrist joints were found in the transplanted side. Conclusion Hyperparathyroidism of forearm transplanted autograft can occur after PTX+AT. Microwave ablation is effective and safe in the treatment of the hyperparathyroidism.
Objective To explore the treatment effect and technical safety of ultrasound-guided microwave ablation for hyperparathyroidism of forearm transplanted autograft. Methods Two patients who had undergone parathyroidectomy with autotransplantation(PTX+AT) and maintenance hemodialysis were diagnosed as having hyperparathyroidism of forearm transplanted autograft based on the increased serum intact parathyroid hormone(iPTH) and aggravated accompanying symptoms. The multimodal high frequency ultrasound was performed to examine the autografts, and ultrasound-guided percutaneous microwave ablation was used to treat the hyperparathyroidism of the patients. Curative effect and symptoms of the patients were observed after treatment. Results Ultrasonography clearly showed the location, number, size and blood perfusion of the parathyroid gland autografts in the forearm of the two patients. After measuring the levels of iPTH in the transplanted tissues of the two patients, one with the lowest iPTH level was retained and the others were treated with microwave ablation, and the ablation treatment was technically successful. In the two patients, 5 and 4 parathyroid gland autografts were ablated and the largest ones were 15 mm×6 mm and 13 mm×5 mm, respectively. The levels of iPTH on the graft side and non-graft side were 87.3 ng/L and 79.6 ng/L, and 66.3 ng/L and 65.2 ng/L after 1 day of microwave ablation, respectively. During the follow-up period of 1 year after microwave ablation, calcium, phosphorus and alkaline phosphatase levels of the two patients were decreased and remained stable, bone and joint pains were relieved, and no numbness or abnormal movement of fingers and wrist joints were found in the transplanted side. Conclusion Hyperparathyroidism of forearm transplanted autograft can occur after PTX+AT. Microwave ablation is effective and safe in the treatment of the hyperparathyroidism.
引文
[1]花瞻,姚力,张凌.继发性甲状旁腺功能亢进的外科治疗[J].临床内科杂志,2012,29:305-307.
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[3]李可,周宇帆,胡宪明.甲状旁腺全切加前臂自体移植术治疗继发性甲状旁腺功能亢进[J].中国现代手术学杂志,2017,21:1-4.
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[7]章建全,仇明,盛建国,卢峰,赵璐璐,张航,等.超声引导下经皮穿刺热消融治疗甲状旁腺结节[J].第二军医大学学报,2013,34:362-370.ZHANG J Q,QIU M,SHENG J G,LU F,ZHAO LL,ZHANG H,et al.Ultrasound-guided percutaneous thermal ablation for benign parathyroid nodules[J].Acad J Sec Mil Med Univ,2013,34:362-370.
[8]章建全,盛建国,赵璐璐,卢峰.超声引导下正常甲状旁腺细针穿刺物甲状旁腺激素含量测定及细胞学验证[J].第二军医大学学报,2013,34:357-361.Z H A N G J Q,S H E N G J G,Z H A O L L,L U F.Determination of parathyroid hormone content in ultrasound-guided fine-needle aspiration of normal parathyroid and cytological verification[J].Acad J Sec Mil Med Univ,2013,34:357-361.
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[10]章建全,马娜,徐斌,刘灿,宋家琳,刁宗平.超声引导监测下经皮射频消融甲状腺腺瘤的方法学研究[J].中华超声影像学杂志,2010,19:861-865.
[11]GOLDSMITH D,KOTHAWALA P,CHALIAN A,BERNAL M,ROBBINS S,COVIC A.Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of fracture and need for parathyroidectomy in CKD[J].Am J Kidney Dis,2009,53:1002-1013.
[12]谢胜学,陈江明,余立权,耿小平,郝丽.尿毒症继发性甲状旁腺功能亢进两种自体移植方式的疗效比较[J].中华内分泌外科杂志,2015,9:287-290.
[13]张凌.继发性甲状旁腺功能亢进的治疗策略[J].中华肾病研究电子杂志,2015,4:5-9.
[14]王海峰,张凌,姚力,鲁瑶,赵振宇,杨猛,等.三种不同甲状旁腺切除术治疗继发性甲状旁腺功能亢进425例疗效比较[J].中国血液净化,2016,15:455-458.
[15]TOMINAGA Y,MATSUOKA S,UNO N.Surgical and medical treatment of secondary hyperparathyroidism in patients on continuous dialysis[J].World J Surg,2009,33:2335-2342.
[16]薛玉仿,郝丽,王德光,袁亮,何衡杰,刘桂凌,等.甲状旁腺全切并自体前臂移植术治疗肾性难治性继发性甲状旁腺功能亢进疗效随访分析[J].临床肾脏病杂志,2015,15:212-216.
[17]SCHLOSSER K,VEIT J A,WITTE S,FERNáNDEZE D,VICTOR N,KNAEBEL H P,et al.Comparison of total parathyroidectomy without autotransplantation and without thymectomy versus total parathyroidectomy with autotransplantation and with thymectomy for secondary hyperparathyroidism:TOPAR PILOT-Trial[J/OL].Trials,2007,8:22.doi:10.1186/1745-6215-8-22.
[18]刁宗礼,王丽妍,代文迪,刘文虎.继发性甲状旁腺功能亢进消融治疗进展[J].中华全科医师杂志,2016,15:318-320.
[19]于明安,董雪娟,穆梦娟,彭丽丽,梁萍.微波消融治疗原发性甲状旁腺功能亢进的初步临床探讨[J].中华老年多器官疾病杂志,2016,15:491-494.
[20]YU M A,YAO L,ZHANG L,PENG L,ZHUO L,ZHANG Y,et al.Safety and efficiency of microwave ablation for recurrent and persistent secondary hyperparathyroidism after parathyroidectomy:a retrospective pilot study[J].Int J Hyperthermia,2016,32:180-186.
[21]章建全.应用高频超声造影评价浅表病灶微循环灌注的缺陷及初步解决方案[J].第二军医大学学报,2007,28:1193-1196.ZHANG J Q.High-frequency contrast-enhanced ultrasound in evaluating perfusion of superficial lesions:limitations and countermeasures[J].Acad J Sec Mil Med Univ,2007,28:1193-1196.
[2]侯爱珍,肖观清,孔耀中,陈伟雄,张剑利.甲状旁腺全切除加前臂移植术治疗继发性甲状旁腺功能亢进患者的临床疗效观察[J].中国血液净化,2016,15:285-288.
[3]李可,周宇帆,胡宪明.甲状旁腺全切加前臂自体移植术治疗继发性甲状旁腺功能亢进[J].中国现代手术学杂志,2017,21:1-4.
[4]王凯,刘章锁,王沛,武静.甲状旁腺全切+前臂移植术后复发性及持续性甲状旁腺功能亢进的治疗观察[J].中国血液净化,2015,14:163-167.
[5]张凌,王文博,姚力,卞维静,陈少轩.甲状旁腺全切加前臂移植术后继发性甲状旁腺功能亢进症复发1例[J].中国血液净化,2011,10:277-282.
[6]余力,勾长龙,李芳,冯芝娅.甲状旁腺全消融与部分消融对继发甲状旁腺功能亢进疗效的观察[J].介入放射学杂志,2016,24:498-501.
[7]章建全,仇明,盛建国,卢峰,赵璐璐,张航,等.超声引导下经皮穿刺热消融治疗甲状旁腺结节[J].第二军医大学学报,2013,34:362-370.ZHANG J Q,QIU M,SHENG J G,LU F,ZHAO LL,ZHANG H,et al.Ultrasound-guided percutaneous thermal ablation for benign parathyroid nodules[J].Acad J Sec Mil Med Univ,2013,34:362-370.
[8]章建全,盛建国,赵璐璐,卢峰.超声引导下正常甲状旁腺细针穿刺物甲状旁腺激素含量测定及细胞学验证[J].第二军医大学学报,2013,34:357-361.Z H A N G J Q,S H E N G J G,Z H A O L L,L U F.Determination of parathyroid hormone content in ultrasound-guided fine-needle aspiration of normal parathyroid and cytological verification[J].Acad J Sec Mil Med Univ,2013,34:357-361.
[9]章建全.甲状旁腺功能性结节的超声诊断与经皮热消融治疗[D].上海:第二军医大学,2014.
[10]章建全,马娜,徐斌,刘灿,宋家琳,刁宗平.超声引导监测下经皮射频消融甲状腺腺瘤的方法学研究[J].中华超声影像学杂志,2010,19:861-865.
[11]GOLDSMITH D,KOTHAWALA P,CHALIAN A,BERNAL M,ROBBINS S,COVIC A.Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of fracture and need for parathyroidectomy in CKD[J].Am J Kidney Dis,2009,53:1002-1013.
[12]谢胜学,陈江明,余立权,耿小平,郝丽.尿毒症继发性甲状旁腺功能亢进两种自体移植方式的疗效比较[J].中华内分泌外科杂志,2015,9:287-290.
[13]张凌.继发性甲状旁腺功能亢进的治疗策略[J].中华肾病研究电子杂志,2015,4:5-9.
[14]王海峰,张凌,姚力,鲁瑶,赵振宇,杨猛,等.三种不同甲状旁腺切除术治疗继发性甲状旁腺功能亢进425例疗效比较[J].中国血液净化,2016,15:455-458.
[15]TOMINAGA Y,MATSUOKA S,UNO N.Surgical and medical treatment of secondary hyperparathyroidism in patients on continuous dialysis[J].World J Surg,2009,33:2335-2342.
[16]薛玉仿,郝丽,王德光,袁亮,何衡杰,刘桂凌,等.甲状旁腺全切并自体前臂移植术治疗肾性难治性继发性甲状旁腺功能亢进疗效随访分析[J].临床肾脏病杂志,2015,15:212-216.
[17]SCHLOSSER K,VEIT J A,WITTE S,FERNáNDEZE D,VICTOR N,KNAEBEL H P,et al.Comparison of total parathyroidectomy without autotransplantation and without thymectomy versus total parathyroidectomy with autotransplantation and with thymectomy for secondary hyperparathyroidism:TOPAR PILOT-Trial[J/OL].Trials,2007,8:22.doi:10.1186/1745-6215-8-22.
[18]刁宗礼,王丽妍,代文迪,刘文虎.继发性甲状旁腺功能亢进消融治疗进展[J].中华全科医师杂志,2016,15:318-320.
[19]于明安,董雪娟,穆梦娟,彭丽丽,梁萍.微波消融治疗原发性甲状旁腺功能亢进的初步临床探讨[J].中华老年多器官疾病杂志,2016,15:491-494.
[20]YU M A,YAO L,ZHANG L,PENG L,ZHUO L,ZHANG Y,et al.Safety and efficiency of microwave ablation for recurrent and persistent secondary hyperparathyroidism after parathyroidectomy:a retrospective pilot study[J].Int J Hyperthermia,2016,32:180-186.
[21]章建全.应用高频超声造影评价浅表病灶微循环灌注的缺陷及初步解决方案[J].第二军医大学学报,2007,28:1193-1196.ZHANG J Q.High-frequency contrast-enhanced ultrasound in evaluating perfusion of superficial lesions:limitations and countermeasures[J].Acad J Sec Mil Med Univ,2007,28:1193-1196.