摘要
目的：手术是唯一治愈原发性甲状旁腺功能亢进症(primary hyperparathyroidism, PHPT)的方法,传统的手术方式为双侧颈部探查(bilateral neck exploration, BNE)。在过去的十几年中,PHPT的治疗发展迅速,对于单发腺瘤,直接或“微创”甲状旁腺切除术(Directed parathyroidectomy, DP)正在逐步取代双侧颈部探查。高质量的术前定位是成功实行DP的关键。异常甲状旁腺的术前定位有多种方法,99mTc-MIBI双时相显像和超声检查是常用的术前定位方法。本研究分析PHPT住院病人资料,评估99mTc-MIBI双时相显像及超声检查在原发性甲状旁腺功能亢进症术前定位中的应用价值,并分析影响99mTc-MIBI显像结果的因素。
方法：分析浙江大学医学院附属第二医院2004年1月1日到2010年3月1日间临床诊断或疑诊为PHPT并行甲状旁腺定位检查及颈部手术的患者资料,共46例,经手术和病理确诊PHPT39例,其余7例为结节性甲状腺肿。所有患者均有甲状旁腺超声检查、9mTc-MIBI双时相显像及手术记录。评价99mTc-MIBI双时相显像检查及超声检查的敏感性与特异性。并对临床特征、生化结果、以及影响9mTc-MIBI双时相显像及超声检查的因素进行统计分析。
结果：本组PHPT患者平均年龄为44.82±14.14岁,90%的患者有明显的PHPT相关临床表现,PHPT有骨病症状患者最多(59.0%),其次为肾结石症状(29%),高血钙症状(12.8%),就诊时无症状者占10.3%。手术后血钙和血PTH水平显著降低。PHPT患者中有和无骨病表现的患者的PTH、ALP水平有显著性差异。PHPT患者中甲状旁腺单发性腺瘤、甲状旁腺增生、甲状旁腺癌的构成比分别为84%(33例),13%(5例),3%(1例)。所有46例患者行99mTc-MIBI双时相显像及超声检查,99mTc-MIBI双时相显像检查定位异常甲状旁腺到颈部侧边的敏感性为87.5%,特异性为87%。术前超声定位异常甲状旁腺到颈部侧边的敏感性为77.5%,特异性为97.6%。MIBI检查正确识别并定位33例单发腺瘤中的32例,超声检查正确识别并定位单发腺瘤24例。MIBI检查正确识别并定位5例增生病例中的2例,超声检查正确识别并定位所有5例增生病例。MIBI检查正确鉴别7例结节性甲状腺肿的1例,超声正确鉴别7例结节性甲状腺肿的5例。MIBI检查阳性PHPT患者术前血钙水平高于MIBI检查阴性患者术前血钙水平(p<0.01)。MIBI检查结果及超声检查结果与血钙水平相关。
结论：本组患者的病程长、临床表现明显,手术切除异常甲状旁腺后,血钙和血PTH水平下降明显。99mTc-MIBI双时相显像对于PHPT术前定位甲状旁腺腺瘤效果较好,对于甲状旁腺增生的患者存在较高的假阴性。MIBI双时相检查假阳性的结果主要为结节性甲状腺肿。超声检查定位单发性腺瘤的敏感性不如99mTc-MIBI双时相显像,但是定位甲状旁腺增生以及鉴别甲状腺结节的能力较99mTc-MIBI双时相显像好。99mTc-MIBI双时相显像结果及超声检查结果与血钙水平相关。
Objective:Surgery has been considered the definitive treatment for symptomatic primary hyperparathyroidism (PHPT). The traditional surgery protocol is bilateral exploration of the neck. However, given the high proportion of the solitary parathyroid adenoma as the cause of PHPT, a better treatment may be the direct excision of the hyperfunction adenoma after its preoprative identification and localization.99mTc-MIBI and ultrasound scan are the imaging modalities most often used for preoprative localization. Knowledge of the clinical and biochemical chemistry characters of PHPT may help in the identification and localization of hyperfunction parathyroid glands. The aim of this study is to analyse the clinical feature of PHPT patient, and evaluate the role of 99mTc-MIBI and ultrasound scan for abnormal parathyroid identification and localization.
Methods:Medical records of hospitalized patients suspecting of PHPT from January 1st 2004 to March 1st 2010 were carefully reviewed. Forty six patients had neck surgery for PHPT, and 39 patients were confirmed by surgery and histopathology as PHPT. The left 7 patients were diagnosed as nodular goiter. Evaluate the sensitivity and specificity of the imaging modalities used in these patients. Statistically analysis the clinical features and evaluate there impact on 99mTc-MIBI imaging.
Results:Ninety percent of the 39 PHPT patients had overt symptom, including bone disease (59%), urolithiasis (29%), and hypercalcemia symptom (12.8%). Only 4 patients were asymptomatic (10%). Serum calcium and PTH level decline significantly after surgery. Patients had bone disease manifestation had higher PTH and ALP level (p<0.01).In this study, the cause of PHPT was comprised of single parathyroid adenoma(84%), parathyroid hyperplasia(13%) and parathyroid adenocarcinoma(3%). The sensitivity of 99mTc-MIBI and ultrasonography for localization of hyperfunctioning glands to the correct side of neck was 87.5% and 77.5%, respectively. The specificity of 99mTc-MIBI and ultrasonography for localization of hyperfunctioing glands to the correct side of neck was 87% and 97.6%, respectively. Thirty two in 33 single adenoma cases were correctly identified and localized by 99mTc-MIBI dual phase scintygraphy. Ultrasound scan only detected 24 single adenomas. Ultrasound scan recognized all 5 hyperplasia cases, when MIBI scintigraphy missed 3 cases. Nodular goiter cases were the main false positive cases recognized by MIBI scintigraphy.99mTc-MIBI positive or ultrasound scan positive PHPT patients had higher serum calcium level than those who were negative.
Conclusion:99mTc-MIBI dual phase scintigraphy and ultrasound scan are effective for preoprative abnormal parathyroid gland identification and localization. Serum calcium level may have impact on 99mTc-MIBI dual phase scintigraphy result.
引文
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