Percutaneous ethanol injection of parathyroid adenomas in primary hyperparathyroidism

Evaluation of the Early Results of Percutaneous Ethanol Ablation in Patients with Primary Hyperparathyroidism

Percutaneous ethanol ablation (PEA) is an alternative non-surgical method for the treatment of patients with primary hyperparathyroidism (PHPT), suitable in cases with comorbidities and high surgical risk.

The aim of the present study was to evaluate the results of PEA in patients with PHPT at the early stages of follow-up.

Materials and methods: The study included 35 patients (30 women and 5 men, mean age 59.7 ± 12.4 years) with biochemical and hormonal data of PHPT and localized parathyroid adenoma (PTA) by ultrasound, nuclear scan, FNB with cytology and evaluation of PTH in the needle washout. All patients were at high surgical risk or refused surgical treatment. PEA was applied and changes in the PTA volume and calcium-phosphate metabolism were monitored at the third (M3) and sixth (M6) months after the procedure.

Results: Normocalcaemia was achieved in 26 patients (74.3%) at M3 and persisted at M6 in 22 of them. A second course of PEA was administered in 11 patients with persistent hypercalcaemia at M3 and M6, respectively. Compared to the baseline, the mean PTA volume decreased significantly by 53% at M3 and 67% at M6 (p < 0.001). Side effects including local pain, edema and dysphonia were observed in 5 patients (14.3%).

Conclusion: PEA is an efficient and safe treatment modality for the management of PHPT. A significant reduction in PTA volume and a normalization of serum calcium and PTH levels were observed at the early stages of follow-up.

Percutaneous ethanol injection therapy: a surgery-sparing treatment for primary hyperparathyroidism

OBJECTIVE

To describe our 3-year experience in the long-term efficacy and safety of percutaneous ethanol injection therapy (PEIT), as an alternative to surgery for the management of patients with primary hyperparathyroidism (p-HPT).

DESIGN

Prospective study with a mean follow-up of 19.6 +/- 10.6 months.

PATIENTS

Our study population included 19 consecutive high risk patients with p-HPT, who met the criteria for surgery.

MEASUREMENTS

Under ultrasonic guidance, ethanol (95%) was injected into parathyroid glands with a volume of >or= 0.15 cm(3). With the aim of normalizing intact parathormone (iPTH) values, repeated ethanol injections were carried out, in an interval of 2 weeks, until normalization of iPTH was reached or until no residual blood supply was detected by ultrasound in the gland. Biochemical parameters were monitored throughout the study.

RESULTS

At 6-month follow-up, normalization of iPTH levels (10-65 ng/l) was achieved in 11 (58%) patients (responders). Of the eight remaining patients (nonresponders), six patients had reduced (but not normalized) iPTH levels and two patients required parathyroid surgery. Seventeen (11 responders and 6 nonresponders) of the 19 patients (89.5%) became normocalcaemic (serum Ca <or= 2.57 mmol/l) and remained so for a mean follow-up of 21 months (8-39 months). The odds ratio (P < 0.05) of response vs. no response to PEIT was 16.7-fold for pretreatment iPTH < 200 vs. > 200 ng/l. The only complication was a transient dysphonia noticed in three patients.

CONCLUSIONS

PEIT is a safe and effective nonsurgical treatment for patients with p-HPT, who are unsuitable for surgical intervention.

[Treatment of parathyroid adenomas with ethanol injection under ultrasonographic guidance]

STUDY OBJECTIVE

The objective of this retrospective study was to report the results of ethanol injection in parathyroid adenomas.

PATIENTS AND METHOD

Since 1988, 31 patients with inoperable primary hyperthyroidism have been treated by ultrasound-guided percutaneous ethanol injection into the adenoma. The main surgical contraindications were heart failure (n = 12) and age over 85 years (n = 11). Plasma calcium and PTH were measured 48 hours after ethanol injection and during subsequent follow-up.

RESULTS

Patients had one to three ethanol injections. With a mean 5-year follow-up, total success with normal plasma calcium and PTH levels was achieved in 20 patients (64.5%), 4 of whom underwent another ethanol injection after 1 to 3 years. Partial success with correction of plasma calcium only was achieved in 9 patients (29%) resulting in an obvious clinical benefit. Failure was observed in 2 patients (6.5%) with nodular goiter, probably due to incorrect localization of the adenoma. Treatment was always well tolerated and no major side effect was observed.

CONCLUSION

Ultrasound-guided percutaneous ethanol injection of parathyroid adenoma is effective in most cases of hyperparathyroidism and very useful in patients with a high surgical risk. The need for precise ultrasound localization of the adenoma is the main limitation of this treatment.

Ethanol Injection to Parathyroid Tissue: Indications and Limitations

Hyperparathyroidism is a potentially life-threatening disease, caused primarily by parathyroid adenoma. Surgical excision of the tumor, with consequent return of calcium levels to the normal range, is considered the treatment of choice.”3 Within the last few years, several reports have described the destruction of parathyroid tissue using ultrasonically guided injection of 96% ethanol into pathologic parathyroid glands, resulting in successful regulation of both primary and secondary hyperparathyroidism.4–9 The procedure was reported as an alternative to operative treatment for patients at high surgical risk, such as the elderly and the critically ill. We report the occurrence of transient Horner's syndrome and vocal fold paralysis after successful injections of ethanol into a parathyroid adenoma, and discuss the implications and restrictions of the procedure in view of the medical literature.

Imaging of the parathyroid glands

Primary hyperparathyroidism resulting in hypercalcemia is the most common presentation of parathyroid pathology and usually is related to a parathyroid adenoma and, less commonly, to hyperplasia. Imaging of the parathyroid glands focuses on the detection of adenomas in patients with primary hyperparathyroidism. The role of imaging (as well as the modality used) for preoperative localization of the parathyroid glands continues to be controversial. The embryology, anatomy, and physiology of the parathyroid glands are reviewed. The diagnostic utility of radiological imaging-including ultrasonography, CT, MR imaging, and nuclear scintigraphy-are discussed, particularly as it pertains to the evaluation of primary hyperparathyroidism.

Ultrasonically guided chemical parathyroidectomy in patients with primary hyperparathyroidism: a follow-up study

OBJECTIVE

We evaluated the long-term results in two different groups of patients with primary hyperparathyroidism treated with ultrasonically guided percutaneous ethanol (96%) injection into parathyroid tumours.

DESIGN

A prospective long-term follow-up (more than 6 months). Ethanol (96%) was injected under ultrasonic guidance into biopsy verified solitary parathyroid tumours. Basic treatment included a maximum of three treatments with an interval of about 1 month (group 1) or 1 week (group 2). Dose of ethanol was half the volume of the parathyroid tumour.

PATIENTS

Two different groups of patients with only one ultrasonically detected and biopsy verified parathyroid tumour were treated. Group 1 (n = 18) were treated regardless of the severity of the hyperparathyroid disease. Group 2 (n = 14) were selected for treatment either due to severe hypercalcaemic symptoms (n = 3), a high surgical risk (n = 5), or refusal of surgery (n = 6).

MEASUREMENTS

The volume of the parathyroid tumours was measured as half the product of maximum length, width, and depth. Blood tests included measurements of ionized calcium, total calcium and PTH.

RESULTS

In group 1, 12 of 18 patients (66%) could be followed more than 6 months. Follow-up ranged from 12 to 58 months (median 45 months). A significant decrease (P < 0.001) in serum concentrations of ionized calcium and total calcium was observed. Eight patients (44%) later underwent surgical parathyroidectomy. Injection therapy was regarded as successful in 10 of 18 patients (56%). In group 2, 11 of 14 patients (79%) were followed more than 6 months. Follow-up ranged from 18 to 50 months (median 39 months). A significant decrease (P < 0.001) in serum concentrations of ionized calcium, total calcium and intact PTH (1-84) was observed. Treatment was successful in 11 of 14 patients (79%). Two patients required parathyroid surgery. Re-examination with ultrasound showed a significant reduction in the volume of the treated parathyroid tumours. Fibrosis surrounding the parathyroid tumours was detected in eight of 10 patients who subsequently had operations. One patient from each group had a complication of a unilateral permanent vocal cord paralysis following injection therapy.

CONCLUSION

Partial or complete long-term remission of primary hyperparathyroidism can be achieved using ultrasound-guided chemical parathyroidectomy. However, the intervals between treatments should be short and the treatment should be reserved only for patients not fit for surgery.

Percutaneous intranodular ethanol injection: a new treatment for autonomous thyroid adenoma

Established methods for definitive ablation of autonomous thyroid nodules are surgery and radioiodine. Since it has been demonstrated that percutaneous ethanol injection can inactivate parathyroid adenomas and small hepatocellular carcinomas, we started a trial of this treatment in patients with autonomous thyroid nodules. Twenty-eight patients, 22 toxic and 6 nontoxic, all with undetectable thyrotropin serum levels and suppressed extranodular tissue on scintigraphy, were treated. Treatment consisted of percutaneous intranodular ethanol injection under ultrasound guidance. The total amount of alcohol injected ranged from 0.4 to 2.2 times the estimated nodule volume, divided into 4 to 9 injections performed at 2 to 7 day intervals. Most patients were treated with a single cycle of injections, but 7 of them required 2 cycles. The signs and symptoms of hyperthyroidism disappeared in all cases. Apparently complete cure (normal serum free thyroid hormones, thyrotropin in basal conditions and after thyrotropin releasing hormone, reactivation of extranodular tissue on scintigraphy with nodule no longer visible) was obtained in 17 patients (13 after 1 cycle and 4 after 2 cycles). Partial cure (normal serum free thyroid hormone levels, detectable thyrotropin levels with normal or blunted response to thyrotropin releasing hormone and partial reactivation of extranodular tissue on scintigraphy with nodule or parts of it still visible) was obtained in 10 patients (8 after 1 cycle and 2 after 2 cycles). In 1 patient with a very large nodule thyrotropin levels remained undetectable, but thyroid hormone levels eventually became normal. No recurrences were observed after a follow-up of 12 to 32 months (mean 20 months). No serious side effects were encountered. A clinically valuable result was obtained in all patients. These data suggest that this form of treatment could constitute an alternative to surgery and radioiodine for the ablation of autonomous thyroid nodules.