| 摘要: |
| 目的 建立经皮射频和微波热消融治疗甲状旁腺腺瘤、增生结节的技术方案和评价指标,探讨其技术特征、方法步骤、安全性及疗效。方法 使用Celon ProBreath双极式射频电极针和Thy-ablationTM微波消融天线针在高频超声引导及超声造影监测下对96例317枚良性病变甲状旁腺进行经皮穿刺消融,就消融策略、穿刺路径、保护重要血管和喉返神经及减少活检出血的措施、判断消融彻底性以及终止消融的指征、每枚腺体消融耗时(AT)及总手术时间(TOT)等消融术中技术问题进行探索与解析,对消融术后消融区的经时变化从多模式超声表现、血清甲状旁腺激素(PTH)和血清钙水平、临床表现以及病理组织学多层面进行跟踪评价。结果 采用横切面引导同时显现穿刺目标、穿刺针和重要的解剖结构是安全穿刺的基础,液体隔离带法有利于制作安全穿刺路径并有效保护喉返神经、气管和食管免受热损伤；“热阻断血流”后活检可有效防止病变腺体内出血,并对1例胸锁乳突肌内出血提供有效止血。超声造影是消融过程的重要指导手段,可避免消融不彻底。原发性甲状旁腺功能亢进(PHPT)组TOT为(572.47±75.79) s、每枚腺体AT为(194.82±46.39) s,继发性甲状旁腺功能亢进(SHPT)组TOT为(1 548.47±323.83) s、每枚腺体AT为(217.55±52.42) s；消融后第2个月起消融区开始缩小,射频消融在体积缩小速度和幅度两个方面均优于微波消融；PHPT组中73.1%(19/26)、SHPT组中53.6%(156/291)的消融区在消融后第12个月超声检查时消失；术前99mTc-MIBI发现93.1%(295/317)的甲状旁腺病变,消融后均不再显现；消融区质地明显变硬,但会逐渐变软，与消融区体积缩小趋势平行；消融后血清PTH快速降低，PHPT组尤其明显；PTH有反跳现象,但在时间和程度上SHPT组与PHPT组明显不同。2例甲状旁腺功能亢进危象患者消融后2 h内意识开始清醒。结论 超声引导下经皮热消融治疗甲状旁腺良性结节是甲状旁腺功能亢进外科治疗手段微创化的最新体现,治疗过程精细、准确,安全省时,病灶灭活彻底,坏死物吸收良好,可迅速降低PTH,具有急救价值。PTH的反跳需引起对新生病灶的警觉。 |
| 关键词: 甲状旁腺肿瘤 腺瘤 甲状旁腺增生 甲状旁腺功能亢进症 热消融 射频消融 微波消融 超声检查 |
| DOI：10.3724/SP.J.1008.2013.00362 |
| 投稿时间：2013-03-09修订日期：2013-04-15 |
| 基金项目:国家自然科学基金(81171436). |
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| Ultrasound-guided percutaneous thermal ablation for benign parathyroid nodules |
| ZHANG Jian-quan1,QIU Ming2*,SHENG Jian-guo1,LU Feng1,ZHAO Lu-lu1,ZHANG Hang1,DIAO Zong-ping1 |
(1. Department of Ultrasound in Medicine, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
2. Third Division of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
*Corresponding author.) |
| Abstract: |
| Objective To establish treatment strategies using percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) for benign parathyroid nodules and to investigate the related techniques, procedures, safety and efficacy. Methods Percutaneous RFA and MWA were conducted on 317 benign parathyroid nodules in 96 patients using an auto-controlled bi-polar electrode system (Celon ProBreath, Germany) and thyroid-specified microwave antenna (Thy-ablationTM, China). The ablation strategy, optimal puncture route, protection of vital neck vessels and recurrent laryngeal nerve, reduction of bleeding from core-needle biopsy, indicator for complete therapy, ablation time (AT) for single nodule, and total operation time (TOT) for each case were investigated and analyzed. The focal changes of ablated region on multimode ultrasound, serum parathyroid hormone (PTH) level, serum calcium values, clinical manifestations and pathological alterations were assessed during follow-up. Results Cross section simultaneously demonstrating the ablation target, ablation needles and vital anatomic structures was essential for a safe ablation procedure of parathyroid lesions. Liquid isolating zone maneuver was beneficial for creating safe puncture route and for protecting laryngeal nerves, esophagus and trachea from heat damage. “Thermal blocking of blood flow” prior to core-needle biopsy effectively reduced bleeding and successfully treated one patient with intensive subcutaneous hemorrhage. Contrast-enhanced ultrasound was an important and essential indicator for a complete therapy. In primary hyperparathyroidism (PHPT) group the TOT for each case was about (572.47±75.79) s and AT for single nodule was about (194.82±46.39) s, and the numbers in secondary hyperparathyroidism (SHPT) group were (1 548.47±323.83) s and (217.55±52.42) s, respectively. Two months after ablation, the ablated region began to shrink, and RFA was superior to MWA regarding the speed and extent of shrinkage. At the end of twelfth month, ultrasound scanning revealed that the ablated region was completely dissolved in 73.1%(19/26) of nodules in PHPT group and 53.6% (156/291) of nodules in SHPT. Pre-ablative 99mTc-MIBI disclosed 93.1% (295/317) of the parathyroid lesions and none of them were visible after ablation. Ultrasound elastography disclosed hardening of the ablated region, and it gradually became soft, paralleling with shrinkage of the ablated region. Serum PTH level decreased rapidly after ablation, particularly in PHPT patients. In the later course PTH levels had relapse in some patients, but the relapses were quite different in timing and extent between PHPT and SHPT groups. Two cases with hyperparathyroidism crisis regained consciousness two hours after ablation therapy. Conclusion Ultrasound-guided percutaneous thermal therapy of parathyroid benign nodules is a new modality of surgical intervention for hyperparathyroidism. The ablative procedure is precise, accurate, safe, and time-saving. The lesion can be completely inactivated and the absorbed. Rapid dropping of PTH level makes it valuable for emergency treatment of crisis. The relapse of PTH may indicate new parathyroid lesion. |
| Key words: parathyroid neoplasms adenoma parathyroid hyperplasia hyperparathyroidism thermal ablation radiofrequency ablation microwave ablation ultrasonography |
