Ultrasound-guided Percutaneous Ethanol Ablation of Parathyroid Hyperplasia: Preliminary Experience in Patients on Chronic Dialysis

Abstract

Objective: We report on a 3-year experience using single-shot, ultrasonography-guided, percutaneous ethanol ablation (PEA) of hyperplastic parathyroid glands in chronic dialysis patients suffering from secondary or tertiary hyperparathyroidism. Materials and Methods: Seventeen uraemic patients (mean age 52 ± 14 years) with hypercalcaemia and elevated serum levels of parathyroid hormone were assessed for ethanol ablation. Ten patients did not fulfil the inclusion criteria and underwent surgical parathyroidectomy. Seven patients were treated using PEA. Results: All patients treated with PEA tolerated the procedure well, and no major complications were observed. Three out of seven patients underwent further ethanol ablation due to recurrent symptomatic hyperparathyroidism. Following the procedures, serum values of total calcium and parathyroid hormone remained within target range with concomitant medical therapy in all patients. Conclusion: PEA performed as a single-shot therapy can be used as a minimally invasive and safe supplement to medical therapy in the treatment of secondary or tertiary hyperparathyroidism in selected patients. In case of recurrence, treatment can be repeated without any problems.

Zusammenfassung

Studienziel: Wir berichten über unsere dreijährige Erfahrung mit ultraschallgezielter perkutaner Ethanolablation (PEA) der Nebenschilddrüse bei chronisch dialysepflichtigen Patienten, die an sekundärem oder tertiärem Hyperparathyroidismus leiden. Patienten/Methode: Siebzehn dialysepflichtige Patienten (Alter 52 ± 14 Jahre) mit Hyperkalzämie und erhöhten Parathormonwerten wurden für eine Ethanolablation vorgestellt. Davon erfüllten zehn Patienten die Einschlusskriterien nicht und wurden chirurgisch parathyroidektomiert. Sieben Patienten wurden mittels PEA behandelt. Resultate: Die PEA wurde von allen Patienten gut toleriert. Drei von sieben Patienten wurden aufgrund eines persistierenden symptomatischen Hyperparathyroidismus einer weiteren Ethanolablation unterzogen. Nach dem Eingriff lagen die Laborwerte von Serum-Kalzium und intaktem Parathormon bei allen Patienten mit entsprechender medikamentöser Therapie im Referenzbereich. Schlussfolgerung: Die PEA als Single-Shot-Therapie stellt bei Patienten mit sekundärem oder tertiärem Hyperparathyroidismus eine minimalinvasive und komplikationsarme Zusatzbehandlung zur medikamentösen Therapie dar. Im Falle eines Rezidivs ist eine neuerliche Behandlung einfach durchführbar.

Hyperparathyroidism - ethanol ablation - ultrasonography - interventional therapy

Hyperparathyroidismus - Ethanolablation - Ultraschall - interventionelle Therapie

References

• 1 Drueke T B. The pathogenesis of parathyroid gland hyperplasia in chronic renal failure.  Kidney Int. 1995;  48 259-72
• 2 Reichel H. Medical management of renal hyperparathyroidism. Pulse treatment with vitamin D metabolites or not?.  Nephrol Dial Transplant. 1994;  9 1368-70
• 3 Tominaga Y, Tanaka Y, Sato K. et al . Histopathology, pathophysiology, and indications for surgical treatment of renal hyperparathyroidism.  Semin Surg Oncol. 1997;  13 78-86
• 4 Akizawa T, Fukagawa M, Koshikawa S. et al . Recent progress in management of secondary hyperparathyroidism of chronic renal failure.  Curr Opin Nephrol Hypertens. 1993;  2 558-565
• 5 Punch J D, Thompson N W, Merion R M. Subtotal parathyroidectomy in dialysis-dependent and post-renal transplant patients. A 25-year single-center experience.  Arch Surg. 1995;  130 538-542; discussion 542 - 543
• 6 Akizawa T, Kinugasa E, Akiba T. et al . Incidence and clinical characteristics of hypoparathyroidism in dialysis patients.  Kidney Int Suppl. 1997;  62 S72-S74
• 7 Chigot J P, Menegaux F, Achrafi H. Should primary hyperparathyroidism be treated surgically in elderly patients older than 75 years?.  Surgery. 1995;  117 397-401
• 8 Fukagawa M, Kitaoka M, Yi H. et al . Serial evaluation of parathyroid size by ultrasonography is another useful marker for the long-term prognosis of calcitriol pulse therapy in chronic dialysis patients.  Nephron. 1994;  68 221-228
• 9 Numerow L M, Morita E T, Clark O H. et al . Persistent/recurrent hyperparathyroidism: a comparison of sestamibi scintigraphy, MRI, and ultrasonography.  J Magn Reson Imaging. 1995;  5 702-708
• 10 Giron J, Ouhayoun E, Dahan M. et al . Imaging of hyperparathyroidism: US, CT, MRI and MIBI scintigraphy.  Eur J Radiol. 1996;  21 167-173
• 11 Lane M J, Desser T S, Weigel R J. et al . Use of color and power Doppler sonography to identify feeding arteries associated with parathyroid adenomas.  AJR Am J Roentgenol. 1998;  171 819-823
• 12 Rickes S, Sitzy J, Neye H. et al . High-resolution ultrasound in combination with colour-Doppler sonography for preoperative localization of parathyroid adenomas in patients with primary hyperparathyroidism.  Ultraschall Med. 2003;  24 85-89
• 13 Cercueil J P, Jacob D, Verges B. et al . Percutaneous ethanol injection into parathyroid adenomas: mid- and long- term results.  Eur Radiol. 1998;  8 1565-1569
• 14 Cintin C, Karstrup S, Ladefoged S D. et al . Tertiary hyperparathyroidism treated by ultrasonically guided percutaneous fine-needle ethanol injection.  Nephron. 1994;  68 217-220
• 15 Fletcher S, Kanagasundaram N S, Rayner H C. et al . Assessment of ultrasound guided percutaneous ethanol injection and parathyroidectomy in patients with tertiary hyperparathyroidism.  Nephrol Dial Transplant. 1998;  13 3111-3117
• 16 Fukagawa M, Kitaoka M, Tominaga Y. et al . Selective percutaneous ethanol injection therapy (PEIT) of the parathyroid in chronic dialysis patients - the Japanese strategy. Japanese Working Group on PEIT of Parathyroid, Tokyo, Japan.  Nephrol Dial Transplant. 1999;  14 2574-2577
• 17 Giangrande A, Castiglioni A, Solbiati L. et al . Ultrasound-guided percutaneous fine-needle ethanol injection into parathyroid glands in secondary hyperparathyroidism.  Nephrol Dial Transplant. 1992;  7 412-421
• 18 Giangrande A, Castiglioni A, Solbiati L. et al . Chemical parathyroidectomy for recurrence of secondary hyperparathyroidism.  Am J Kidney Dis. 1994;  24 421-426
• 19 Kakuta T, Fukagawa M, Fujisaki T. et al . Prognosis of parathyroid function after successful percutaneous ethanol injection therapy guided by color Doppler flow mapping in chronic dialysis patients.  Am J Kidney Dis. 1999;  33 1091-1099
• 20 Kakuta T, Kunimatsu K, Tadaki F. et al . Long-term prognosis of parathyroid function after successful percutaneous ethanol injection therapy (PEIT) guided by color Doppler flow mapping in chronic dialysis patients.  Biomed Pharmacother. 2000;  54 (Suppl 1) 60 s-65 s
• 21 Karstrup S, Holm H H, Glenthoj A. et al . Nonsurgical treatment of primary hyperparathyroidism with sonographically guided percutaneous injection of ethanol: results in a selected series of patients.  AJR Am J Roentgenol. 1990;  154 1087-1090
• 22 Kitaoka M, Fukagawa M, Ogata E. et al . Reduction of functioning parathyroid cell mass by ethanol injection in chronic dialysis patients.  Kidney Int. 1994;  46 1110-1117
• 23 Solbiati L, Giangrande A, De Pra L. et al . Percutaneous ethanol injection of parathyroid tumors under US guidance: treatment for secondary hyperparathyroidism.  Radiology. 1985;  155 607-610
• 24 Tominaga Y, Kitaoka M, Fukagawa M. et al . Tentative Guideline for PEIT of Parathyroid in Dialysis Patients (in Japanese).  Jp Soc Dial Ther. 1999;  32 1099-1103
• 25 Karstrup S, Hegedus L, Holm H H. Ultrasonically guided chemical parathyroidectomy in patients with primary hyperparathyroidism: a follow-up study.  Clin Endocrinol (Oxf). 1993;  38 523-530