原發性副甲狀腺功能亢進的術前偵測和定位

Abstract

背景 副甲狀腺切除術是治療原發性副甲狀腺功能亢進症的首選方法。原發性副甲狀腺功能亢進症可以通過手術很好地治療。術前定位影像學研究對於副甲狀腺切除術至關重要，包括識別副甲狀腺、微創手術、降低風險和併發症（如損傷附近結構如喉返神經或意外切除正常甲狀腺組織）等好處。超音波（Ultrasonography）和99mTechnetium-sestamibi (Tc-99m MIBI) SPECT/CT在術前影像調查中常規使用，但它們在確定副甲狀腺不同位置的價值尚不清楚。儘管雙側頸部探查手術傳統上是手術的標準方法，但準確的術前定位病變的副甲狀腺至關重要。然而，對於影像不一致時的最佳定位方法尚無共識。

方法 本回顧性研究納入在2004年至2023年間在單一醫療中心接受副甲狀腺切除術的副甲狀腺功能亢進症患者。記錄了術前定位副甲狀腺瘤的超音波和Tc-99m MIBI SPECT/CT檢查。計算了每種方法的敏感性和陽性預測值。

結果 本回顧性研究共納入331名患者。超音波的敏感性為77.3%，陽性預測值為94.31%。MIBI掃描的敏感性為89.61%，陽性預測值為94.07%。根據結果，MIBI掃描的敏感性比超音波更高，而兩者的陽性預測值則非常接近。新的術前定位方法包含正子斷層造影，4D電腦斷層和術中副甲狀腺賀爾蒙靜脈取樣，能提供臨床上更多選擇。

結論 超音波結合Tc-99m MIBI SPECT/CT在原發性副甲狀腺功能亢進患者術前定位副甲狀腺瘤方面具有很大的臨床價值。對於影像不一致的病例，Tc-99m MIBI SPECT/CT顯示出更高的可靠性。此外，我們提出了一個流程表包含近來開發的影像偵測方法以及術中副甲狀腺賀爾蒙靜脈取樣。影像學的選擇應透過個別患者的臨床資料進行量身定制，並考慮了輻射暴露、成本以及手術醫師對該方法的可操作性等因素，並謹慎選擇新的方法。

Background Parathyroidectomy is the definite treatment for primary hyperparathyroidism (pHPT). pHPT is well treatable surgically. Preoperative localization imaging studies are crucial for parathyroidectomy, including the benefit as identification of parathyroid glands, minimally invasive surgery, reduced risk and complications such as damage to nearby structures like the recurrent laryngeal nerve or accidental removal of normal thyroid tissue. Ultrasonography (US) and technetium-99m-sestamibi-single photon emission computed tomography/computed tomography (MIBI SPECT/CT) are used routinely in pre-operative image surveys, but it is unclear how valuable they are in determining parathyroid glands' distinct locations. However, when image discordancy, there is no consensus on the optimal modality for localization.

Method Retrospectively reviewed who had pHPT and underwent parathyroidectomy in National Taiwan University Hospital, 2004-2023. Preoperative localization between US and MIBI SPECT/CT for parathyroid nodules were recorded. The sensitivity and positive predictive value of each imaging method were determined. New preoperative localization modalities, including PET/CT, 4D CT, and intraoperative parathyroid venous sampling, offer more clinical options.

Result 331 patients were enrolled in this retrospective study. US sensitivity is 77.3% and the positive predictive value is 94.31%. MIBI SPECT/CT sensitivity is 89.61%, and the positive predictive value is 94.07%. According to the results, the MIBI SPECT/CT has a higher sensitivity compared to ultrasound, while the positive predictive value of both is remarkably close.

Conclusion US combined with MIBI SPECT/CT achieved highly valuable for preoperative localization of parathyroid nodules in patients with pHPT. For discordancy cases, MIBI SPECT/CT showed more reliability. Furthermore, we proposed an algorithm containing recently developed detections method for pHPT, tailored to each patient's clinical profile, considering factors such as radiation exposure, cost, and the surgeon's accessibility.