Primer Hiperparatiroidizme Yol Açan Paratiroid Adenomlarının Lokalizasyonunda İnce İğne Aspirasyon Yıkama Yönteminin Önemi

Öz

Amaç: Paratiroid adenomlarının tespitinde ultrasonografi (USG) ve sintigrafidir çok sık kullanılmasına rağmen bazen yetersiz kalabilmektedirler. Bu durum da cerrahi tedavide başarısızlıklara yol açmaktadır. USG kılavuzluğunda ince iğne aspirasyon (İİA) ile elde edilen yıkama sıvısında parathormon (PTH) ölçümü ise kolay, maliyet etkin ve güvenli olması dolayısıyla paratiroid lezyonunu lokalize etmekte kullanılabilmektedir. İİA ile elde edilen yıkama sıvısında PTH ölçümü yaptığımız olgularımızı sunarak literatür bilgilerini gözden geçirmeyi amaçladık. Metot: Toplam 16 olgu geriye doğru taranarak yaş, cinsiyet, laboratuvar değerleri, görüntüleme, DEXA raporları ve opere olanların patoloji sonuçları kaydedildi. Yıkama sıvısında PTH ölçümü için şüpheli lezyona 10 mL/22 gauge iğne ile girildi, negatif aspirasyon yapıldI ve aspirasyon yapılan iğne 1 mL %0.9 NaCl ile durulanarak yıkama sıvısından PTH bakıldı. Serum değerinden daha yüksek çıkan yıkama PTH değeri pozitif olarak kabul edildi. Bulgular: Hastaların 13’ü kadın, 3’ü erkekti, ortalama yaş 57.1 ± 14.2 (18-73) yıl idi.. Sintigrafide tutulum olan 3 hastanın yıkama sonucu pozitif, tutulum olmayan 5 hastanın yıkama sonucu negatif, şüpheli tutulum olan 2 hastanın ise yıkama sonucu pozitifti. Sintigrafide tutulum olmayan 4 hastanın ise yıkama sonucu pozitifti ve tutulum olmayanların ise %44.5’i bu yöntemle tespit edildi. Sintigrafide tutulum olduğu halde 2 hastanın yıkama sonucu negatif saptandı. Hiç bir hastada işleme bağlı bir yan etki oluşmadı. Sonuç: Ultrasonografi eşliğinde yapılan İİA yıkama sıvısında PTH ölçümü USG ve sintigrafi ile yeri tespit edilemeyen veya sintigrafide şüpheli tutulumu olan, kanseri şüphesi olmayan seçilmiş vakalarda, bu konuda tecrübeli kişilerce güvenle uygulanabilecek bir işlemdir.

Anahtar Kelimeler

• Primer Hiperparatiroidizm
• Paratiroid Adenomu
• Parathormon
• Parathormon Yıkama

Importance of Fine Needle Aspiration Washout Method in Localization of Parathyroid Adenomas Caused by Primary Hyperparathyroidism

Öz

Aim: Although ultrasonography (USG) and scintigraphy are frequently used in the detection of parathyroid adenomas, they are sometimes insufficient for this task. This situation leads to failures in surgical treatment. Measurement of parathormone (PTH) in the washout fluid obtained by USG-guided fine needle aspiration (FNA) is easy, cost-effective and safe, and can be used to localize the parathyroid lesion. We aimed to present our cases in which we measured PTH in the washing liquid obtained by FNA and review the literature. Method: A total of 16 cases were evaluated retrospectively, and age, gender, laboratory values, imaging, DEXA reports and pathology results of the operated patients were recorded. For the measurement of PTH in the washout liquid, negative aspiration was performed from the suspicious lesion with a 10 mL/22 gauge needle and the aspirated needle was rinsed with 1 mL of 0.9% NaCl and PTH was measured from the washing liquid. A washout PTH value higher than the serum value was considered as positive. Results: Thirteen of the patients were female and 3 were male, with a mean age of 57.1 ± 14.2 (18-73) years. Washout PTH result was positive in 3 patients with involvement in scintigraphy, negative in 5 patients without involvement, and positive in 2 patients with suspicious involvement. Washout PTH result was positive in 4 patients without involvement in scintigraphy, and 44.5% positive result were detected with this method in those without involvement. Although there was involvement in scintigraphy, the washing result of 2 patients was negative. No procedure-related side effects occurred in any of the patients Conclusion: PTH measurement in the FNA washing fluid performed under ultrasonography is a procedure that can be safely performed by experienced people in selected cases whose location cannot be determined by USG and scintigraphy, or with suspicious involvement in scintigraphy and without suspected cancer.

Anahtar Kelimeler

• Primary Hyperparathyroidism
• Parathyroid Adenoma
• Parathormone
• Parathormone Washout

Kaynakça

1. Hyperparathyroidism (primary): diagnosis, assessment and initial management. London: National Institute for Health and Care Excellence (NICE); 2019 May 23. (NICE Guideline, No. 132.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK542087/
2. Walker M, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol. 2018;14:115–25.
3. Khan AA, Hanley DA, Rizzoli R, Bollerslev J, Young J, Rejnmark, L, et al. Primary hyperparathyroidism: Review and recommendations on evaluation, diagnosis, and management. A Canadian and international consensus. Osteoporos Int. 2017;28:1–19.
4. Heo I, Park S, Jung CW, Koh JS, Lee SS, Seol H, et al. Fine needle aspiration cytology of parathyroid lesions. Korean J Pathol. 2013;47(5):466-71. doi: 10.4132/KoreanJPathol.2013.47.5.466.
5. Obołończyk Ł, Karwacka I, Wiśniewski P, Sworczak K, Osęka T. The Current Role of Parathyroid Fine-Needle Biopsy (P-FNAB) with iPTH-Washout Concentration (iPTH-WC) in Primary Hyperparathyroidism: A Single Center Experience and Literature Review. Biomedicines. 2022;10(1):123. doi: 10.3390/biomedicines10010123. PMID: 35052802; PMCID: PMC8773275.
6. Mihai R, Gleeson F, Buley ID, Roskell DE, Sadler GP. Negative imaging studies for primary hyperparathyroidism are unavoidable: correlation of sestamibi and high-resolution ultrasound scanning with histological analysis in 150 patients. World J Surg. 2006;30(5):697-704. doi: 10.1007/s00268-005-0338-9. PMID: 16680585.
7. Yüksel S, Ferlengez A, Çıtlak G. Is focused parathyroidectomy effective in primary hyperparathyroidism? Med Bull Haseki; 2019;57(4):345-8. doi: 10.4274/haseki.4966.
8. Prades JM, Lelonge Y, Farizon B, Chatard S, Prevot-Bitot N, Gavid M. Positive predictive values of ultrasound-guided fine-needle aspiration with parathyroid hormone assay and Tc-99m sestamibi scintigraphy in sporadic primary hyperparathyroidism. Eur Ann Otorhinolaryngol Head Neck Dis. 2022:S1879-7296(22)00070-9. doi: 10.1016/j.anorl.2022.07.001. Epub ahead of print. PMID: 35963762.

9. Doppman JL, Krudy AG, Marx SJ, Saxe A, Schneider P,Norton JA, et al. Aspiration of enlarged parathyroid glands for parathyroid hormone assay. Radiology 1983;148: 31-35.
10. Stephen AE, Milas M, Garner CN, Wagner KE, Siperstein AE. Use of surgeon-performed office ultrasound and parathyroid fine needle aspiration for complex parathyroid localization. Surgery. 2005;138(6):1143-50; discussion 1150-1. doi: 10.1016/j.surg.2005.08.030.
11. Callender GG, Udelsman R. Surgery for primary hyperparathyroidism. Cancer. 2014;120(23):3602-16. Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, et al. The American Association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surgery. 2016;151:959–968. (https://doi.org/10.1001/jamasurg.2016.2310)
12. Marcocci C, Mazzeo S, Bruno-Bossio G, et al. Preoperative localization of suspicious parathyroid adenomas by assay of parathyroid hormone in needle aspirates. Eur J Endocrinol. 1998;139:72‐77.
13. Abdelghani R, Noureldine S, Abbas A, Moroz K, Kandil E. The diagnostic value of parathyroid hormone washout after fineneedle aspiration of suspicious cervical lesions in patients with hyperparathyroidism. Laryngoscope 2013; 123: 1310-13.
14. Gökçay Canpolat A, Şahin M, Ediboğlu E, Erdoğan MF, Güllü S, Demir Ö, Emral R, Çorapçıoğlu D. Diagnostic accuracy of parathyroid hormone levels in washout samples of suspicious parathyroid adenomas: A single-centre retrospective cohort study. Clin Endocrinol (Oxf). 2018 Oct;89(4):489-495. doi: 10.1111/cen.13812.
15. Maser C, Donovan P, Santos F, et al. Sonographically guided fine needle aspiration with rapid parathyroid hormone assay. Ann Surg Oncol. 2006;13:1690‐1695.
16. Trimboli P, D’Aurizio F, Tozzoli R, Giovanella L. Measurement of thyroglobulin, calcitonin, and PTH in FNA washout fluids. Clin Chem Lab Med. 2016;55:914‐925.
17. Bancos I, Grant CS, Nadeem S, et al. Risks and benefits of parathyroid fine-needle aspiration with parathyroid hormone washout. Endocr Pract. 2012;18(4):441-449.
18. Patel KN, Yip L, Lubitz CC, et al. The American association of endocrine surgeons guidelines for definitive surgical management of thyroid disease in adults. Ann Surg. 2020;271(3):21-93.
19. Suzuki A, Hirokawa M, Kanematsu R, Tanaka A, Yamao N, Higuchi M, et al. Fine-needle aspiration of parathyroid adenomas: Indications as a diagnostic approach. Diagn Cytopathol. 2021 Jan;49(1):70-76. doi: 10.1002/dc.24595.
20. Kendrick ML, Charboneau JW, Curlee KJ, van Heerden JA, Farley DR. Risk of parathyromatosis after fine-needle aspiration. Am Surg.2001;67(3):290‐3;
21. Castellana M, Virili C, Palermo A, Giorgino F, Giovanella L, Trimboli P. Primary hyperparathyroidism with surgical indication and negative or equivocal scintigraphy: safety and reliability of PTH washout. A systematic review and meta-analysis. Eur J Endocrinol. 2019;181(3):245-253. doi: 10.1530/EJE-19-0160.