sdü tıp fak derg

Medical Journal of Süleyman Demirel University

2602-2109

Süleyman Demirel Üniversitesi

10.17343/sdutfd.492994

Surgery

Cerrahi

EKTOPİK PARATİROİD BEZLERİNE KLİNİK VE CERRAHİ YAKLAŞIM CLINICAL AND SURGICAL APPROACH TO ECTOPIC PARATIROID GLANDS

https://orcid.org/0000-0003-1665-3607

Turan

Bilal

Süleyman Demirel Üniversitesi Tıp Fakültesi Genel Cerrahi Anabilim Dalı, Isparta Yazkan

Rasih

Süleyman Demirel Üniversitesi Tıp Fakültesi Göğüs Cerrahisi Anabilim Dalı, Isparta

06 01 2019

26 2 221 227 12 06 2018 12 27 2018

1994

Süleyman Demirel Üniversitesi Tıp Fakültesi Dergisi

ÖZETEktopik paratiroid bezleri, gözden kaçırıldıklarında, persistan veyarekürren hiperparatiroidizmin ortak bir etiyolojisini oluştururlar. Ektopikparatiroid bezleri, embriyogenez sürecinde anormal göçten kaynaklanır vebaşarılı bir identifikasyon olmaması paratiroid cerrahisinde başarı eksikliğineneden olabilir. Ektopik inferior paratiroidler anterior mediastende, timus veyatiroid bezinde en sık görülürken, ektopik superior paratiroidler için en sıkgörülen pozisyon trakeoözofageal oluk ve retro özofageal bölgedir. Boyunultrasonografisi, 99mTc Sestamibi taraması ve tek foton emisyonlu bilgisayarlıtomografi (SPECT) veya CT (SPECT / CT) ektopik paratiroidlerin tanısaldoğruluğunu arttıran görüntüleme yöntemleridir. Paratiroid dokusu için şüphelibir lezyonun ince iğne aspirasyon sitolojisi ve aspire edilen materyalinparatiroid hormonu ölçümü ektopik bezlerin preoperatif lokalizasyonuna yardımcıolur. Cerrahi inceleme için yaygın alanlar, üst paratiroidler için üst tiroidkutbu, üst tiroid vasküler yapıları ve servikal özofagus, inferiorparatiroidler için karotis arter bifurkasyonu ve timustur. Radyografik olarakbaşarılı lokalizasyondan sonra minimal invaziv paratiroidektomi, postoperatifhızlı parathormon ölçümü ile desteklenerek ektopik paratiroid adenomu olanhastalarda cerrahi sonuçları önemli ölçüde artırmaktadır. Anahtarkelimeler: Ektopik paratiroid, parathormon, primerhiperparatiroidizmABSTRACTEctopic parathyroidglands, when missed, form a common etiology of persistent or recurrenthyperparathyroidism. Ectopic parathyroid glands originate from abnormalmigration in the embryogenesis process and lack of a successful identificationmay lead to a lack of success in parathyroid surgery. While ectopic inferiorparathyroids are most common in the anterior mediastinum, thymus or thyroidgland, the most common position for ectopic superior parathyroids is thetracheoesophageal groove and the retro esophageal region. Neckultrasonography, 99mTc Sestamibiscanning and single-photon emission computed tomography (SPECT) or CT (SPECT /CT) are imaging modalities that increase the diagnostic accuracy of ectopicparathyroids. The fine needle aspiration cytology of the suspected lesion forparathyroid tissue and the parathyroid hormone measurement of the aspiratedmaterial help preoperative localization of ectopic glands. Common areas forsurgery are upper thyroid pole, upper thyroid vascular structures and cervicalesophagus for upper parathyroids and bifurcation of the carotid artery andthymus for inferior parathyroids. After radiographic successful localization,minimally invasive parathyroidectomy is supported by postoperative rapidparathyroid hormone measurement, which significantly increases surgicaloutcomes in patients with ectopic parathyroid adenoma.Keywords: Ectopic parathyroid, parathormone, primaryhyperparathyroidism

Anahtar kelimeler: Ektopik paratiroid parathormon

1. Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes. 2012 Nov;120(10):604-10.

2. Francisco B, Luiz G, Narriane C, Nara CCa, Lívia MB, Marise LC et al.. Diagnosis and management of primary hyperparathyroidism – a scientific statement from the Department of Bone Metabolism, the Brazilian Society for Endocrinology and Metabolism. Arq Bras Endocrinol Metab 2013; 57(6) São Paulo.

3. Yu N, Donnan PT, Flynn RW, Murphy MJ, Smith D, Rudman A et al. Increased mortality and morbidity in mild primary hyperparathyroid patients. The Parathyroid Epidemiology and Audit Research Study (PEARS) . Clin Endocrinol (Oxf ) 2010;73 : 30–34

4. Weber A L , Randolph G , Aksoy F G . The thyroid and parathyroid glands. CT and MR imaging and correlation with pathology and clinical ﬁndings . Radiol Clin North Am 2000; 38:1105–29

5. Akerstrom G, Malmeus J, Bergstrom R. Surgical anatomy of human parathyroid glans. Surgery. 1984;95:14-21

6. Brunicardi FC, Geeta L, Orlo H.C. Tiroid,Paratiroid ve Adrenal. Schwartz Cerrahinin İlkeleri(10. Baskı). 2016;1556-57.

7. Mohebati A, Shaha A R. Anatomy of thyroid and parathyroid glands and neurovascular relations . Clin Anat 2012;25 :19–31

8. Roy Phitayakorn M.D., Christopher R, McHenry M.D. Incidence and location of ectopic abnormal parathyroid glands. The American Journal of Surgery 2006; 191(3):418-23

9. Vail, A.D., Coller, F.C. The parathyroid glands: clinicopathologic correlation of parathyroid disease as found in 200 unselected autopsies. Missouri Medicine Volume 64, Issue 3, March 1967, Pages 234-38

10. Hojaij F, Vanderlei F, Plopper C, Rodrigues CJ, Jacomo A, Cernea C. Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study. Anat Sci Int 2011 ; 86 : 204–12

11. Zerizer I, Parsaï A, Win Z, Al-Nahhas A. Anatomical and functional localization of ectopic parathyroid adenomas: 6-year institutional experience . Nucl Med Commun 2011 ; 32 : 496-502.

12. Reyhan K, Mustafa K. Paratiroid adenomlarının preoperatif lokalizasyonunun saptanmasında paratiroid sintigrafisi ve minimal invaziv cerrahide gama prob kullanımı. Klinik ve Deneysel Araştırmalar Dergisi 2011; 2 (2): 238-43.

13. Uludag M, Isgor A , Yetkin G, Atay M, Kebudi A, Akgun I. Supernumerary ectopic parathyroid glands. Persistent hyperparathyroidism due to mediastinal parathyroid adenoma localized by preoperative single photon emission computed tomography and intraoperative gamma probe application . Hormones (Athens) 2009 ; 8 : 144–49.

14. Dedivitis R A , Guimarães A V , Pontes G B . Multiple ectopic parathyroid adenomas . Sao Paulo Med J 2004 ; 122 : 32 – 34.

15. Mariani G , Gulec S A , Rubello D, Boni G, Puccini M, Pelizzo MR et al. Preoperative localization and radioguided parathyroid surgery. J Nucl Med 2003 ; 44 : 1443–58.

16. C.A. Wang The anatomic basis of parathyroid surgery. Ann Surg, 183 (1976), pp. 271-75

17. Gomes EMS, Nunes RC, Lacativa PGS, Almeida MH de, Franco FM, Leal CTS et al. Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease . Acta Cir Bras 2007 ; 22 : 105–09

18. Pattou FN, Pellissier LC, Noël C, Wambergue F, Huglo DG, Proye CA. Supernumerary parathyroid glands: frequency and surgical signiﬁ cance in treatment of renal hyperparathyroidism . World J Surg 2000 ; 24 : 1330–34.

19. Jesse H, Ngiam KY , Parameswaran R . Mediastinal parathyroid adenomas and their surgical implications. Ann R Coll Surg Engl. 2015; 97(4): 259–61.

20. Mendoza V, Ramírez C, Espinoza AE, González GA, Peña JF, Ramírez ME et al. Characteristics of ectopic parathyroid glands in 145 cases of primary hyperparathyroidism . Endocr Pract 2010 ; 16 : 977–81

21. Akimoto T, Saito O, Muto S, Hasegawa T, Nokubi M, Numata A et al. A case of thoracic hemorrhage due to ectopic parathyroid hyperplasia with chronic renal failure. Am J Kidney Dis. 2005 Jun; 45(6):e109-14.

22. Chaffanjon PC, Chavanis N, Chabre O, Brichon PY. Extracapsular hematoma of the parathyroid glands World J Surg. 2003 Jan; 27(1):14-7.

23. Meng Z, Li D, Zhang Y, Zhang P, Tan J. Ectopic parathyroid carcinoma presenting with hypercalcemic crisis, ectopic uptake in bone scan and obstruction of superior vena cava . Clin Nucl Med 2011 ; 36 : 487–90.

24. Karvounaris D C , Symeonidis N , Triantafyllou A, Flaris N, Sakadamis A. Ectopic parathyroid adenoma located inside the hypoglossal nerve . Head Neck 2010 ; 32 : 1273–76

25. Schneider R , Waldmann J , Ramaswamy A, Fernández ED, Bartsch DK, Schlosser K. Frequency of ectopic and supernumerary intrathymic parathyroid glands in patients with renal hyperparathyroidism: analysis of 461 patients undergoing initial parathyroidectomy with bilateral cervical thymectomy . World J Surg 2011 ; 35 : 1260–65

26. C.R. McHenry, M. Walsh, H. Jarosz, Henkin R, Tope J, Lawrence AM. Resection of parathyroid tumor in the aortopulmonary window without prior neck exploration Surgery, 104 (1988), 1090-94

27. B.D. Nguyen. Parathyroid imaging with Tc-99m sestamibi planar and single photon emission computed tomographic imaging scintigraphy Radiographics, 19 (1999), pp. 601-14

28. M.P. Joseph, J.B. Nadol, B.Z. Pilch, Goodman ML. Ectopic parathyroid tissue in the hypopharyngeal mucosa (pyriform sinus). Head Neck Surg, 5 (1982), 70-74

29. A.O. Udekwu, E.L. Kaplan, T.C. Wu, Arganini M. Ectopic parathyroid adenoma of the lateral triangle of the neck: report of two cases Surgery, 101 (1987), 114-18

30. Billingsley KG, Fraker DL, Doppman JL, Norton JA, Shawker TH, Skarulis MC. Localization and operative management of undescended parathyroid adenomas in patients with persistent primary hyperparathyroidism . Surgery 1994 ; 116 : 982–89

31. Beierwaltes W H . Endocrine imaging: parathyroid. adrenal cortex and medulla and other endocrine tumors . J Nucl Med 1991 ; 32 : 1627-39

32. Castellani M , Reschini E , Longari V, Paracchi A, Corbetta S, Marotta G. Role of Tc-99m sestamibi scintigraphy in the diagnosis and surgical decision-making process in primary hyperparathyroid disease . Clin Nucl Med 2001 ; 26 : 139–44

33. Oh S Y , Kim S , Eskandar Y, Kim DW, Krynyckyi BR, Machac J et al. Appearance of intrathymic parathyroid adenomas on pinhole sestamibi parathyroid imaging . Clin Nucl Med 2006 ; 31 : 325–27

34. Axelrod D , Sisson J C , Cho K, Miskulin J, Gauger PG. Appearance of ectopic undescended inferior parathyroid adenomas on technetium Tc 99m sestamibi scintigraphy: a lesson from reoperative parathyroidectomy . Arch Surg 2003 ; 138 : 1214–18

35. McHenry C R . What’s new in general surgery: endocrine surgery . J Am Coll Surg 2002 ; 195 : 364–71

36. Taki J, Higuchi T, Sumiya H, Tsuchiya H, Minato H, Tomita K et al. Prediction of final tumor response to preoperative chemotherapy by Tc-99m MIBI imaging at the middle of chemotherapy in malignant bone and soft tissue tumors: comparison with Tl-201 imaging. J Orthop Res. 2008 Mar;26(3):411-8.

37. Yazkan R, Çeviker K, Aydı B, İlhan AA, Çiriş İM. Parathyroid adenoma located on anterior mediastinum. Turk J Clin Lab 2016; 7(3): 83-85

38. Caron N R , Sturgeon C , Clark O H . Persistent and recurrent hyperparathyroidism . Curr Treat Options Oncol 2004 ; 5 : 335–45

39. Akram K, Parker J A, Donohoe K, Kolodny G . Role of single photon emission computed tomography/computed tomography in localization of ectopic parathyroid adenoma: a pictorial case series and review of the current literature . ClinNucl Med 2009 ; 34 : 500-02

40. Lorberboym M , Minski I , Macadziob S, Nikolov G, Schachter P. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma . J Nucl Med 2003 ; 44 : 904–08

41. Ansquer C, Mirallie E, Carlier T, Abbey-Huguenin H, Aubron F, Kraeber-Bodere F. Preoperative localization of parathyroid lesions: value of 99mTc-MIBI tomography and factors inﬂuencing detection . Nuklearmedizin 2008 ; 47 : 158–62

42. Gimm O , Juhlin C , Morales O, Persson A. Dual-energy computed tomography localizes ectopic parathyroid adenoma . J Clin Endocrinol Metab 2010 ; 95 : 3092–093

43. Purz S, Kluge R, Barthel H, Steinert F, Stumpp P, Kahn T et al. Visualization of ectopic parathyroid adenomas. N Engl J Med. 2013 Nov 21;369(21):2067-9.

44. Lorberboym M , Minski I , Macadziob S, Nikolov G, Schachter P. Incremental diagnostic value of preoperative 99mTc-MIBI SPECT in patients with a parathyroid adenoma . J Nucl Med 2003 ; 44 : 904-08

45. Kobayashi T, Man-I M, Shin E, Kikkawa N, Kawahara K, Kurata A et al. Hyperfunctioning intrathyroid parathyroid adenoma: report of two cases . Surg Today 1999 ; 29 : 766–68

46. Francis D.M., Atul G. Sekonder ve tersiyer hiperparatiroidizm. Master of Surgery Türkçe (5. Baskı). 2011;37:439-42

47. Çakmak H, Tokat AO, Karasu S, Özkan M. Giant mediyastinal parathyroid adenoma. Tuberk Toraks. 2011;59(3):263-5.

48. Wells S A Jr , Debenedetti M K , Doherty G M . Recurrent or persistent hyperparathyroidism. J Bone Miner Res 2002 ; 17 : (Suppl 2 ): N158–62

49. Marcocci C , Cetani F . Primary hyperparathyroidism . N Engl J Med 2011 ; 365 : 2389–97

50. Rubello D , Casara D , Giannini S, Piotto A, De Carlo E, Muzzio PC. Importance of radio-guided minimally invasive parathyroidectomy using hand-held gamma probe and low (99m)Tc-MIBI dose. Technical considerations and long-term clinical results . Q J Nucl Med 2003 ; 47 : 129–38

51. Batırel HF. Mediyastinal Kitlelere Yaklaşımda VATS. Toraks Cerrahisi Bülteni, Mediyasten Hastalıkları II, Editörler: Liman ŞT, Cangır AK, Mart 2011;57-60.

52. Randone B, Costi R, Scatton O, Fulla Y, Bertagna X, Soubrane O. Thoracoscopic removal of mediyastinal parathyroid glands: a critical appraisal of an emerging technique. Ann Surg. 2010;251(4):717-21.

53. Ohe M N , Santos R O , Kunii I S, Barros ER, Lage A, Abrahão M et al. Usefulness of intraoperative PTH measurement in primary and secondary hyperparathyroidism: experience with 109 patients . Arq Bras Endocrinol Metabol 2006 ; 50 : 869–75

54. Phillips I J , Kurzawinski T R , Honour J W . Potential pitfalls in intraoperative parathyroid hormone measurements during parathyroid surgery . Ann Clin Biochem 2005 ; 42 : 453–58

55. Harvey A , Bohacek L , Neumann D, Mihaljevic T, Berber E. Robotic thoracoscopic mediastinal parathyroidectomy for persistent hyperparathyroidism: case report and review of the literature . Surg Laparosc Endosc Percutan Tech 2011 ; 21 : e24–27

56. Anagnostis P , Karagiannis A , Tziomalos K, Athyros VG, Kita M, Mikhailidis DP. Endocrine Hypertension: Diagnosis and Management of a Complex Clinical Entity . Curr Vasc Pharmacol 2010 ; 8 : 646–60

57. Picazo Sánchez M , Cuxart Pérez M , Sans Lorman R, C. Sarda Borroy. Cinacalcet in the treatment of hypercalcaemia and control of hyperparathyroidism due to ectopic parathyroid glands . Nefrologia 2011 ; 31 : 126–27