British Journal of Radiology 74 (2001),905-907 © 2001 The British Institute of Radiology
Ultrasound guided laser ablation of a parathyroid adenoma
F N Bennedbæk, MD, PhD
1
S Karstrup, MD, Dr Med
2 and
L Hegedüs, MD, Dr Med
1
1Department of Endocrinology, Odense University Hospital, DK-5000 Odense C and 2Department of Diagnostic Radiology, Roskilde Hospital, University of Copenhagen, DK-4000 Roskilde, Denmark
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Abstract
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We present a case of primary hyperparathyroidism with severe hypercalcaemia, treated successfully with ultrasound (US) guided percutaneous interstitial laser photocoagulation (ILP) of a single parathyroid tumour. To our knowledge, this is the first reported case of ILP applied in primary hyperparathyroidism. US guided thermic tissue coagulation with ILP may be a non-surgical alternative in patients with symptomatic hypercalcaemia due to a parathyroid tumour when surgery is contraindicated.
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Introduction
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Surgical treatment remains the standard therapy in symptomatic primary hyperparathyroidism (pHPT). Although minimally invasive surgical techniques have been introduced [1], there is still a need for a non-surgical approach in patients with a high surgical and anaesthetic risk. This has lead to the introduction of ultrasound (US) guided percutaneous ethanol ablation of parathyroid tumours, which has proven useful in highly selected patients with pHPT [2]. However, the technique has some side effects, primarily owing to ethanol escaping outside the parathyroid tumour. The technique of US guided interstitial laser photocoagulation (ILP) has become useful for tumour palliation in patients with different kinds of advanced cancers [3] and has also been introduced for ablation of benign tumours [4]. The feasibility and efficacy of US guided ILP in parathyroid tumours has not been reported previously.
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Case report
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An 87-year-old woman with obstructive lung disease and a 30-year history of multiple osteoporotic vertebral fractures and peptic ulcer disease was admitted to hospital because of dementia, memory loss, fatigue, loss of appetite, dizziness and dehydration. A diagnosis of pHPT was established, based on an elevated serum ionized calcium (Ca2+) level of 1.81 mmol l-1 (normal range 1.19–1.29 mmol l-1) and a parathyroid hormone (PTH) level of 16.5 pmol l-1 (normal range 1.1–6.9 pmol l-1) in addition to a low serum phosphate level of 0.66 mmol l-1 (normal range 0.78–1.50 mmol l-1). Symptoms persisted after rehydration. 2 months after presentation, US of the neck demonstrated a single 20 mm x 12 mm x 16 mm oval and hypoechoic parathyroid tumour on the left side. Owing to the high surgical risk, it was decided to treat the patient with US guided percutaneous ethanol (99%) in three daily sessions, injecting 1.0 ml, 1.5 ml and 1.3 ml on each day. Complete intranodular dissemination of ethanol was achieved in all three sessions. The injections were accompanied by transient pain spreading to the ipsilateral jaw. Immediately before treatment, serum Ca2+ was 1.70 mmol l-1 and PTH was 15.9 pmol l-1. Following treatment, serum Ca2+ returned to normal and serum PTH remained slightly above the upper normal limit. The patient's neuropsychiatric symptoms resolved. 4 years after initial presentation, the patient was re-admitted to hospital with clinical relapse and elevation of the serum Ca2+ level to 1.63 mmol l-1 and the PTH level to 17.9 pmol l-1. The following year she was treated symptomatically with bisphosphonates but the serum Ca2+ remained unchanged and the patient became disabled due to symptoms of weakness and dementia.
1 year later, US of the neck showed a 19 mm x 12 mm x 19 mm hypoechoic parathyroid tumour with focal heterogenicity compatible with fibrosis following the previous ethanol injection therapy. It was decided to attempt US guided laser ablation. The US examination was performed using a LOGIQ 500 US scanner (GE Medical Systems, Milwaukee, WI) with a 12 MHz linear transducer (type 739L) mounted with a needle steering device for precise US guided punctures. Under sterile conditions, using local anaesthesia and guided by US, a needle with a stylet (0.9 mm in diameter) was positioned centrally in the parathyroid tumour and a 0.4 mm quartz laser fibre was inserted through the needle lumen. The needle was withdrawn 20 mm, leaving the fibre tip in direct contact with the tissue. The patient was treated with an output power of 1.5 W for 600 s, 600 s and 480 s, respectively, in three monthly sessions. The entire procedure was performed under continuous US guidance with an infrared diode (Diomed 15, Cambridge, UK) laser power source (Figure 1
). During laser treatment the main feature was an irregular echogenic area enlarging over time (Figure 2) and the procedure was terminated when this area became stationary in size. Serum Ca2+ and PTH changes are shown in Figure 3. Normal vocal cord function was confirmed by indirect laryngoscopy after the third treatment. Within 4 weeks of the second treatment the patient regained her former capacity.
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Figure 2. (a) Pre-treatment longitudinal ultrasound of the neck showing a hypoechoic parathyroid tumour on the left side with the needle tract visible inside the tumour. (b) An echogenic area is seen centrally during interstitial laser photocoagulation.
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Figure 3. Serum concentrations of ionized calcium ( ) and parathyroid hormone (PTH) (•) before ultrasound guided laser ablation of recurrent parathyroid tumour and at 1 month, 2 months, 3 months and 5 months into treatment. Interstitial laser photocoagulation (ILP) was given at 0 months, 1 month and 2 months. —, upper normal limit of serum ionized calcium; ......, upper normal limit of serum PTH.
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Discussion
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In pHPT, abnormality of the parathyroid glands leads to inappropriate secretion of PTH. The inappropriately high serum PTH level causes excessive renal calcium reabsorption, phosphaturia, 1,25 (OH)2D (vitamin D) synthesis and increased bone resorption. The actions of increased PTH levels produce the various clinical sequelae of chronic hypercalcaemia. pHPT is caused, in 80% of cases, by the presence of one or more adenomas; in 20% of cases all parathyroid glands may be hyperplastic, and rarely (less than 1% of cases) parathyroid carcinoma may be found. The diagnosis of pHPT is suspected by clinical findings and is based on a raised serum concentration of calcium and PTH. No satisfactory medical treatment for pHPT is available, although bisphosphonates, hormone replacement therapy (oestrogens) and selective oestrogen receptor modulators (SERMs) reverse bone loss in post-menopausal women with mild asymptomatic pHPT [5–7]. Calcimimetics are a new class of drugs that increase the sensitivity of the calcium receptor to ionized calcium, resulting in acute lowering of PTH [8]. However, these drugs have no potential for the ultimate curing of pHPT. Parathyroidectomy provides effective treatment for pHPT, with a predictable response on symptoms related to hypercalcaemia and elevated PTH. However, a non-surgical alternative is needed in patients with symptomatic pHPT and a high surgical and anaesthetic risk.
Chemical ablation with ethanol, injected under continuous US control, has proven to be a useful alternative to surgery in selected patients with pHPT [9]. Partial or complete long-term remission can be achieved in 70–80% of patients, but side effects such as vocal cord paralysis and paraglandular fibrosis due to ethanol escaping outside the capsule, as well as pain has lead us to introduce an alternative approach for tissue ablation. US guided percutaneous ILP has proven useful for palliation of malignant as well as benign tumours, and has recently been evaluated in a feasibility study of recurrent thyroid carcinoma [10]. ILP is a minimally invasive technique of focal tissue ablation and, unlike ethanol, the laser-induced destruction zone and necrotic area can be controlled, resulting in no or only minimal damage to the surrounding tissues [11]. Histological examination of tissues after ILP confirms the presence of a well defined necrotic area,demonstrating the ability of this technique to cause coagulative necrosis in a controlled fashion [4].
In our patient a normal serum calcium level was achieved after the second treatment and the PTH level became normal 2 months after the third treatment. The treatment was well tolerated and without pain. No side effects were encountered. Although the entire parathyroid tumour had undergone echogenic changes suggesting total fibrosis, the question of long-term efficacy remains unanswered. Repeat treatment could be considered in the case of relapse.
These preliminary results suggest that US guided ILP is a feasible, minimally invasive technique for focal parathyroid tumour ablation and may be a useful non-surgical alternative for selected patients with pHPT for whom surgery is contraindicated.
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Acknowledgments
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This work was supported by grants from the Maersk McKinney Møller Foundation and The Agnes and Knut Mørk Foundation.
Received for publication March 7, 2001.
Revision received June 4, 2001.
Accepted for publication June 22, 2001.
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References
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Abstract
Introduction
