Paratiroid Hastalıklarının Tanısında Nükleer Tıpta Yenilikler ve Minimal İnvaziv Gama Prob Cerrahisi
Özet
Primer hiperparatiroidizm (PHPT), genellikle tek bir paratiroid adenomundan kaynaklanan ve parathormon yüksekliği ile seyreden bir klinik tablodur. Hastalığın geleneksel tedavisi bilateral boyun eksplorasyonu iken, günümüzde nükleer tıp görüntüleme yöntemlerindeki gelişmeler sayesinde minimal invaziv paratiroidektomi (MIP) ön plana çıkmıştır. Preoperatif değerlendirmede kullanılan planar statik görüntüleme, SPECT ve özellikle anatomik-fonksiyonel verileri birleştiren SPECT/BT yöntemleri, paratiroid lezyonlarının ve ektopik adenomların lokalizasyonunu yüksek duyarlılıkla belirlemektedir. Son yıllarda 18F-Kolin ve 11C-Metyonin ile yapılan PET/BT taramaları da özellikle tanısı güç ve nüks vakalarda üstün başarı sağlamaktadır. Cerrahi sırasında kullanılan intraoperatif gama prob kılavuzluğu, cerraha lezyonun yerini tam olarak bulmada büyük kolaylık sunarak operasyon süresini kısaltmakta, daha küçük kesi ve lokal anestezi imkanı tanımaktadır. Gama prob yardımıyla yapılan ameliyatlarda "%20 kuralı" ve intraoperatif PTH ölçümleri cerrahi başarıyı doğrulamada kritik rol oynamaktadır. Ayrıca bu teknoloji, diferansiye tiroid kanserlerinde rezidü dokuların temizlendiği tamamlayıcı tiroidektomi operasyonlarında ve ROLL tekniğiyle palpe edilemeyen lezyonların işaretlenmesinde de güvenle uygulanmaktadır. Sonuç olarak, yenilikçi nükleer tıp yöntemleri ve gama prob entegrasyonu, paratiroid ve tiroid cerrahisinde morbiditeyi azaltarak yüksek başarı oranları sunan standart bir yaklaşım haline gelmiştir.
Primary hyperparathyroidism (PHPT) is a clinical condition characterized by elevated parathyroid hormone levels, predominantly caused by solitary parathyroid adenomas. While traditional treatment relied on bilateral neck exploration, advancements in nuclear medicine imaging have enabled minimally invasive parathyroidectomy (MIP) as the modern standard. Preoperative modalities including planar imaging, SPECT, and especially hybrid SPECT/CT provide high sensitivity in identifying lesion anatomy and atypical or ectopic adenoma locations. Furthermore, 18F-Choline and 11C-Methionine PET/CT scans offer superior localization accuracy, particularly in challenging reoperative or negative-scanned cases. During surgery, intraoperative gamma probe guidance facilitates precise, real-time localization of hyperfunctioning tissue, successfully reducing operative time, minimizing incision size, and allowing for local anesthesia. Surgical curation is effectively confirmed using the "20% rule" via gamma probe counts along with quick intraoperative PTH monitoring. Additionally, radioguided surgery serves as a safe modality in completion thyroidectomy for differentiated thyroid cancer to completely clear remnant tissues, as well as in Radioguided Occult Lesion Localization (ROLL) for non-palpable lesions. In conclusion, the synergy between innovative nuclear medicine techniques and gamma probe-assisted interventions optimizes surgical success and patient outcomes while significantly reducing overall morbidity.
Referanslar
Salti GI, Fedorak I, Yashiro T, et al. Continuing evolution in the operative management of primary hyperparathyroidism. Archives of Surgery. 1992;127(7):831-836. doi: 10.1001/archsurg.1992.01420070095018.
Akerström G, Malmaeus J, Bergström R. Surgical anatomy of human parathyroid glands. Surgery. 1984;95(1):14-21.
Melloul M, Paz A, Koren R, et al. 99mTc-MIBI scintigraphy of parathyroid adenomas and its relation to tumour size and oxyphil cell abundance. European Journal of Nuclear Medicine and Molecular Imaging. 2001;28(2):209-213. doi: 10.1007/s002590000406.
Papathanassiou D, Flament JB, Pochart JM, et al. SPECT/CT in localization of parathyroid adenoma or hyperplasia in patients with previous neck surgery. Clinical Nuclear Medicine. 2008;33(6):394-397. doi: 10.1097/RLU.0b013e318170d4a5.
Wei WJ, Shen CT, Song HJ, et al. Comparison of SPET/CT, SPET and planar imaging using 99mTc-MIBI as independent techniques to support minimally invasive parathyroidectomy in primary hyperparathyroidism: A meta-analysis. Hellenic Journal of Nuclear Medicine. 2015;18(2):127-135. doi: 10.1967/s002449910207.
Wong KK, Fig LM, Gross MD, et al. Parathyroid adenoma localization with 99mTc-sestamibi SPECT/CT: a meta-analysis. Nuclear Medicine Communications. 2015;36(4):363-375. doi: 10.1097/MNM.0000000000000262.
Mihai R, Simon D, Hellman P. Imaging for primary hyperparathyroidism--an evidence-based analysis. Langenbecks Archives of Surgery.. 2009;394(5):765-784. doi: 10.1007/s00423-009-0534-4.
Greenspan BS, Dillehay G, Intenzo C, et al. SNM practice guideline for parathyroid scintigraphy 4.0. Journal of Nuclear Medicine Technology. 2012;40(2):111-8. doi: 10.2967/jnmt.112.105122.
Caveny SA, Klingensmith WC 3rd, Martin WE, et al. Parathyroid imaging: the importance of dual-radiopharmaceutical simultaneous acquisition with 99mTc-sestamibi and 123I. Journal of Nuclear Medicine Technology. 2012;40(2):104-110. doi: 10.2967/jnmt.111.098400.
Woods AM, Bolster AA, Han S, et al. Dual-isotope subtraction SPECT-CT in parathyroid localization. Nuclear Medicine Communications. 2017;38(12):1047-1054. doi: 10.1097/MNM.0000000000000765.
Liddy S, Worsley D, Torreggiani W, et al. Preoperative Imaging in Primary Hyperparathyroidism: Literature Review and Recommendations. Canadian Association of Radiologists Journal. 2017;68(1):47-55. doi: 10.1016/j.carj.2016.07.004.
Thanseer N, Bhadada SK, Sood A, et al. Comparative Effectiveness of Ultrasonography, 99mTc-Sestamibi, and 18F-Fluorocholine PET/CT in Detecting Parathyroid Adenomas in Patients With Primary Hyperparathyroidism. Clinical Nuclear Medicine. 2017;42(12):e491-e497. doi: 10.1097/RLU.0000000000001845.
Beheshti M, Hehenwarter L, Paymani Z, et al. 18F-Fluorocholine PET/CT in the assessment of primary hyperparathyroidism compared with 99mTc-MIBI or 99mTc-tetrofosmin SPECT/CT: a prospective dual-centre study in 100 patients. European Journal of Nuclear Medicine and Molecular Imaging.. 2018;45(10):1762-1771. doi: 10.1007/s00259-018-3980-9.
Amadou C, Bera G, Ezziane M, et al. 18F-Fluorocholine PET/CT and Parathyroid 4D Computed Tomography for Primary Hyperparathyroidism: The Challenge of Reoperative Patients. World Journal of Surgery. 2019;43(5):1232-1242. doi: 10.1007/s00268-019-04910-6.
Broos WAM, van der Zant FM, Knol RJJ, et al. Choline PET/CT in parathyroid imaging: a systematic review. Nuclear Medicine Communications. 2019;40(2):96-105. doi: 10.1097/MNM.0000000000000952.
Winters R, Friedlander P, Noureldine S, et al. Preoperative parathyroid needle localization: a minimally invasive novel technique in reoperative settings. Minimally Invasive Surgery. 2011; 2011:487076. doi: 10.1155/2011/487076.
Stern S, Mizrachi A, Strenov Y, et al. Parathyroid adenoma: a comprehensive biochemical and histological correlative study. Clinical Otolaryngology. 2017 Apr;42(2):381-386. doi: 10.1111/coa.12761.
Chan RK, Ibrahim SI, Pil P, et al. Validation of a method to replace frozen section during parathyroid exploration by using the rapid parathyroid hormone assay on parathyroid aspirates. Archives of Surgery. 2005;140(4):371-373. doi: 10.1001/archsurg.140.4.371.
Murphy C ,Norman J. The 20% rule: a simple, instantaneous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery. 1999;126(6):1023-1028; discussion 1028-9. doi: 10.1067/msy.2099.101578.
Norman J, Chheda H. Minimally invasive parathyroidectomy facilitated by intraoperative nuclear mapping. Surgery. 1997;122(6):998-1003; discussion 1003-4. doi: 10.1016/s0039-6060(97)90201-4.
Rubello D, Piotto A, Casara D, et al. Role of gamma probes in performing minimally invasive parathyroidectomy in patients with primary hyperparathyroidism: optimization of preoperative and intraoperative procedures. European Journal of Endocrinology. 2003;149(1):7-15. doi: 10.1530/eje.0.1490007.
Tobin K, Ayers RR, Rajaei M, et al. Use of the gamma probe to identify multigland disease in primary hyperparathyroidism. International Journal of Endocrine Oncology. 2016;3(1):13-19. doi: 10.2217/ije.15.27.
Desiato V, Melis M, Amato B, et al. Minimally invasive radioguided parathyroid surgery: A literature review. International Journal of Surgery. 2016;28 Suppl 1: S84-93. doi: 10.1016/j.ijsu.2015.12.037.
Chen H, Mack E, Starling JR. Radioguided parathyroidectomy is equally effective for both adenomatous and hyperplastic glands. Annals of Surgery. 2003;238(3):332-337; discussion 337-8. doi: 10.1097/01.sla.0000086546.68794.9a.
Spiegel AM, Marx SJ, Doppman JL, et al. Intrathyroidal parathyroid adenoma or hyperplasia. An occasionally overlooked cause of surgical failure in primary hyperparathyroidism. JAMA. 1975;234(10):1029-1033. doi: 10.1001/jama.234.10.1029.
Weigel TL. Murphy J, Kabbani L, et al. Radioguided thoracoscopic mediastinal parathyroidectomy with intraoperative parathyroid hormone testing. The Annals of Thoracic Surgery. 2005;80(4):1262-1265. doi: 10.1016/j.athoracsur.2005.04.024.
McGreal G, Winter DC, Sookhai S, et al. Minimally invasive, radioguided surgery for primary hyperparathyroidism. Annals of Surgical Oncology. 2001;8(10):856-860. doi: 10.1007/s10434-001-0856-0.
Chen H, Sippel RS, Schaefer S. The effectiveness of radioguided parathyroidectomy in patients with negative technetium tc 99m-sestamibi scans. Archives of Surgery.2009;144(7):643-648. doi: 10.1001/archsurg.2009.104.
You CJ, Zapas JL. Diminished dose minimally invasive radioguided parathyroidectomy: a case for radioguidance. The American Journal of Surgery. 2007;73(7):669-672; discussion 673.
Pitt SC, Panneerselvan R, Sippel RS, et al. Radioguided parathyroidectomy for hyperparathyroidism in the reoperative neck. Surgery. 2009;146(4):592-598; discussion 598-9. doi: 10.1016/j.surg.2009.06.031.
Dudley NE. Methylene blue for rapid identification of the parathyroids. British Medical Journal. 1971;3(5776):680-681. doi: 10.1136/bmj.3.5776.680.
Cabanillas ME, McFadden DG, Durante C. Thyroid cancer. Lancet. 2016;388(10061):2783-2795. doi: 10.1016/S0140-6736(16)30172-6.
Reeve TS, Delbridge L, Brady P, et al. Secondary thyroidectomy: a twenty-year experience. World Journal of Surgery. 1988;12(4):449-453. doi: 10.1007/BF01655417.
Levin KE, Clark AH, Duh, QY, et al. Reoperative thyroid surgery. Surgery. 1992;111(6):604-609.
Erbil Y, Barbaros U, Deveci U, et al. Gamma probe-guided surgery for revision thyroidectomy: in comparison with conventional technique. Journal of Endocrinological Investigation. 2005;28(7):583-588. doi: 10.1007/BF03347255.
Bender O, Karyagar S, Levent BF, et al. Gamma probe (99m)Tc-pertechnetate assisted completion thyroidectomy vs conventional thyroidectomy in differentiated thyroid carcinoma. Hellenic Journal of Nuclear Medicine. 2009;12(2):138-141.
Aras G, Gültekin SS, Küçük NO, et al. Intraoperative gamma probe guidance with 99mTc-pertechnetate in the completion thyroidectomy. Annals of Nuclear Medicine. 2009;23(5):421-426. doi: 10.1007/s12149-009-0251-7.
