Comparison of the clinical features and surgical effect between ectopic and orthotopic parathyroid lesions_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

HU Lin ¹ , CUI Aimin ¹ , BAI Nan ¹ ,  ZHANG Ziqin ¹ , SONG Lei ² , ZHANG Qiang ² , WANG Yanbin ²

1. Department of General Surgery, Jishuitan Hospital, The 4^th Medical College of Peking University, Beijing 100096, P. R. China;
2. Department of Thoracic Surgery, Jishuitan Hospital, The 4^th Medical College of Peking University, Beijing 100035, P. R. China;

Corresponding author：

ZHANG Ziqin, Email: zhziqin@sina.com

Keywords：

parathyroid disease; ectopic; orthotopic; parathyroid hormone; preoperative location; parathyroidectomy

DOI：

10.7507/1007-9424.201707022

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Objective To compare the clinical features and surgical effect between ectopic and orthotopic parathyroid lesions. Methods The clinical data of 136 patients with parathyroid lesions who had undergone parathyroidectomy between May 2010 and May 2017 were retrospectively analyzed. Results The ectopic parathyroid location was detected in 20 patients (14.7%) of the 136 patients with parathyroid lesions. Of the 20 patients, prevalence of superior mediastinal ectopic lesions accounted for 30.0% (6/20), prevalence of thyrothymic ligament accounted for 20.0% (4/20), prevalence of intrathymic accounted for 15.0% (3/20), prevalence of tracheoesophageal groove accounted for 25.0% (5/20), prevalence of submandibular accounted for 5.0% (1/20), prevalence of carotid sheath accounted for 5.0% (1/20), respectively. Patients with ectopic lesions had significantly higher level of serum parathyroid hormone (PTH) and alkaline phosphatase (AKP) than patients with orthotopic parathyroid lesions (P≤0.05). In addition, osteitis fibrosa cystica of metabolic bone disease was significantly more frequent in patients with ectopic parathyroid lesions than those with orthotopic parathyroid lesions (P=0.04). Preoperative ultrasonography had a sensitivity of 50.0% (10/20) for ectopic lesions and 90.1% (100/111) for orthotopic lesions. Preoperative ⁹⁹Tc^m methoxyisobutylisonitrile (⁹⁹Tc^m-MIBI) had a sensitivity of 100% (19/19）for ectopic lesions and 95.3% (101/106) for orthotopic lesions. Preoperative CT had a sensitivity of 81.3% (13/14) for ectopic lesions and 93.6% (102/109) for orthotopic lesions. Preoperative combination examination had a sensitivity of 100% (20/20) for ectopic lesions and 99.1% (108/109) for orthotopic lesions. Of the 20 patients with ectopic leisions, 17 patients (85.0%) had undergone 1 time of operation, 2 patients (10.0%) had undergone twice operations, 1 patient (5.0%) had undergone trice operations. The onset of hypocalcemia happened in 13 patients (65.0%) after operation. Of 116 patients with orthotopic leisions, only 1 patient had twice operations, the onset of hypocalcemia happened in 74 patients (63.8%) after operation. The reoperation rate of orthotopic leisions was lower than that of patients with ectopic leisions (P=0.01), but there was no significant difference on the incidence of hypocalcemia (P=0.92). Excessive bleeding and recurrent laryngeal nerve injury didn’t happen after all operations. Of 136 patients, 111 patients had followed-up, among which 17 patients with ectopic leisions and 94 patients with orthotopic leisions. During the followed-up period, there were no recurrence happened. Conclusions The ectopic parathyroid lesions are associated with higher serum PTH and AKP levels and more frequent metabolic bone disease in comparison with the orthotopic parathyroid lesions, as well as high reoperation rate. Combined examination, including cervical ultrasonography, ⁹⁹Tc^m-MIBI, and cervical enhanced CT are needed for preoperative location. Parathyroid lesions resection is the main surgical approach, and patients with parathyroid lesions are prone to be onset of hypocalcemia.

Citation： HU Lin, CUI Aimin, BAI Nan, ZHANG Ziqin, SONG Lei, ZHANG Qiang, WANG Yanbin. Comparison of the clinical features and surgical effect between ectopic and orthotopic parathyroid lesions. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2017, 24(12): 1480-1486. doi: 10.7507/1007-9424.201707022 Copy

1.	Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands. Am J Surg, 2006, 191(3): 418-423.
2.	Mendoza V, Ramírez C, Espinoza AE, et al. Characteristics of ectopic parathyroid glands in 145 cases of primary hyperparathyroidism. Endocr Pract, 2010, 16(6): 977-981.
3.	Roy M, Mazeh H, Chen H, et al. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg, 2013, 37(1): 102-106.
4.	李志辉, 朱精强, 魏涛, 等. 甲状旁腺在人体中的分布特点及临床意义 (附 50 例解剖研究报告). 中国普外基础与临床杂志, 2008, 15(5): 311-313, 317.
5.	Nanka O, Libánsky P, Sedý J, et al. Surgical-anatomical study as a part of operative treatment of primary hyperparathyroidism. Rozhl Chir, 2006, 85(12): 618-623.
6.	Hojaij F, Vanderlei F, Plopper C, et al. Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study. Anat Sci Int, 2011, 86(4): 204-212.
7.	Alveryd A. Parathyroid glands in thyroid surgery. I. Anatomy of parathyroid glands. II. Postoperative hypoparathyroidism–identification and autotransplantation of parathyroid glands. Acta Chir Scand, 1968, 389: 1-120.
8.	Gray SW, Skandalakis JE, Akin JT Jr. Embryological considerations of thyroid surgery: developmental anatomy of the thyroid, parathyroids and the recurrent laryngeal nerve. Am Surg, 1976, 42(9): 621-628.
9.	Scharpf J, Kyriazidis N, Kamani D, et al. Anatomy and embryology of the parathyroid gland. Oper Techn Otolaryngol-Head Neck Surg, 2016, 27(3): 117-121.
10.	Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes, 2012, 120(10): 604-610.
11.	Beierwaltes WH. Endocrine imaging: parathyroid, adrenal cortex and medulla, and other endocrine tumors. Part II. J Nucl Med, 1991, 32(8): 1627-1639.
12.	Andrew JR, David LS. Essentials of parathyroid imaging. Oper Techn Otolaryngol-Head Neck Surg, 2016, 27(3): 122-128.
13.	Calcutt VG, Franco-Saenz R, Morrow LB, et al. Localization of abnormal parathyroid tissue with use of technetium-99m-sestamibi. Endocr Pract, 1998, 4(4): 184-189.
14.	Chang CW, Tsue TT, Hermreck AS, et al. Efficacy of preoperative dual-phase sestamibi scanning in hyperparathyroidism. Am J Otolaryngol, 2000, 21(6): 355-359.
15.	Kluijfhout WP, Pasternak JD, Beninato T, et al. Diagnostic performance of computed tomography for parathyroid adenoma localization; a systematic review and meta-analysis. Eur J Radiol, 2017, 88: 117-128.
16.	Ishibashi M, Nishida H, Hiromatsu Y, et al. Localization of ectopic parathyroid glands using technetium-99m sestamibi imaging: comparison with magnetic resonance and computed tomographic imaging. Eur J Nucl Med, 1997, 24(2): 197-201.
17.	Cheung K, Wang TS, Farrokhyar F, et al. A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol, 2012, 19(2): 577-583.
18.	杜海磊, 朱良纲, 车嘉铭, 等. 纵隔异位甲状旁腺的外科治疗. 外科理论与实践, 2016, 21(4): 318-320.
19.	Medrano C, Hazelrigg SR, Landreneau RJ, et al. Thoracoscopic resection of ectopic parathyroid glands. Ann Thorac Surg, 2000, 69(1): 221-223.
20.	Phillips IJ, Kurzawinski TR, Honour JW. Potential pitfalls in intraoperative parathyroid hormone measurements during parathyroid surgery. Ann Clin Biochem, 2005, 42(Pt 6): 453-458.
21.	Marcocci C, Cetani F. Clinical practice. Primary hyperparathyroidism. N Engl J Med, 2011, 365(25): 2389-2397.
22.	Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery, 1999, 126(6): 1016-1021, 1021-1022.
23.	Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1 650 consecutive patients with primary hyperparathyroidism. Ann Surg, 2011, 253(3): 585-591.
24.	Rathi MS, Ajjan R, Orme SM. A case of parathyroid carcinoma with severe hungry bone syndrome and review of literature. Exp Clin Endocrinol Diabetes, 2008, 116(8): 487-490.
25.	Witteveen JE, van Thiel S, Romijn JA, et al. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol, 2013, 168(3): R45-R53.

1. Phitayakorn R, McHenry CR. Incidence and location of ectopic abnormal parathyroid glands. Am J Surg, 2006, 191(3): 418-423.
2. Mendoza V, Ramírez C, Espinoza AE, et al. Characteristics of ectopic parathyroid glands in 145 cases of primary hyperparathyroidism. Endocr Pract, 2010, 16(6): 977-981.
3. Roy M, Mazeh H, Chen H, et al. Incidence and localization of ectopic parathyroid adenomas in previously unexplored patients. World J Surg, 2013, 37(1): 102-106.
4. 李志辉, 朱精强, 魏涛, 等. 甲状旁腺在人体中的分布特点及临床意义 (附 50 例解剖研究报告). 中国普外基础与临床杂志, 2008, 15(5): 311-313, 317.
5. Nanka O, Libánsky P, Sedý J, et al. Surgical-anatomical study as a part of operative treatment of primary hyperparathyroidism. Rozhl Chir, 2006, 85(12): 618-623.
6. Hojaij F, Vanderlei F, Plopper C, et al. Parathyroid gland anatomical distribution and relation to anthropometric and demographic parameters: a cadaveric study. Anat Sci Int, 2011, 86(4): 204-212.
7. Alveryd A. Parathyroid glands in thyroid surgery. I. Anatomy of parathyroid glands. II. Postoperative hypoparathyroidism–identification and autotransplantation of parathyroid glands. Acta Chir Scand, 1968, 389: 1-120.
8. Gray SW, Skandalakis JE, Akin JT Jr. Embryological considerations of thyroid surgery: developmental anatomy of the thyroid, parathyroids and the recurrent laryngeal nerve. Am Surg, 1976, 42(9): 621-628.
9. Scharpf J, Kyriazidis N, Kamani D, et al. Anatomy and embryology of the parathyroid gland. Oper Techn Otolaryngol-Head Neck Surg, 2016, 27(3): 117-121.
10. Noussios G, Anagnostis P, Natsis K. Ectopic parathyroid glands and their anatomical, clinical and surgical implications. Exp Clin Endocrinol Diabetes, 2012, 120(10): 604-610.
11. Beierwaltes WH. Endocrine imaging: parathyroid, adrenal cortex and medulla, and other endocrine tumors. Part II. J Nucl Med, 1991, 32(8): 1627-1639.
12. Andrew JR, David LS. Essentials of parathyroid imaging. Oper Techn Otolaryngol-Head Neck Surg, 2016, 27(3): 122-128.
13. Calcutt VG, Franco-Saenz R, Morrow LB, et al. Localization of abnormal parathyroid tissue with use of technetium-99m-sestamibi. Endocr Pract, 1998, 4(4): 184-189.
14. Chang CW, Tsue TT, Hermreck AS, et al. Efficacy of preoperative dual-phase sestamibi scanning in hyperparathyroidism. Am J Otolaryngol, 2000, 21(6): 355-359.
15. Kluijfhout WP, Pasternak JD, Beninato T, et al. Diagnostic performance of computed tomography for parathyroid adenoma localization; a systematic review and meta-analysis. Eur J Radiol, 2017, 88: 117-128.
16. Ishibashi M, Nishida H, Hiromatsu Y, et al. Localization of ectopic parathyroid glands using technetium-99m sestamibi imaging: comparison with magnetic resonance and computed tomographic imaging. Eur J Nucl Med, 1997, 24(2): 197-201.
17. Cheung K, Wang TS, Farrokhyar F, et al. A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol, 2012, 19(2): 577-583.
18. 杜海磊, 朱良纲, 车嘉铭, 等. 纵隔异位甲状旁腺的外科治疗. 外科理论与实践, 2016, 21(4): 318-320.
19. Medrano C, Hazelrigg SR, Landreneau RJ, et al. Thoracoscopic resection of ectopic parathyroid glands. Ann Thorac Surg, 2000, 69(1): 221-223.
20. Phillips IJ, Kurzawinski TR, Honour JW. Potential pitfalls in intraoperative parathyroid hormone measurements during parathyroid surgery. Ann Clin Biochem, 2005, 42(Pt 6): 453-458.
21. Marcocci C, Cetani F. Clinical practice. Primary hyperparathyroidism. N Engl J Med, 2011, 365(25): 2389-2397.
22. Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi-SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery, 1999, 126(6): 1016-1021, 1021-1022.
23. Udelsman R, Lin Z, Donovan P. The superiority of minimally invasive parathyroidectomy based on 1 650 consecutive patients with primary hyperparathyroidism. Ann Surg, 2011, 253(3): 585-591.
24. Rathi MS, Ajjan R, Orme SM. A case of parathyroid carcinoma with severe hungry bone syndrome and review of literature. Exp Clin Endocrinol Diabetes, 2008, 116(8): 487-490.
25. Witteveen JE, van Thiel S, Romijn JA, et al. Hungry bone syndrome: still a challenge in the post-operative management of primary hyperparathyroidism: a systematic review of the literature. Eur J Endocrinol, 2013, 168(3): R45-R53.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Comparison of the clinical features and surgical effect between ectopic and orthotopic parathyroid lesions

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