Nejčastější indikací k chirurgickému řešení patologie příštítných tělísek je primární hyperparathyreóza, kdy je exstirpace patologicky změněného příštítného tělíska se zvýšenou produkcí parathormonu léčbou první volby. Embryonální vývoj dolního páru příštítných tělísek je poměrně složitý a úzce spjatý s tkání thymu, z tohoto důvodu není vzácností lokalizace adenomu příštítného tělíska v oblasti mediastina či přímo ve tkáni thymu. Léčba primární hyperparathyreózy se stává multioborovou problematikou, ve které má výraznou úlohu radiodiagnostika a metody nukleární medicíny, které jsou nezbytné k přesné lokalizaci postiženého tělíska a k naplánování adekvátního výkonu. Při nitrohrudní lokalizaci adenomu příštítného tělíska patří terapie do rukou pracoviště hrudní chirurgie. Na našem pracovišti má endokrinochirurgický program včetně chirurgie příštítných tělísek dlouholetou tradici a jsou zde soustřeďováni komplikovaní pacienti, často pacienti s refrakterní hyperparathyreózou po předchozím výkonu. V posledních 10 letech bylo na III. chirurgické klinice 1. LF UK a FN Motol provedeno téměř 2300 výkonů pro patologii příštítného tělíska, část při mediastinální lokalizaci miniinvazivně, tj. videotorakoskopicky či roboticky asistovaně.
The most common indication for surgical treatment of parathyroid gland pathology is primary hyperparathyroidism where extirpation of the pathologically changed parathyroid gland is the first-choice treatment. Embryonic development of the lower pair of parathyroid glands is quite complex and is closely related to the tissue of the thymus; for this reason it is not uncommon for a parathyroid adenoma to be located in the mediastinum or directly in the tissue of the thymus. The treatment of primary hyperparathyroidism is becoming a multidisciplinary issue in which radiodiagnostics and nuclear medicine methods play a significant role as they are needed to accurately localize the affected gland and to plan an adequate surgery. In case of intrathoracic localization of parathyroid adenoma, the therapy belongs in the hands of thoracic surgery. At our department, the endocrine surgery program, including parathyroid gland surgery, has a long tradition, and complicated patients are concentrated here, often patients with refractory hyperparathyroidism after a previous procedure. In the last 10 years, almost 2,300 procedures for parathyroid pathology have been performed at the IIIrd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital in Motol, of which some pathologies with mediastinal localization were managed using minimally invasive methods, i.e. videothoracoscopy or robotic-assisted surgery.
- MeSH
- Middle Aged MeSH
- Humans MeSH
- Parathyroid Neoplasms * surgery diagnostic imaging complications MeSH
- Parathyroid Glands surgery diagnostic imaging MeSH
- Parathyroidectomy methods MeSH
- Hyperparathyroidism, Primary surgery MeSH
- Robotic Surgical Procedures MeSH
- Treatment Outcome MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
U seniorů se můžeme setkat s velkou uzlovou strumou s cystami, která může způsobovat až mechanické komplikace. Dalším nálezem může být primární hyperparatyreóza doprovázená hyperkalcemií. Obě tyto situace se standardně řeší chirurgicky. U geriatrických pacientů ve zvýšeném operačním riziku lze jako alternativu ve vybraných situacích provést sklerotizaci alkoholem pod ultrasonografickou kontrolou. Jsou prezentovány čtyři kazuistiky úspěšné sklerotizace u pacientů starších 80 let, nevyžadující již nutnost operačního zákroku. U dvou obrovských cyst štítné žlázy 240 ml a 170 ml bylo sklerotizací dosaženo redukce objemu 99,5, resp. 99 %. U dvou pacientek s velkými solitárními adenomy příštítného tělíska a s těžkou hyperkalcemií bylo sklerotizací dosaženo redukce objemu velkých adenomů 2,1, resp. 2,5 ml o 91,5, resp. 76 % a poklesu sérového kalcia z 3,1 mmol/l a 2,85 mmol/l do normy.
Older adults can encounter a large nodular goiter with cysts causing mechanical complications. Another finding may be primary hyperparathyroidism with hypercalcemia. Both situations are usually treated surgically. For the senior population at increased surgical risk, ethanol ablation under ultrasonographic control can be performed as an alternative in selected situations. We present four cases of successful ethanol ablation in patients older than 80 years who no longer required surgery. In two patients with 240 ml and 170 ml huge thyroid cysts, we achieved volume reduction was 99.5 and 99 %, respectively. In two patients with large solitary parathyroid adenomas with severe hypercalcemia, the volume of large adenomas was reduced by 2.1 ml and 2.5 ml (91.5 % and 76 %) and a decrease in serum calcium from 3.1 mmol/l and 2.85 mmol/l to norm.
- Keywords
- sklerotizace absolutním alkoholem pod kontrolou ultrazvuku,
- MeSH
- Adenoma diagnostic imaging therapy MeSH
- Ambulatory Care MeSH
- Cysts diagnostic imaging therapy MeSH
- Ethanol therapeutic use MeSH
- Hypothyroidism complications MeSH
- Humans MeSH
- Parathyroid Neoplasms diagnostic imaging therapy MeSH
- Thyroid Diseases * diagnostic imaging therapy MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Sclerotherapy * MeSH
- Check Tag
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
- Research Support, Non-U.S. Gov't MeSH
Skeletal deformation like genu valgum is reported to be rare in Primary hyperparathyroidism (PHPT). The solitary adenoma or hyperplasia of the parathyroid glands are the cause in 80-85% of the cases. We report 2 cases of girls on 12 years and 15 years of age, complaining from pain and genu valgum deformation of the lower extremities before the planned orthopaedic surgical correction. The first patient had complaints for 3 years and lost ability to walk independently, the second case lost normal gate for a period of 5 months. The paraclinical screening discovered hypercalcemia, hypophosphatemia, elevated alkaline phosphatase, normal creatinine, raised parathormone. In the first case the X-rays depicted fibrocystic osteodistrophy from a hyperparathyroid type with bone cysts, giant cell "brown tumors" and pathological bone reorganization, in the second case - coarse fibrous structure of the left knee joint with genu valgum with bone cysts in the distal metaphysis of the left femur. The ultrasound of the thyroid gland found oval hypoechoic formations with suspicious origin from the parathyroid glands. These findings were confirmed from the SPECT/CT pointing active adenomas in the parathyroid glands. Skeletal deformation like genu valgum is the reason to search for the primary diagnosis in our 2 cases. Investigation of the serum calcium and parathormone are diagnostic in 100%. The imaging diagnosis has a critical role for indicating surgical treatment of the parathyroid gland adenoma. Key words: genu valgum, hypercalcemia, paediatric parathyroid adenoma, ultrasound, SPECT/CT.
Prezentujeme kazuistiku 51letého muže léčeného hemodialýzou pro chronické selhání ledvin, s anamnézou transplantace kadaverózní ledviny, sledovaného po nefrektomii nativní ledviny pro adenokarcinom. Při kontrolním CT vyšetření po roce od operace byl zaznamenán nádor lokalizovaný v lopatě kyčelní kosti. Nález byl zhodnocen jako metastáza primárního tumoru a pacientovi byla nabídnuta paliativní léčba. V dalších letech však pacient dobře prospívá. Nemá jiné obtíže než bolesti kostí v oblasti „nádorových hmot“. Z iniciativy pacienta i nefrologa byl původní závěr zpochybněn a postupně byl přehodnocen na možný a posléze i histologicky verifikovaný tzv. hnědý tumor při těžké sekundární hyperparathyreóze. Až po opakované chirurgické parathyreoidektomii se sérové koncentrace PTH významně snížily a ustoupily i klinické projevy (kostní bolesti). Pacient byl opětně zařazen do čekací listiny na transplantaci a byl podruhé úspěšně transplantován. Kazuistika upozorňuje na obtížnou diferenciální diagnostiku kostních postižení, obzvláště při koincidenci s jinými onemocněními (iniciální záměna kostního tumoru z hnědých buněk za kostní metastázu). V současné době se sice s „hnědým tumorem“ u dialyzovaných pacientů setkáváme jen ojediněle, ale stále je potřeba o této komplikaci vědět.
A 51 years maintenance dialysis patient with recent history of kidney graft failure was found to have bone mass on his left hip on CT scan one year after nefrectomy for renal cell carcinoma. The diagnosis of bone metastasis was done and only palliative care was ordered. Two years later, the bone mass progressed, but clinical picture of the patient was good. Thus, patient himself together with his nephrologist, questioned the diagnosis. Due to necessity of living expectance assessment before pacemaker implantation, bone biopsy from the affected bone was done. Histology finding confirmed the „brown tumor“, bone lesion associated with advanced hyperparathyroidism. Several surgical procedures were necessary to remove all autonomic parathyroid glands. Finally, after great improvement of subjective bone pain the patients was successfully re-transplanted. The differential diagnosis of bone tumor mass in dialysis patients is difficult. It must include also the non-malignancy etiology, as in this case.
- Keywords
- nádor z hnědých buněk,
- MeSH
- Renal Insufficiency, Chronic * therapy MeSH
- Diagnostic Errors MeSH
- Renal Dialysis MeSH
- Diagnosis, Differential MeSH
- Carcinoma, Renal Cell surgery diagnosis MeSH
- Middle Aged MeSH
- Humans MeSH
- Bone Neoplasms * diagnostic imaging secondary MeSH
- Parathyroid Neoplasms surgery diagnostic imaging therapy MeSH
- Hyperparathyroidism, Secondary * surgery diagnosis therapy MeSH
- Kidney Transplantation MeSH
- Check Tag
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Publication type
- Case Reports MeSH
- Research Support, Non-U.S. Gov't MeSH
- Review MeSH
PURPOSE: Identification of pathologic parathyroid glands in primary hyperparathyroidism, traditionally based on neck ultrasound (US) and/or 99mTc-Sestamibi scintigraphy, can be challenging. PET/CT with 18F-Fluorocholine (18F-FCH) might improve the detection of pathologic parathyroid glands. We aimed at comparing the diagnostic performance of 18F-FCH-PET/CT with that of dual-phase dual-isotope parathyroid scintigraphy and neck US. METHODS: Thirty-four consecutive patients with primary hyperparathyroidism were prospectively enrolled, 7 had normocalcemic hyperparathyroidism, and 27 had classic hypercalcemic hyperparathyroidism. All patients underwent high-resolution neck US, dual-phase dual-isotope 99mTc-Pertechnetate/99mTc-Sestamibi scintigraphy, and 18F-FCH-PET/CT. RESULTS: In the whole patients' group, the detection rates of the abnormal parathyroid gland were 68% for neck US, 71% for 18F-FCH-PET/CT, and only 15% for 99mTc-Sestamibi scintigraphy. The corresponding figures in normocalcemic and hypercalcemic hyperparathyroidism were 57 and 70% for neck US, 70 and 71% for 18F-FCH-PET/CT, and 0 and 18% for 99mTc-Sestamibi scintigraphy, respectively. In the 17 patients in whom the abnormal parathyroid gland was identified, either at surgery or at fine needle aspiration cytology/biochemistry, the correct detection rate was 82% for neck US, 89% for 18F-FCH-PET/CT, and only 17% for 99mTc-Sestamibi scintigraphy. CONCLUSIONS: 18F-FCH-PET/CT can be considered a first-line imaging technique for the identification of pathologic parathyroid glands in patients with normocalcemic and hypercalcemic hyperparathyroidism, even when the parathyroid volume is small.
- MeSH
- Choline analogs & derivatives MeSH
- Adult MeSH
- Hypercalcemia diagnostic imaging pathology surgery MeSH
- Hyperparathyroidism diagnostic imaging pathology surgery MeSH
- Cohort Studies MeSH
- Middle Aged MeSH
- Humans MeSH
- Parathyroid Neoplasms diagnostic imaging pathology surgery MeSH
- Follow-Up Studies MeSH
- Positron Emission Tomography Computed Tomography methods MeSH
- Prognosis MeSH
- Radiopharmaceuticals MeSH
- Radionuclide Imaging methods MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Ultrasonography methods MeSH
- Check Tag
- Adult MeSH
- Middle Aged MeSH
- Humans MeSH
- Male MeSH
- Aged, 80 and over MeSH
- Aged MeSH
- Female MeSH
- Publication type
- Journal Article MeSH
Preoperative localization with Tc-sestaMIBI or ultrasound is a common prerequisite for successful minimally invasive parathyroid adenoma (PA) surgery. SPECT/CT with Tc-sestaMIBI and PET/CT with F-FCH offer the possibility of attenuation correction and coregistration of functional and anatomical images providing more accurate PA localization. F-FCH PET/CT is used predominantly in patients with prostate cancer and is under investigation in PA. We report the case of a 43-year-old man with early FCH uptake in a cystic PA with delayed washout at 60 minutes.
- MeSH
- Adenoma diagnostic imaging MeSH
- Choline analogs & derivatives MeSH
- Adult MeSH
- Humans MeSH
- Parathyroid Neoplasms diagnostic imaging MeSH
- Positron Emission Tomography Computed Tomography * MeSH
- Radiopharmaceuticals MeSH
- Technetium Tc 99m Sestamibi MeSH
- Check Tag
- Adult MeSH
- Humans MeSH
- Male MeSH
- Publication type
- Journal Article MeSH
- Case Reports MeSH
- MeSH
- Renal Insufficiency, Chronic complications MeSH
- Kidney Failure, Chronic complications MeSH
- Phosphorus blood MeSH
- Hyperparathyroidism diagnosis etiology therapy MeSH
- Calcimimetic Agents therapeutic use MeSH
- Calcinosis etiology MeSH
- Skin Diseases etiology MeSH
- Humans MeSH
- Chronic Kidney Disease-Mineral and Bone Disorder * diagnosis physiopathology therapy MeSH
- Adolescent MeSH
- Parathyroid Neoplasms diagnostic imaging surgery MeSH
- Parathyroid Diseases diagnosis therapy MeSH
- Parathyroid Hormone blood MeSH
- Parathyroidectomy MeSH
- Peritoneal Dialysis MeSH
- Child, Preschool MeSH
- Calcium blood MeSH
- Check Tag
- Humans MeSH
- Adolescent MeSH
- Male MeSH
- Child, Preschool MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
Porucha homeostázy kalcia je u pacientov s nefrotickým syndrómom pomerne častým javom. Typickým nálezom je hypokalciémia, ktorá je zvyčajne dôsledkom závažnej hypoalbuminémie (pseudohypokalciémie). K hypokalciémii prispievajú aj močové straty vitamín D viažucich proteínov a následná hypovitaminóza D, ktorá znižuje absorpciu kalcia v čreve. V kazuistike prezentujeme nezvyčajnú príčinu hyperkalciémie u 12-ročného dievčaťa s primárne kortikorezistentným nefrotickým syndrómom na podklade fokálnej segmentálnej glomerulosklerózy. Pacientka bola liečená kortikosteroidmi a početnými imunosupresívami 2. línie bez dosiahnutia kompletnej remisie. Prekvapivým nálezom bola hyperkalciémia pri rozvinutých laboratórnych známkach nefrotického syndrómu, ktorá pretrvávala aj po vysadení substitučnej liečby vitamínom D a vápnikom pre glukokortikoidmi indukovanú osteoporózu. Na základe ultrasonografického vyšetrenia prištítnych teliesok a pozitrónovej emisnej tomografie bolo vyslovené podozrenie na adenóm prištítneho telieska, diagnózu potvrdilo histologické vyšetrenie po exstirpácii adenómu.
Calcium homeostasis imbalance occurs frequently in patients with nephrotic syndrome. Characteristic finding is hypocalcemia that is usually a result of severe hypoalbuminemia (pseudohypocalcemia). Other contributing factor is a urinary loss of vitamin D binding proteins with subsequent vitamin D deficiency that decreases intestinal calcium absorption. We describe the unusual case of hypercalcemia in a 12-year old girl with primary steroid-resistant nephrotic syndrome caused by focal segmental glomerulosclerosis. The patient was treated with corticosteroids and multiple 2-line imunosupressive medications without achievement of complete remission. Hypercalcemia was unexpected finding at the state of fully developed laboratory signs of nephrotic syndrome. Hypercalcemia persisted despite discontinuation of vitamin D and calcium supplementation administered for corticosteroid induced osteoporosis. Ultrasonography and positron emission tomography of parathyroid glands raised suspicion for parathyroid adenoma. Histological evaluation following adenoma exstirpation confirmed the diagnosis.
- MeSH
- Child MeSH
- Glucocorticoids therapeutic use MeSH
- Hypercalcemia * diagnosis etiology MeSH
- Immunosuppressive Agents therapeutic use MeSH
- Humans MeSH
- Parathyroid Neoplasms diagnostic imaging diagnosis surgery MeSH
- Nephrotic Syndrome * diagnosis therapy MeSH
- Prednisone administration & dosage therapeutic use MeSH
- Tacrolimus administration & dosage therapeutic use MeSH
- Vitamin D contraindications therapeutic use MeSH
- Treatment Outcome MeSH
- Check Tag
- Child MeSH
- Humans MeSH
- Female MeSH
- Publication type
- Case Reports MeSH
