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甲状旁腺功能亢进症(简称甲旁亢)是指甲状旁腺分泌过多的甲状旁腺激素,可分为原发性、继发性和三发性。原发性甲状旁腺功能亢进症(primary hyperparathyroidism,PHPT)是由于甲状旁腺本身病变引起的甲状旁腺激素的合成和分泌过多所引起的,病因为甲状旁腺腺瘤(癌)或增生,其中腺瘤占80%~85%,且绝大多数为单发腺瘤,甲状旁腺增生约占10%~15%,甲状旁腺癌所占比例不到1%。继发性甲状旁腺功能亢进症(secondary hyperparathyroidism,SHPT)是由于各种原因所致的低钙血症,刺激甲状旁腺增生肥大,分泌过多甲状旁腺素(parathyroid hormone,PTH),多见于肾功能不全和骨软化患者。三发性甲旁亢的甲状旁腺长期受低血钙刺激,部分增生组织转变为腺瘤,具有自主分泌过多PTH的能力,多见于慢性肾病患者。
手术是治疗PHPT的有效办法,术前对病变的准确定位至关重要,不仅可缩短术中寻找病灶的时间,使手术范围达到最小,而且也可避免因术中漏诊而再次进行手术。99Tcm-MIBI显像已成为术前诊断和定位甲状旁腺病灶的重要检查方法。以下就99Tcm-MIBI对甲旁亢的诊断价值作一综述。
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在没有任何术前显像的情况下,传统的颈部探查手术对于PHPT患者的成功率为92%~96%,一直以来都有学者更推荐生化指标检测而非显像来作为甲旁亢患者的术前常规检查。Wachtel等[12]认为,相比于能够准确定位的甲状旁腺腺瘤,99Tcm-MIBI SPECT显像难以定位体积较小、质量较轻的甲状旁腺病灶以及多发腺体增生,PHPT患者的术前评估更重要的是生化诊断而非术前显像。
更多的观点认为,甲旁亢患者的术前显像能够给手术定位提供帮助,特别是异位的甲状旁腺腺瘤或者解剖变异的甲状旁腺。微创甲状旁腺切除术将传统的甲状旁腺切除术治愈率从97.1%提高到了99.4%,术后的并发症发生率从3.10%降低到了1.45%。在许多国家,微创甲状旁腺切除术已经代替了传统的颈部探查甲状旁腺切除术,术前准确定位不仅对于微创手术的成功至关重要,其定位准确率也能影响到手术时间、术中出血以及手术并发症。于是,许多学者将SPECT/CT在微创甲状旁腺切除术前的显像提升到更高的地位。
本文对PHPT术前各种影像学检查的诊断价值广为探究,列举了2010年至2014年关于甲旁亢术前不同影像学方法的比较研究(表 1)。
第一作者 发表年份 研究对象 例数 研究内容 影像学方法 超声 平面显像 SPECT SPECT/CT MRI Hassler[13] 2014 PHPT 51 灵敏度、特异度 - 75%、90% - 86%、100% - 合并甲状腺疾病 24 灵敏度、特异度 - 62%、95% - 88%、100% - 未合并甲状腺疾病 27 灵敏度 - 85% - 85% - Vitetta[14] 2014 PHPT 108 灵敏度、特异度 - 78%、94% - 72%、90% - 单一的异位甲状旁腺腺瘤 18 灵敏度 55.0% 77.7% - - - Noda[15] 2014 PHPT 61 定位准确率 77.0% 75.4% - 88.5% - Zhen[16] 2013 SHPT 90 灵敏度、特异度 - 55.6%、100% - 78.9%、100% - Smith[17] 2013 PHPT 220 定位准确率 82.0% 85.0% - - - Michel[18] 2013 PHPT 58 灵敏度、阳性预测值 - 88%、93.6% 94.3%、96.2% Kwon[19] 2013 甲状旁腺腺瘤 112 灵敏度、阳性预测值 93.1%、96.9% 92.2%、96.9% - - - Kim[20] 2012 PHPT 24 灵敏度 70.8% 75.0% - 100% Akbaba[21] 2012 PHPT 98 定位成功率、灵敏度、特异度、诊断准确率 83.7%、87.2%、25.0%、83.0% 67.3%、70.2%、50.0%、69.4% 72.4%、75.5%、50.0%、74.5% - 61.2%、63.8%、50.0%、63.3% Cheung[22] 2012 PHPT meta分析 灵敏度、阳性预测值 76.1%、93.2% - 78.9%、90.7% - - Untch[23] 2011 PHPT 516 定位准确率 87.0%(有经验的外科医师) - 76.0% - - Oksüz[24] 2011 PHPT、SHPT 60 真阳性率 - 76.0% 97.0% 97.0% - Leupe[25] 2011 PHPT 368 阳性预测值(左右叶定位/象限定位) 84%、40% 93%、61% - - - Wimmer[26] 2010 多发性腺病 30 定位准确率 - - 13.3% 46.7% - Vulpio[27] 2010 尿毒症性SHPT 21 灵敏度、特异度 55%、95% 62%、95% - - - 异位甲状旁腺 9 检出率 0.0% 78.0% - - - Pata[28] 2010 PHPT 33 灵敏度、特异度、阳性预测值(左右叶定位) - - 80.0%、87.5%、88.9% 93.7%、93.7%、92.9% - 灵敏度、特异度、阳性预测值(象限定位) - - 55.6%、88.5%、62.5% 87.5%、95.5%、87.5% - Patel[29] 2010 甲旁腺瘤 59 检出率 64.0% - - 90.0% - 注:表中,PHPT:原发性甲状旁腺功能亢进症;SHPT:继发性甲状旁腺功能亢进症;“-”表示未作研究分析。 表 1 2010-2014年关于甲状旁腺功能亢进症术前不同影像学方法的比较研究
Table 1. Comparative studies of different imaging methods of preoperative hyperparathyrodism from 2010 to 2014
由表 1可看出,相比于99Tcm-MIBI平面显像,99Tcm-MIBI SPECT断层显像提供了三维功能图像,提高了PHPT患者术前定位的准确率。尽管有研究表明,99Tcm-MIBI SPECT/CT与SPECT对甲状旁腺病灶的诊断灵敏度相当[24],但更多的研究认为SPecT/cT比单独SPecT及平面显像提供了更可靠的三维解剖结构信息,其最大的优势在于更准确的解剖定位[30],尤其是对于异位的体积较小的甲状旁腺腺瘤。Serra等[31]发现SPecT/cT比单独的SPecT能多提供39%的PHPT或SHPT病灶信息。TaIeb等[32]在系统性研究中发现,对于异位甲状旁腺腺瘤的精确定位、有过颈部手术史、PHPT术后复发、甲状旁腺癌远处转移[33]、PHPT合并结节性甲状腺肿或多发性内分泌腺病患者中,SPecT/cT比SPecT及平面显像能给甲状旁腺微创手术的术前计划提供更多的帮助。Bural等[34]在对32例甲旁亢患者99Tcm-MIBI显像中发现,SPECT发现了22例阳性病灶,而SPECT/CT发现了31例阳性病灶,并且小于10 mm的甲状旁腺功能亢进病灶并不能靠单独SPECT检出。有学者认为,99Tcm-MIBI SPECT/CT应作为PHPT微创术前的常规显像,然而如果考虑到显像的时间以及增加的辐射剂量等因素,是否应该在PHPT微创术前常规使用SPECT/CT仍然存在争议[35]。
超声是最简便的筛查手段。由富有经验的超声医师操作,合并有甲状腺疾病的甲旁亢患者超声检查的灵敏度和准确率高于99Tcm-MIBI SPECT。99Tcm-MIBI SPECT显像优于超声的主要优势在于发现异位甲状旁腺病灶的高灵敏度。目前较为一致的观点是,在超声阴性或定位不准确的甲旁亢患者中进一步应用99Tcm-MIBI SPECT显像能提高诊断和定位的准确率;另一方面,联合超声或CT图像对于99Tcm-MIBI SPECT的准确定位能提供更多的信息,尤其是在PTH水平低、年龄大以及多发甲状腺结节的患者中[36]。Cheung等[22]通过Meta分析得出结论,超声和99Tcm-MIBI SPECT在异常甲状旁腺的术前定位中价值相当。
大多数研究认为MRI与99Tcm-MIBI显像具有相似的灵敏度和阳性预测值[37]。MRI探测甲旁亢病灶的缺点在于其对于小病灶的灵敏度低、误将增生的淋巴结或甲状腺疾病认为是甲状旁腺腺瘤,而其优点在于没有电离辐射损伤,以及对术后持续或复发的甲旁亢患者的诊断价值较高。Michel等[18]通过比较发现,MRI相比于99Tcm-MIBI显像对于甲旁亢病灶的探测有更高的灵敏度和阳性预测值,两者的联合能提高探测异常甲状旁腺的灵敏度和阳性预测值,减少手术切除范围和手术时间。
CT在甲旁亢中的应用主要集中在融合图像上,单独使用CT对于甲旁亢病灶的探测准确率较低,然而Ernst[38]发现三期增强CT对于甲旁亢病灶的定位有很高的准确率。较新的研究认为,四维CT有更高的灵敏度和定位准确率,将在后文中详述。
99Tcm-MIBI显像在甲状旁腺功能亢进症中的应用及进展
Application and progress of 99Tcm-MIBI scintigraphy in parathyroidism
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摘要: 99Tcm-MIBI SPECT对甲状旁腺功能亢进症的术前诊断有较高的灵敏度,联合超声或CT能提高诊断和定位的准确率,尤其是对异位的甲状旁腺腺瘤。随着微创甲状旁腺切除术的发展,99Tcm-MIBI SPECT/CT在术前准确定位上的价值日益凸显。甲状旁腺病灶的大小、生化指标等因素会影响99Tcm-MIBI显像的灵敏度和定位准确率。对于部分难以准确诊断和定位的甲状旁腺功能亢进症患者,11C-蛋氨酸PET/CT、四维CT、术中放射导航等是目前的研究热点和发展方向。
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关键词:
- 甲状旁腺功能亢进症 /
- 99m锝甲氧基异丁基异腈 /
- 体层摄影术, 发射型计算机, 单光子 /
- 体层摄影术, X线计算机
Abstract: 99Tcm-MIBI SPECT exhibited high sensitivity in hyperparathyroidism. Combination of ultrasound or CT can raise the diagnostic and location accuracy, especially in ectopic parathyroid adenoma. With the development of minimally invasive parathyroidectomy, the value of 99Tcm-MIBI SPECT/CT in preoperative location accuracy stands out. Many factors such as size of the gland lesions and biochemical indexes affect the sensitivity and location accuracy of 99Tcm-MIBI scintigraphy. For the negative imaging hyperparathyroidism patients, 11C-methionine PET/CT, 4D-CT and intraoperative radiation navigation is current research hot spot and development orientation. -
表 1 2010-2014年关于甲状旁腺功能亢进症术前不同影像学方法的比较研究
Table 1. Comparative studies of different imaging methods of preoperative hyperparathyrodism from 2010 to 2014
第一作者 发表年份 研究对象 例数 研究内容 影像学方法 超声 平面显像 SPECT SPECT/CT MRI Hassler[13] 2014 PHPT 51 灵敏度、特异度 - 75%、90% - 86%、100% - 合并甲状腺疾病 24 灵敏度、特异度 - 62%、95% - 88%、100% - 未合并甲状腺疾病 27 灵敏度 - 85% - 85% - Vitetta[14] 2014 PHPT 108 灵敏度、特异度 - 78%、94% - 72%、90% - 单一的异位甲状旁腺腺瘤 18 灵敏度 55.0% 77.7% - - - Noda[15] 2014 PHPT 61 定位准确率 77.0% 75.4% - 88.5% - Zhen[16] 2013 SHPT 90 灵敏度、特异度 - 55.6%、100% - 78.9%、100% - Smith[17] 2013 PHPT 220 定位准确率 82.0% 85.0% - - - Michel[18] 2013 PHPT 58 灵敏度、阳性预测值 - 88%、93.6% 94.3%、96.2% Kwon[19] 2013 甲状旁腺腺瘤 112 灵敏度、阳性预测值 93.1%、96.9% 92.2%、96.9% - - - Kim[20] 2012 PHPT 24 灵敏度 70.8% 75.0% - 100% Akbaba[21] 2012 PHPT 98 定位成功率、灵敏度、特异度、诊断准确率 83.7%、87.2%、25.0%、83.0% 67.3%、70.2%、50.0%、69.4% 72.4%、75.5%、50.0%、74.5% - 61.2%、63.8%、50.0%、63.3% Cheung[22] 2012 PHPT meta分析 灵敏度、阳性预测值 76.1%、93.2% - 78.9%、90.7% - - Untch[23] 2011 PHPT 516 定位准确率 87.0%(有经验的外科医师) - 76.0% - - Oksüz[24] 2011 PHPT、SHPT 60 真阳性率 - 76.0% 97.0% 97.0% - Leupe[25] 2011 PHPT 368 阳性预测值(左右叶定位/象限定位) 84%、40% 93%、61% - - - Wimmer[26] 2010 多发性腺病 30 定位准确率 - - 13.3% 46.7% - Vulpio[27] 2010 尿毒症性SHPT 21 灵敏度、特异度 55%、95% 62%、95% - - - 异位甲状旁腺 9 检出率 0.0% 78.0% - - - Pata[28] 2010 PHPT 33 灵敏度、特异度、阳性预测值(左右叶定位) - - 80.0%、87.5%、88.9% 93.7%、93.7%、92.9% - 灵敏度、特异度、阳性预测值(象限定位) - - 55.6%、88.5%、62.5% 87.5%、95.5%、87.5% - Patel[29] 2010 甲旁腺瘤 59 检出率 64.0% - - 90.0% - 注:表中,PHPT:原发性甲状旁腺功能亢进症;SHPT:继发性甲状旁腺功能亢进症;“-”表示未作研究分析。 -
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