Abstract
Parathyroidectomy is considered the definitive cure for primary hyperparathyroidism due to a single parathyroid adenoma, which represents the most common cause of chronic hypercalcemia. However, in few cases, surgery may be technically difficult or risky. We report the use of percutaneous ultrasound-guided alcohol ablation of a parathyroid adenoma as an alternative to surgery in an 88-year-old male patient with significant medical comorbidities.
1
Introduction
Surgical parathyroidectomy is considered the best curative treatment option for patients with symptomatic primary hyperparathyroidism (PHPT) caused by parathyroid adenoma . Medical therapy is approved by the Food and Drug Administration (FDA) as a treatment option only in secondary hyperparathyroidism, while in PHPT, it offers little hope for long-term eucalcemia. Percutaneous alcohol ablation (PAA) of the parathyroid adenoma may represent an alternative therapeutic approach in a small number of cases of PHPT in which, due to other comorbidities, surgery carries a high risk associated with anesthesia and/or technical difficulties .
A few studies have reported the use of PAA for the management of PHPT. We present here the first case of parathyroid adenoma treated by PAA in our institution, with a follow-up period of one year after the ablation.
2
Case report
An 88-year-old male patient with hypercalcemia was referred to our institute after failure of medical therapy (calcimimetics and vitamin D) to achieve long-term normocalcemia. His hypercalcemia was due to PHPT caused by a single parathyroid adenoma. The patient’s chief complaint was severe musculoskeletal weakness. He had a medical history of myocardial infarction, chronic obstructive pulmonary disease, renal impairment, and severe kyphoscoliosis. Laboratory investigations showed very high levels of parathyroid hormone (PTH), up to 1900 pg/mL (normal range 11.1–79.5 pg/mL), and serum calcium was elevated to 11.3 mg/dL (normal range 8.6–10.1 mg/dL) in spite of the use of calcimimetic therapy. Ultrasound (US) examination of the neck revealed a well-defined hypoechoic mass measuring 34 × 21 mm in diameter. The mass involved the posterolateral aspect of the left thyroid lobe, suggesting the presence of a parathyroid adenoma. Parathyroid scintigraphy (sestamibi scan) confirmed the diagnosis of a left inferior parathyroid gland adenoma ( Fig. 1 ).
The patient was considered a high-risk patient for anesthesia due to his multiple comorbidities. We suggested that the patient could undergo PAA as an alternative to surgical parathyroidectomy, and he agreed by signing a written informed consent form. An experienced interventional radiologist performed the procedure. After sterilization of the skin, a small amount of local anesthetic was injected into the skin and subcutaneous tissue. A 25-gauge needle attached to a syringe containing 96% ethyl alcohol was carefully inserted into the parathyroid adenoma under real-time US guidance; a total of 6 mL of ethanol was injected into the 4 quadrants of the adenoma while monitoring the diffusion of the alcohol by US ( Fig. 2 ). Ablation was confirmed by a marked decrease in the vascularity of the adenoma on Doppler US ( Fig. 3 ). Another injection was administered after 4 months due to slowly elevated levels of both calcium and PTH. The patient is now normocalcemic, and his PTH level has been stable at around 400 pg/mL for a period of one year of follow-up.
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