Abstract:

Aim: was to determine possibilities of ultrasound in estimation of the status of parathyroid glands (PTG) in patients with secondary hyperparathyroidism (SHPT) treated with percutaneous ethanol injections.

Materials and methods: we examined 200 patients with end-stage of renal disease on dialysis. Enlargement and structural alteration of PTG were noted in 125 patients (62,5 %). Higher level of intact parathyroid hormone (iPTH) over 300 pg/ml was noted in the majority of patients with diagnosed parathyroic hyperplasia (81,6 %). Percutaneous ethanol injection therapy under ultrasound guidance was performed in 13 patients with SHPT resistant to medical therapy Average number of injections was 2,8 (from 1 to 6). Treatment effect was assessed based on iPTH level, calcium-phosphorus product level, as well as ultrasound evaluation.

Results: statistically significant decrease of iPTH after injections was noted averaging by 57,3% (p=0,0007), calcium-phosphorus product - by 12,2% (p=0,003). The biggest effect was noted in case of single hyperplastic PTG. During the follow-up, tendency to continued decreasing in levels of iPTH remained in 61,5 %. Decrease of the largest dimension of PTG after ethanol injections was noted on average by 15,1%, decrease of volume by 31,6%. Significant decrease in systolic velocity as well as resistive index of the feeding artery of PTG were observed (p=0,001 and 0,03 respectively). An important sign of diminished functional activity in the injected gland was statistically significant decrease in the vascularization index as assessed by the color Doppler during the process of injections (p=0,002).

Conclusion: ultrasound method provides information necessary for patients' selection for conduction of percutaneous ethanol injection therapy It assists at the time of the manipulation as well as during the follow-up assessing the condition of PTG and effectiveness of treatment. 

References

1.     KDIGO clinical practice guideline for the diagnosis, evaluation, prevention, and treatment of Chronic Kidney Disease-Mineral and Bone Disorder (CKD-MBD). Kidney Int. 2009; 113: 1-130.

2.     Cunningham J., Locatelli F., Rodriguez M. Secondary Hyperparathyroidism: Pathogenesis, Disease Progression, and Therapeutic Options. Clin. J. Am. Soc. Nephrol. 2011;6: 913-921.

3.     Fukagawa M., Nakanishi S., Kazama J.J. Basic and clinical aspects of parathyroid hyperplasia in chronic kidney diseases. Kidney Int. 2006; 70 (102): 3-7.

4.     Tominaga Y, Matsuoka S., Sato T. et al. Clinical features and hyperplastic pattern of parathyroid glands in hemodialysis patients with advanced secondary hyperparathyroidism refractory to maxacalcitol treatment and required parathyroidectomy. Ther. Dial. Apher. 2007; 11: 266-273.

5.     Latus J., Renate Lehmann R., Roesel M. et al. Analysis of -Klotho, Fibroblast Growth Factor, Vitamin-D and Calcium-Sensing Receptor in 70 Patients with Secondary Hyperparathyroidism. Kidney Blood Press Res. 2013; 37: 84-94.

6.     Tokumoto M., Taniguchi M. The mechanisms of parathyroid hyperplasia and its regression. Clin. Calcium. 2007; 17 (5): 665-676.

7.     Onoda N., Fukagawa M., Tominaga Y et al. New clinical guidelines for selective direct injection therapy of the parathyroid glands in chronic dialysis patients. Nephrol. Dial. Transplant. Plus. 2008; 1 (3): 26-28.

8.     Solbiati L., Giangrande A., Pra L.D. et al. Percutaneous ethanol injection of parathyroid tumor under US guidance: treatment for secondary HPT. Radiology. 1985; 155: 607-610.

9.    Gerasimchuk R., Zemchenkov A., Kondakov S. Maloinvazivnyj metod korrekcii vtorichnogo giperparatireoza pri hronicheskoj bolezni pochek. [Miniinvasive technique in the correction of secondary hyperparathyroidism in cronic renal disease]. Vrach. 2009; 11: 15-22 [in Russ].

10.   Fukagawa M., Kitaoka M., Tominaga Y et al. Guidelines for percutaneous ethanol injection therapy of the parathyroid glands in chronic dialysis patients. Nephrol Dial Transplant. 2003; 18 (3): 31-33.

11.   Koiwa F., Kakuta T., Tanaka R. et al. Efficacy of percutaneous ethanol injection therapy (PEIT) is related to the number of parathyroid glands in hemodialysis patients with secondary HPT. Nephrol. Dial. Transplant. 2007; 22: 522-528.

12.   Yumita S. Intervention for recurrent secondary hyperparathyroidism from a residual parathyroid gland. Nephrol. Dial. Transplant. 2003; 18 (3): 62-64.

13.   Polukhina E.V., Glazun L.O. Ul'trazvukovaja diagnostika patologii parashhitovidnyh zhelez u bol'nyh hronicheskoj pochechnoj nedostatochnost'ju, nahodjashhihsja na zamestitel'noj pochechnoj terapii. [Ultrasound diagnosis of the parathyroid glands pathology in patients being on replacement therapy in case of chronic renal insufficiency]. Ul'trazvukovaja i funkcional'naja diagnostika. 2008; 1: 35-42 [in Russ].

14.   Anari H., Bashardoust B., Pourissa M. The Diagnostic Accuracy of High Resolution Ultrasound Imaging for Detection of Secondary Hyperparathyroidism in Patients with Chronic Renal Failure. Acta Medica Iranica. 2011; 49 (8): 527-530.

15.   Meola M., Petrucci I., Cup-isti A. Ultrasound in clinical setting of secondary hyperparathyroidism. J. Nephrol. 2013; 26 (5): 848-855.

16.   National Kidney Foundation. K/DOQI clinical practice guidelines for Bone Metabolism and Disease in Chronic Kidney Disease // Am. J. Kidney Dis. 2003; 42: 1-202.

17.   Kakuta T., Tanaka R., Kanai G. et al. Can cinacalcet replace parathyroid intervention in severe secondary hyperparathyroidism? Ther. Apher. Dial. 2009; 13 (1): 20-27.

18.   Kalinin A.P., Pavlov A.V., Aleksandrov Ju.K. et al. Metody vizualizacii okoloshhitovidnyh zhelez i paratireoidnaja hirurgija: rukovodstvo dlja vrachej; Pod. red. A.P. Kalinina. [Parathyroid imaging techniques and parathyroid surgery: The management for doctors. Ed. A.P. Kalinin]. M.: Vidar M, 2010; 311 [in Russ].

19.   Chen H.H., Lu K.C., Lin C.J. et al. Role of the Parathyroid Gland Vascularization Index in Predicting Percutaneous Ethanol Injection Efficacy in Refractory Uremic Hyperparathyroidism. Nephron Clin. Pract. 2010; 117 (2): 120-126. 

Abstract:

Aim: was to increase the level of differential diagnosis of thyroid nodules by evaluating their rigidity according to two ultrasound techniques - compressive elastography and shear wave elastography.

Materials and methods: study is based on the result of analysis of complex clinical anc ultrasound diagnostics, performed for the period from 2010 to 2015 , on the base of ultrasound department of «Central Clinical Hospital of Ministry of Internal Affairs» of the RF in Moscow, and Medical Radiological Research Center named after AF Tsyba - FGBU branch of «National Medical Research Radiological Center» MoH Obninsk.

Results: performed shear wave elastography, obtained quantitative data of rigidity of benign nodules and papillary carcinoma. Used methods of nonparametric statistics and ROC-analysis. Statistical processing was performed in SPSS 13.0 program. For benign nodes median of regidity was 15.6; 2,5-97,5 percentiles - 3,6-81,3; for papillary cancer: median 112.92; 2,5-97,5 percentiles - 13,5-196,4. Then followed an orange and yellow-red: blue color was not more than 20%, but mostly he was absent. In case of papillary cancer we observed two-color, three-color, four-color and six-color color, with prevailing of two colors - purple and blue.

Conclusions: both types of elastography - compressive and shear wave elastography - help to improve the differential diagnosis of thyroid cancer. Informativeness of shear wave elastography is higher, in comparison with compressive elastography.

References

1.     Kotljarov P.M., Harchenko V.P., Aleksandrov Ju.K., Mogunov  M.S., Sencha A.N., Patrunov Ju.N., Beljaev D.V. Ul'trazvukovaja diagnostika zabolevanij shhitovidnoj zhelezy [Ultrasonic diagnosis of thyroid diseases.]. M.: VIDAR. 2009: 239S [In Russ].

2.     Mit'kov V.V., Huako S.A., Cyganov S.E., Kirillova T.A., Mit'kova M.D. Sravnitel'nyj analiz dannyh jelastografii sdvigovoj volnoj i rezul'tatov morfologicheskogo issledovanija tela matki (predvaritel'nye rezul'taty) [Comparative analysis of data of shear wave elastography and results of uterine body morphological study (preliminary results)]. Ul'trazvukovaja i funkcional'naja diagnostika. 2013; 5: 99-114 [In Russ].

3.     Sencha A.N., Mogutov M.S., Patrunov U.N. et al. Kolichestvennie i kachastvennie pokazateli ul’trazvukovoi jelastografii v diagnostike raka shhitovidnoj zhelezy [Quantitative and qualitative indicators of ultrasound elastography in the diagnosis of thyroid cancer.]. Ul'trazvukovaja ifunkcional'naja diagnostika. 2013; 5: 85-98 [In Russ].

4.     Osipov L.V. Tehnologii jelastografii v ul’trazvukovoi diagnostike. Obzor. [ Elastography technologies in ultrasound diagnostics. Overview.] Diagnosticheskaya radiologiya i onkoterapiya. 2013; 3,4: 5-23 [In Russ].

5.     Parshin V.S., Yamasita C, Cib A.F. Zob. Ul'trazvukovaja diagnostika. Klinicheskii atlas [Ultrasound diagnostics. Clinical atlas]. Nagasaki-Obninsk. Universitet Nagasaki, 2000; S 106 [In Russ].

6.     Parshin V.S., Cib A.F., Yamasita C. Rak shhitovidnoj zhelezy. Ul'trazvukovaja diagnostika. Klinicheskii atlas [Thyroid cancer. Ultrasound diagnostics. A clinical atlas. In Chernobyl materials.]. Po materialam Cyernobilya. Obninsk. MRNC RAMN. 2002; S 230 [In Russ].

7.     Parshin V.S.,Yamashita S., Tsyb A.F. Ultrasound Diagnosis of Thyroid Diseases in Russia. Obninsk-Nagasaki. 2013; S147.

8.     Cib A.F., Parshin V.S., Yamasita C. Ul'trazvukovaja diagnostika zabolevanij shhitovidnoj zhelezy [Ultrasonic diagnosis of thyroid diseases.]. M.: Medicina. 1997; S 329 [In Russ].

9.     Asteria C., Giovanardi A., Pizzocaro A., Cozzaglio L., Morabito A., Somalvico F., Zoppo A. US-elastography in the differential diagnosis of benign and malignant thyroid nodules. Thyroid. 2008; 18: 523-531.

10.   Cantisani V., D'Andrea V., Biancari F., Medvedyeva O., Di Segni M., Olive M., Patrizi G., Redler A., De Antoni E.E., Masciangelo R., Frezzotti F., Ricci P Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: preliminary experience. Eur. J. Radiol. 2012; 81: 2678-2683.

11.   Vorlander C., Wolff J., Saalabian S., Lienenluke R.H., Wahl R.A. Real-time ultrasound elastographya non-invasive diagnostic procedure for evaluating dominant thyroid nodules Langenbecks Arch. Surg. 2010; 395: 865-871.

12.   Bojunga J., Herrmann E., Meyer G., Weber S., Zeuzem S., Friedrich-Rust M. Real-time elastography for the differentiation of benign and malignant thyroid nodules: a metaanalysis Thyroid. 2010; 20: 1145-1150.

13.   Gharib H., Papini E., Paschke R., Duick D.S., Valcavi R., Hegedus L., Vitti P American Association of Clinical Endocrinologists, Associazione Medici Endocrinologi and European Thyroid Association Medical Guidelines for Clinical Practice for the Diagnosis and Management of Thyroid Nodules. Endocr. Pract. 2010;16: 1-43.

14.   Moon H.J., Kim E.K., Yoon J.H., Kwak J.Y Clinical implication of elastography as a prognostic factor of papillary thyroid microcarcinoma. Ann. Surg. Oncol. 2012; 19: 2279-2287.