自体荧光基点光谱分析联合免疫胶体金技术在继发性甲旁亢术中识别异位微型旁腺的临床探索

Clinical research of near-infrared autofluorescence point-spectral analysis combined with immune colloidal gold technique for identification of ectopic micro-parathyroid glands during surgery of secondary hyperparathyroidism

目的研究近红外自体荧光基点光谱分析(near-infrared autofluorescence point-spectral analysis,NIAPSA)联合免疫胶体金技术(immune colloidal gold technique,ICGT)在继发性甲状旁腺功能亢进(secondary hyperparathyroid,SHPT)术中识别异位微型旁腺组织并指导手术切除的效果。方法回顾性分析2021年10月至2022年9月手术治疗的34例SHPT患者的临床资料。术中于双侧颈中央区使用NIAPSA探测分析,结合肉眼辨认后以注射器针头穿刺取洗脱稀释液行ICGT检测。联合检测为阴性者仅全切正常解剖位置腺体,阳性者加行阳性侧颈中央区纤维脂肪组织廓清术。分析联合检测的识别效果、相关生化指标、术后临床症状转归、甲状腺功能与骨代谢情况。结果本组34例手术均成功,其中经NIAPSA联合ICGT检测后行甲状旁腺廓清术(clean parathyroidectomy,CPTX)8例,仅行甲状旁腺全切术(total parathyroidectomy,TPTX)26例;共切除甲状旁腺143枚,其中正常位置134枚(显著增生),异位9枚(4枚轻度增生,5枚未见明显增生)。本组颈中央区纤维脂肪组织内NIAPSA探测阳性共10例12处,联合ICGT识别阳性病例8例共9份样本,联合检测阳性的廓清样本经术后病理证实均为异位旁腺。NIAPSA阳性样本预测值为75.0%,阳性病例预测值为80.0%,NIAPSA联合ICGT阳性预测值为100%。术前、术后1 d、3 d、术后1周及1月、3月、6月甲状旁腺激素(parathyroid hormone,PTH)、血钙、血磷、钙磷乘积(calcium-phosphorus product,CPP)、碱性磷酸酶(alkaline phosphatase,ALP)比较均有统计学差异(P<0.001)。PTH、血钙、血磷及CPP术后各时段均较术前明显改善,ALP自术后1周始至术后6月较术前改善(P<0.05)。PTH、血钙和CPP于术后1 d降至最低,血磷于术后1月降至最低,此后逐渐升高趋于正常;ALP自围术期开始向中远期缓慢降低。术后患者关节骨痛、皮肤瘙痒、肌无力症状明显改善,且随着时间的延长,术后各时间段有症状患者持续减少(P<0.001),术后3月及末次随访所有患者症状消失。本组患者术前与术后1月游离三碘甲状腺原氨酸(free triiodothyronine,FT3)、游离甲状腺素(free thyroxine,FT4)、促甲状腺激素(thyroid stimulating hormone,TSH)甲状腺功能指标比较均无统计学差异(P>0.05);术后6月N端中段骨钙素(N-terminal mid-fragment of osteocalcin,N-MID)、Ⅰ型前胶原氨基末端前肽(procollagen typeⅠamino-terminal propeptide,P1NP)、β-胶原特殊序列(β-crosslaps,β-CTX)骨代谢功能指标较术前均明显降低(P<0.001)。结论NIAPSA联合ICGT技术识别并指导SHPT术中清除颈中央区增生状态不明确的微型甲状旁腺组织安全有效,术后可有效降低PTH水平,调节钙磷代谢,抑制骨代谢活性,改善临床预后。

Objective To explore the clinical effect of near-infrared autofluorescence point-spectral analysis(NIAPSA)combined with immune colloidal gold technique(ICGT)to identify ectopic micro-parathyroid tissue,and guide surgical resection in the surgery of secondary hyperparathyroidism(SHPT).Methods The clinical data of 34 SHPT patients treated surgically from October 2021 to September 2022 were retrospectively studied.During the surgery,NIAPSA detection analysis combination with visual identification was used in the central region of bilateral neck,and followed by ICGT testing of elution dilution obtained by syringe needle puncture.According to combined test outcome,the surgical procedure was determined:Only the normal anatomical position of the gland was completely excised for the patients with negative outcome,and fibroadipose tissue dissection was combined in the central region of the neck for the patients with positive test.The effect of combined detection,related biochemical indexes,improvement of clinical symptom,thyroid function and bone metabolism were analyzed.Results The surgery was successful in all 34 cases,including 26 of total parathyroidectomy(TPTX)and 8 of additional clean parathyroidectomy(CPTX).A total of 143 parathyroid glands were removed,of which 134 were in normal position(with significant hyperplasia)and 9 were ectopic(with 4 of mild hyperplasia and 5 of non-significant hyperplasia).The NIAPSA detection was positive in 10 cases with 12 focuses,combined with ICGT test was positive in 8 cases with 9 samples,and the clearance samples with positive outcome of combined detection was confirmed to be ectopic parathyroid by postoperative pathology.The predictive value of NIAPSA positive samples,positive cases and NIAPSA combined with ICGT was 75.0%,80.0%and 100%respectively.There were statistically significant differences in parathyroid hormone(PTH),serum calcium,serum phosphorus,calcium-phosphorus product(CPP)and alkaline phosphatase(ALP)level before surgery,1-and 3 d,1 week,1-,3-and 6 months after surgery(P<0.001).Compared with the pre-operation,PTH,serum calcium,serum phosphorus and CPP were significantly improved at each time point postoperatively,while ALP was improved from 1 week to 6 months after operation(P<0.05).PTH,serum calcium and CPP decreased to the lowest on the day 1 after surgery,and serum phosphorus decreased to the lowest 1 month after operation,and then all of them increased to normal gradually.ALP decreased slowly from perioperative period to the middle and long term.The symptoms of joint bone pain,skin itching and muscle weakness were significantly improved after operation,with the prolongation of time,the rate of symptomatic patients continued to decrease at each time after surgery(P<0.001),until the symptoms relieved in all patients 3 and 6 months after operation(the last fellow-up).There was no significant difference in the thyroid function(FT3,FT4 and TSH)in all patients between before and 1 month after operation(P>0.05).And the bone metabolic function(β-CTX,P1NP,N-MID)was significantly lower 6 months after operation than those before operation(P<0.001).Conclusion The combined detection with NIAPSA and ICGT is safe and effective to identify and guide the clearance of micro-parathyroid tissue with indefinite hyperplasia status located in the central region of neck with reducing PTH level effectively,regulating calcium-phosphorus metabolism,inhibiting bone metabolism activity and improving the clinical prognosis.