Microwave ablation vs. parathyroidectomy for secondary hyperparathyroidism in maintenance hemodialysis patients

Comparison of thermal ablation and surgery for hyperparathyroidism: a meta-analysis

OBJECTIVE

Surgery and thermal ablation are both viable treatment modalities for patients diagnosed with hyperparathyroidism (HPT). However, the comparative efficacy of these approaches remains uncertain. The objective of this meta-analysis is to evaluate the effectiveness of surgical complications and therapeutic strategies in managing HPT.

METHODS

The databases PubMed, EMBASE, the Cochrane Library, the Web of Science, CNKI and Wan Fang were systematically searched from inception to December 12, 2023 to identify relevant studies comparing thermal ablation with surgical parathyroid hormone therapy. Data analysis was conducted using Review Manager Version 5.4.

RESULT

A total of 15 studies were incorporated into the meta-analysis, comprising 1,115 participants drawn from 12 cohort studies and three randomized controlled trials. The results indicated no significant difference in parathyroid hormone levels between the two treatment options (mean difference: 29.25, 95% CI: -4.99-63.69, p = 0.09), calcium (MD: 0.00, 95%CI: 0.07-0.08, p = 0.94), phosphorus (MD: -0.05, 95% CI: -0.13-0.04, p = 0.28) and the risk of persistence and/or recurrence (OR: 1.01, 95% CI: 0.63-1.62, p = 0.97). The probability of hoarseness (OR: 0.57, 95% CI: 0.35-0.93, p = 0.02) and hypocalcemia (OR: -0.12, 95% CI: -0.19- -0.05, p < 0.01) was lower after thermal ablation than with surgery. Comparable results were observed in instances of secondary and primary hyperparathyroidism.

CONCLUSION

It can be concluded that surgery and thermal ablation are effective modalities for treating hyperparathyroidism. Thermal ablation has been shown to reduce the likelihood of hoarseness and hypocalcemia. Further validation of these results necessitates conducting comprehensive multicenter randomized controlled trials.

US-Guided Thermal Ablation for Secondary Hyperparathyroidism: A Prospective Multicenter Study

Background Interest in microwave ablation (MWA) and radiofrequency ablation (RFA) use for treating secondary hyperparathyroidism (SHPT) is rising; however, ablation outcomes in patients with SHPT are not well characterized. Purpose To assess the response of parathyroid hormone (PTH), calcium, phosphorus, and alkaline phosphatase (ALP) levels to US-guided parathyroid MWA and RFA and the safety of these treatments in participants with SHPT. Materials and Methods This prospective multicenter cohort study, conducted from September 2017 to March 2022, included participants with SHPT. The primary end point was the proportion of participants achieving the target PTH level (≤585 pg/mL). The secondary end points included PTH, calcium, phosphorus, and ALP levels before ablation and time points for follow-up assessments after ablation (2 hours, 1 day, 1 month, 3 months, and 6 months, and then every 6 months) and complications and technical success rates. Mixed-effects logistic regression models were used to identify factors associated with treatment failure. Results A total of 215 participants (median age, 53 years [IQR, 43-60 years]; 109 [50.7%] male participants) were evaluated, and 183 (85.1%) achieved target PTH levels. Compared with baseline levels, there was an 85.9%, 6.3%, 15.3%, and 37.4% reduction in PTH, calcium, phosphorus, and ALP levels at 24 months after ablation, respectively. For major complications, one (0.5%) participant experienced persistent hoarseness, and severe hypocalcemia (<1.87 mmol/L) was present in 74 (34.4%) participants. After adjustments, predictors associated with treatment failure included the preablation PTH level (adjusted odds ratio [OR], 3.78; 95% CI: 1.19, 12.04; P = .03), maximum tumor volume (adjusted OR, 5.02; 95% CI: 1.74, 14.53; P = .003), and number of glands ablated (adjusted OR, 0.32; 95% CI: 0.11, 0.98; P = .046). The prediction model showed good discrimination ability in the development and validation cohorts (area under the receiver operating characteristic curve, 0.78 [95% CI: 0.66, 0.90] and 0.73 [95% CI: 0.55, 0.91], respectively). Conclusion US-guided thermal ablation techniques were effective and safe treatments in participants with SHPT because they effectively reduced PTH, calcium, phosphorus, and ALP levels. © RSNA, 2025 Supplemental material is available for this article. See also the editorial by Gemmete in this issue.

Secondary hyperparathyroidism in chronic kidney disease: A narrative review focus on therapeutic strategy

Chronic kidney disease (CKD) affects over 10% of the global population. One crucial complication of CKD is secondary hyperparathyroidism (SHPT), marked by elevated parathyroid hormone levels due to hyperphosphataemia, hypocalcaemia, and low active vitamin D from impaired renal function. SHPT increases risks of bone deformities, vascular calcification, cardiovascular events and mortality. This review examines SHPT treatment strategies in patients with CKD. First-line treatments include phosphate binders, vitamin D receptor activators and calcimimetics. When these fail, invasive options like parathyroidectomy (PTX) and thermal ablation are considered. PTX effectively reduces symptoms and improves radiological outcomes, outperforming medical treatment alone in reducing cardiovascular risk and mortality. Thermal ablation techniques, such as microwave, radiofrequency, laser or high-intensity focused ultrasound, offer less invasive alternatives with promising results. Future research should explore the molecular mechanisms of parathyroid gland hyperplasia and evaluate various treatments' impacts.

Ultrasound-Guided Radiofrequency Ablation for Primary Hyperparathyroidism Induced by Multiple Endocrine Neoplasia 1—A Case Report

Multiple endocrine neoplasia type 1 (MEN1) is a syndrome characterized by the occurrence of two or more endocrine gland tumors. Here, we show a case of a 52-year-old man diagnosed with MEN1 through gastrinoma, parathyroid adenoma and gene detection. The MEN1 patient’s case was complicated with relapsed primary hyperparathyroidism (PHPT), and they received ultrasound-guided radiofrequency ablation (RFA). The patient had a remarkable recovery after RFA treatment for the relapsed PHPT. It might be an alternative treatment for MEN1 patients with poor conditions such as high surgical risk, unwillingness to choose parathyroid surgery or those unable to tolerate surgery. Individualized therapy significantly benefits the prognosis of MEN1 patients.

The American Association of Endocrine Surgeons Guidelines for the Definitive Surgical Management of Secondary and Tertiary Renal Hyperparathyroidism

OBJECTIVE

To develop evidence-based recommendations for safe, effective, and appropriate treatment of secondary (SHPT) and tertiary (THPT) renal hyperparathyroidism.

BACKGROUND

Hyperparathyroidism is common among patients with chronic kidney disease, end-stage kidney disease, and kidney transplant. The surgical management of SHPT and THPT is nuanced and requires a multidisciplinary approach. There are currently no clinical practice guidelines that address the surgical treatment of SHPT and THPT.

METHODS

Medical literature was reviewed from January 1, 1985 to present January 1, 2021 by a panel of 10 experts in SHPT and THPT. Recommendations using the best available evidence was constructed. The American College of Physicians grading system was used to determine levels of evidence. Recommendations were discussed to consensus. The American Association of Endocrine Surgeons membership reviewed and commented on preliminary drafts of the content.

RESULTS

These clinical guidelines present the epidemiology and pathophysiology of SHPT and THPT and provide recommendations for work-up and management of SHPT and THPT for all involved clinicians. It outlines the preoperative, intraoperative, and postoperative management of SHPT and THPT, as well as related definitions, operative techniques, morbidity, and outcomes. Specific topics include Pathogenesis and Epidemiology, Initial Evaluation, Imaging, Preoperative and Perioperative Care, Surgical Planning and Parathyroidectomy, Adjuncts and Approaches, Outcomes, and Reoperation.

CONCLUSIONS

Evidence-based guidelines were created to assist clinicians in the optimal management of secondary and tertiary renal hyperparathyroidism.

Efficacy and safety of radiofrequency ablation versus parathyroidectomy for secondary hyperparathyroidism in dialysis patients: a single-center retrospective study

We compared the efficacy and safety of ultrasound (US)-guided radiofrequency ablation (RFA) and parathyroidectomy (PTX) for the treatment of secondary hyperparathyroidism (SHPT). In this single-center retrospective study, we divided patients into PTX (n = 53) and RFA (n = 47) groups. The primary outcome was the proportion of patients who achieved the target intact parathyroid hormone (iPTH) concentration range (≤ 300 pg/mL). Secondary outcomes were the differences in the changes in iPTH, calcium, and phosphorus levels over time and prognosis. iPTH concentrations of 82.1% and 64.1% in the PTX and RFA groups, respectively, were within the recommended range at the endpoint (P = 0.07). iPTH concentrations in the PTX and RFA groups dropped sharply after treatment (82 ± 163 pg/mL and 280 ± 307 pg/mL, respectively, P < 0.001). There was no difference in the trends of iPTH, calcium, and phosphorus levels between the two groups (P > 0.05). Survival analysis revealed no differences in all-cause mortality and cumulative response rate between the two groups (P = 0.90, P = 0.14, respectively). Notably, the incidence of infection and length of the hospital stay in the RFA group were significantly lower. The preoperative bone-specific alkaline phosphatase concentration was a risk factor for postoperative hypocalcemia. US-guided RFA is minimally invasive and compared to PTX in terms of long-term efficacy and complications in the treatment of severe SHPT in maintenance dialysis patients. It may be used as an alternative technique to PTX; however, further studies are needed.

Ultrasound-guided thermal ablation for hyperparathyroidism: current status and prospects

BACKGROUND

Hyperparathyroidism (HPT) is classified into primary HPT (PHPT), secondary HPT (SHPT), tertiary HPT (THPT), and pseudohyperparathyroidism. Parathyroid surgery is generally reserved for patients with symptomatic PHPT and asymptomatic patients who meet the surgical guideline criteria. However, the risk of complications and mortality after parathyroid gland surgery increases with increasing patient age.

AIM

This study aimed to review existing research on laser ablation, radiofrequency ablation, microwave ablation, and high-intensity focused ultrasound in the treatment of HPT and analyze its application prospects.

CONCLUSIONS

Thermal ablation is a good alternative treatment for patients with parathyroid hyperplasia who do not meet the criteria or decline surgery. Being a type of minimally invasive treatment, ultrasound-guided thermal ablation has the advantages of easy operation, rapid recovery, and reusability and is used widely.

Long-Term Effect of Microwave Ablation on Patients Undergoing Hemodialysis for Moderate Secondary Hyperparathyroidism: A Retrospective Cohort Study

OBJECTIVES

A previous 12-month study confirmed that microwave ablation (MWA) was effective for moderate secondary hyperparathyroidism (SHPT). A further analysis was performed in this study to evaluate the efficacy of MWA for moderate SHPT over an observational follow-up period of up to 60 months.

METHODS

This was a retrospective cohort study of patients involved in a previous randomized controlled trial. Patients were divided into an MWA group (those who underwent MWA followed by drug therapy according to the patient's clinical situation) and a control group (those who received drug therapy only). The primary outcome was the composite endpoint. During the efficacy assessment phase, the two groups were compared in terms of the proportion of patients with intact parathyroid hormone (iPTH) levels <300 pg/ml and the differences in iPTH levels.

RESULTS

Twenty-seven patients were included in this study: 13 in the MWA group and 14 in the control group. The median (interquartile range) follow-up periods of the MWA and control groups were 58 (54-60) and 58 (49-60) months, respectively. The proportion of patients with iPTH levels <300 pg/ml in the MWA group was slightly higher than that in the control group (6/13 [46.2%] versus 2/14 [14.3%], respectively; p = .08). Furthermore, iPTH levels in the MWA group were lower than in the control group during the efficacy assessment phase (411 ± 299 pg/ml versus 516 ± 369 pg/ml, respectively; p <.01).

CONCLUSIONS

MWA helped to contain the necessary iPTH levels in patients undergoing hemodialysis for moderate SHPT in a 60-month timeframe.

Ultrasound-guided microwave ablation for secondary hyperparathyroidism: a systematic review and meta-analysis

OBJECTIVES

Microwave ablation (MWA) is used for the treatment of severe secondary hyperparathyroidism (SHPT), but its efficacy and safety still remained unclear. This study aimed to investigate the efficacy and safety of ultrasound (US)-guided MWA in patients with SHPT.

METHODS

The PubMed, Cochrane library, Embase, China national knowledge infrastructure (CNKI) and Wanfang databases were searched to identify published studies that evaluated the efficacy and safety of US-guided MWA in patients with SHPT. The primary outcomes were parathyroid hormone (PTH), serum calcium and phosphorus levels.

RESULTS

A total of 26 studies with 932 patients were identified. The PTH levels showed significant reduction at 1 month [weighted mean difference (WMD) = 945.33, 95% CI: 797.15∼1093.52] and 6 months (WMD = 1,151.91, 95% CI: 990.93∼1312.89) after MWA of SHPT patients. The serum calcium (WMD = 0.39, 95% CI: 0.30 ∼ 0.48) and phosphorus levels (WMD = 0.64, 95% CI: 0.43 ∼ 0.85) showed significant reduction at 6 months after MWA of SHPT patients. The most common complications observed were hypocalcemia (35.2%) and transient hoarseness (9.2%). No other major complications or death occurred in our study patients.

CONCLUSION

These findings suggest MWA as a safe and effective minimally invasive technique for the management of SHPT. PTH, calcium, and phosphorus levels were significantly reduced at 1 and 6 months after MWA.

Microwave ablation versus parathyroidectomy for severe secondary hyperparathyroidism in patients on hemodialysis: a retrospective multicenter study

BACKGROUND

Microwave ablation is effective for severe secondary hyperparathyroidism, but the difference in efficacy between microwave ablation and parathyroidectomy remains unclear. In this multicenter retrospective cohort study, we compared the long-term clinical efficacy of microwave ablation and parathyroidectomy for severe secondary hyperparathyroidism undergoing hemodialysis.

MATERIALS AND METHODS

The patients were divided into microwave ablation and parathyroidectomy groups. The primary endpoint was the proportion of patients with intact parathyroid hormone (iPTH) concentrations within the target range (100-600 pg/mL) during the efficacy assessment phase. The secondary endpoints were (i) differences in iPTH concentrations over time between the two groups, and (ii) decreases in iPTH concentrations over time in the two groups.

RESULTS

Microwave ablation was performed in 47/92 patients and parathyroidectomy in 45/92. Primary endpoint: iPTH concentrations within the target range were achieved during the efficacy assessment phase in 26/47 patients (55.3%) and in 14/45 (31.1%) patients in the microwave ablation and parathyroidectomy groups, respectively (p = .02). Secondary endpoints: (i) Mean iPTH concentrations during the efficacy assessment phase were significantly higher in the microwave ablation versus parathyroidectomy groups (649 ± 519 pg/mL versus 136 ± 228 pg/mL, respectively; p < .01). (ii) Mean decrease in iPTH concentration from baseline was 725 ± 605 pg/mL versus 1369 ± 478 pg/mL in the MWA versus parathyroidectomy groups, respectively (p < .01).

CONCLUSIONS

Ultrasound-guided percutaneous microwave ablation provides higher iPTH target-achieving rates than parathyroidectomy in patients with severe secondary hyperparathyroidism undergoing hemodialysis.

Long-term outcomes of microwave ablation for secondary hyperparathyroidism in maintenance hemodialysis patients

Microwave ablation has been increasingly used to secondary hyperparathyroidism (SHPT) in patients with maintenance hemodialysis. However, the current data are inconclusive. This study was to assess the long-term outcomes of microwave ablation on SHPT. We enrolled 53 SHPT patients who underwent microwave ablation. Primary outcome measures were the rate of achieving recommended goal for iPTH and the events of all-cause death during the follow-up period. Survival analysis was performed to assess the long-term prognosis. During follow-up period of 42.4 ± 15.6 months (range, 12-70 months), there were 12 all-cause deaths, and the cumulative proportion surviving was 0.74. The rates of achieving the recommended goal for iPTH were 62.3% at 1 month, 57.7% at 6 months, 51.0% at 12 months, 62.5% at 24 months, and 68.8% at 36 months, respectively. Microwave ablation produces a lasting resolution of secondary hyperparathyroidism in about 60% of patients with maintenance hemodialysis. The characteristics of patients suitable for microwave ablation should be clarified in the future.

Efficacy and safety of microwave ablation treatment for secondary hyperparathyroidism: systematic review and meta-analysis

Purpose: The present systematic review and meta-analysis was designed to evaluate the efficacy and safety of microwave ablation (MWA) treatment for secondary hyperparathyroidism (SHPT).Materials and methods: The study authors systematically searched the Web of Science, Cochrane Library, PubMed, Embase and Ovid databases for studies published in English prior to 7October 2019. All studies included in the meta-analysis measured levels of parathyroid hormone (PTH), calcium and phosphorus, and included data related to complications following MWA treatment for SHPT.Results: The meta-analysis ultimately included 233 patients from two retrospective cohort studies and six retrospective self-control studies. Compared to PTH level measurements obtained after MWA, measurements obtained at one day (weighted mean differences (WMD): 890.314, 95% confidence interval (CI): 767.121-1013.506, p < 0.01) , one week (WMD: 860.298, 95% CI: 759.401-961.194, p < 0.01), one month (WMD: 800.846, 95% CI: 687.709-913.983, p < 0.01) and six months (WMD: 860.847, 95% CI: 745.214-976.480, p < 0.01) after MWA were significantly lower. Calcium and phosphorus levels at one day and one week after MWA were also significantly lower than those measured before MWA. After MWA, the incidence of nerve injury was 1.2% (3/233; effect size (ES): 0.022, 95% CI: -0.003-0.048, p < 0.01). After MWA, the incidence of hypocalcemia was 15.8% (37/233; ES: 0.449, 95% CI: 0.341-0.556, p < 0.01).Conclusion: The preliminary results of this meta-analysis indicate that MWA may be effective and safe in treating patients with SHPT, and that future prospective research and randomized controlled trials (RCT) are necessary.

Minimally Invasive Treatment for Benign Parathyroid Lesions: Treatment Efficacy and Safety Based on Nodule Characteristics

OBJECTIVE

This study aimed to evaluate the efficacy and safety of ultrasound (US)-guided minimally invasive treatment in patients with parathyroid lesions.

MATERIALS AND METHODS

This study included 27 patients who had undergone US-guided radiofrequency ablation (RFA) or ethanol ablation (EA) for parathyroid lesions between January 2010 and 2018. RFA was performed in 19 patients with primary hyperparathyroidism (PHPT, n = 11) or secondary hyperparathyroidism (SHPT, n = 8), and EA was performed in eight patients with symptomatic nonfunctioning parathyroid cysts (SNPCs). Nodule size, volume, serum parathyroid hormone (PTH) and calcium levels were recorded before and after treatment. Complications were evaluated during and after treatment.

RESULTS

In patients with PHPT, significant reductions in size and volume were noted after RFA at 6- and 12-month follow-up (all, p < 0.05). Seven nodules nearly completely disappeared (residual volume < 0.1 mL); serum PTH and calcium levels were reduced to normal ranges (7/11, 63.6%). Four patients experienced partial reductions of serum PTH and calcium levels (4/11, 36.4%). In patients with SHPT, three experienced therapeutic response of serum PTH (3/8, 37.5%), while five showed persistent hyperparathyroidism (5/8, 62.5%) within 6 months after RFA. In patients with SNPCs, EA resulted in significant reductions in cyst size and volume (all, p < 0.05) at the last follow-up. A total of four complications (two transient hypocalcemia [RFA], one permanent [RFA], and one transient [EA] hoarseness) were observed.

CONCLUSION

Minimally invasive treatments, such as RFA and EA, may serve as therapeutic alternatives for patients with PHPT or SNPCs; they may have limited usefulness in patients with SHPT.

Hypocalcemia after ultrasound-guided microwave ablation and total parathyroidectomy for secondary hyperparathyroidism: a retrospective study

OBJECTIVE

To compare the postoperative hypocalcemia between ultrasound-guided microwave ablation (MWA) and total parathyroidectomy (TPTX) for secondary hyperparathyroidism (SHPT).

METHODS

The retrospective study reviewed 286 SHPT patients (171 received MWA and 115 underwent TPTX) between March 2018 and May 2019. Propensity-score matching was used to assemble a cohort of patients with similar baseline characteristics. A total of 184 SHPT patients (92 in each group) were finally enrolled, the occurrence and prognosis of postoperative hypocalcemia were compared. And the risk factors associated with severe hypocalcemia (SH) in each group were analyzed.

RESULTS

Hypocalcemia encountered in 95cases (49 in the MWA group and 46 in the TPTX group). SH occurred in 76 cases (40 in the MWA group and 36 in the TPTX group). There were no statistically significant differences in the detection time, incidence, minimum value of serum calcium and symptomatic hypocalcemia between MWA and TPTX group (all p values > 0.05). Of patients developing hypocalcemia, serum calcium did not recover to normal range in 5 cases (10.2%) in the MWA group, while 13 cases (28.3%) were still hypocalcemia at 6 months follow-up in TPTX group (p = 0.035). The time to recovery from hypocalcemia in the TPTX group (mean 30 days, range 3-180 days) was longer than the WA group (mean 14 days, range 3-126 days) (p = 0.000). High serum alkaline phosphatase (ALP) level and low serum calcium level were the main risk factors of postoperative SH.

CONCLUSION

There was no difference in hypocalcemia between MWA and TPTX group. Hypocalcemia in the TPTX group might need a longer time to recover.

Risk Factors of Severe Hypocalcemia After US-Guided Percutaneous Microwave Ablation of the Parathyroid Gland in Patients with Secondary Hyperparathyroidism

Our aim was to identify potential risk factors associated with severe hypocalcemia (SH) after microwave ablation (MWA) in patients with secondary hyperparathyroidism (SHPT). This retrospective cross-sectional study enrolled 204 consecutive patients (with 387 parathyroid glands) who underwent MWA between July 2015 and May 2018. Clinical parameters, laboratory indices, and parathyroid gland characteristics were analyzed to assess risk factors associated with SH after MWA. SH was defined as serum calcium level lower than 1.875 mmol/L (7.5 mg/dL) after MWA. Two models (I and II) for pre-MWA and post-MWA prediction were established, respectively. In accordance with the KDIGO guidelines, the target value for intact parathyroid hormone (iPTH) less than 300 pg/mL within 7 days after MWA was considered as a successful procedure. The success rate of MWA was 71.6% (146/204). The incidence of hypocalcemia and SH after MWA was 35.8% and 22.06%, respectively. The pre-MWA prediction models I and II showed that high pre-MWA iPTH, a dramatic reduction in iPTH, low pre-MWA serum calcium, multiple ablated gland, and lack of pruritus symptoms were risk factors for developing SH. The accuracy (82.23% versus 83.25% in models I and II, respectively), sensitivity (34.88% versus 44.19%), specificity (95.45% versus 94.59%), positive predictive value (PPV) (68.18% versus 70.37%), and negative predictive value (NPV) (84% versus 85.37%) of both models were promising. The logistic regression fitting of the nomograms showed high prediction efficiency (0.845 and 0.863). High pre-MWA iPTH, dramatic reductions in iPTH, low pre-MWA serum calcium, multiple gland ablation, and no pruritus symptoms were predictors of SH. © 2019 American Society for Bone and Mineral Research.