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Retrospective Evaluation of Three Treatment Methods for Primary Hyperparathyroidism in Dogs

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Retrospective Evaluation of Three Treatment Methods for Primary Hyperparathyroidism in Dogs Retrospective Evaluation of Three Treatment Methods for Primary Hyperparathyroidism in Dogs The medical records of 110 dogs treated for primary hyperparathyroidism were reviewed. Dogs were treated via parathyroidectomy (n=47), percutaneous ultrasound-guided ethanol ablation (n=15), or percutaneous ultrasound-guided heat ablation (n=48). Forty-five of 48 (94%) parathyroidectomies resulted in control of hypercalcemia for a median of 561 days. Thirteen of 18 (72%) ethanol ablation procedures resulted in control of hypercalcemia for a median of 540 days. Forty-four of 49 (90%) heat-ablation treatments resulted in control of hypercalcemia for a median of 581 days. J Am Anim Hosp Assoc 2007;43:70-77. Liberty Rasor, DVM Introduction In dogs with naturally occurring primary hyperparathyroidism, hypercal- Rachel Pollard, DVM, PhD, Diplomate ACVR cemia develops secondary to autonomous production of parathyroid hor- mone (PTH).1,2 The condition is most commonly caused by a solitary Edward C. Feldman, DVM, parathyroid gland adenoma.3,4 Less commonly, the condition develops as Diplomate ACVIM a result of a parathyroid gland carcinoma or autonomously functioning hyperplastic parathyroid gland(s).5 About 10% of afflicted dogs have two abnormal parathyroid glands, either simultaneously or sequentially.6,7 Naturally occurring primary hyperparathyroidism is usually suspected in a dog with hypercalcemia, mild clinical signs, and a serum phospho- RS rous concentration within or less than the reference range.8 Serum PTH concentrations within or above the reference range help confirm the diag- nosis.9-11 In the past two decades, cervical ultrasonography has been used as a diagnostic aid for dogs with hypercalcemia.12 Dogs with primary hyperparathyroidism usually have a solitary round or oval hypoechoic mass in close association with one thyroid lobe.6,7,9,12,13 Abnormal parathyroid nodules usually measure 4 to 6 mm, but they can be as large as 20 mm in their greatest dimension.6,7,9,12,13 Once the condition has been confirmed, surgical removal of the abnormal parathyroid gland or glands has been a permanent treatment option. More recently, novel ther- apeutic strategies using ultrasound-guided alcohol or heat ablation have been described, but reports have had limited numbers of dogs and short From the Veterinary Medical Teaching Hospital follow-up times.14-16,a The purposes of this study were to evaluate and (Rasor) and the Departments of Surgical compare the treatment of primary hyperparathyroidism via surgery, and Radiological Sciences (Pollard) ethanol ablation, and chemical ablation in a larger group of dogs and to and Medicine and Epidemiology (Feldman), determine the long-term efficacy of the three treatments. School of Veterinary Medicine, University of California, Davis, California 95616. Materials and Methods Medical records of dogs diagnosed with naturally occurring primary Doctor Rasor’s current address is the hyperparathyroidism between November 1997 (date of the first ultra- Animal Referral and Emergency sound-guided percutaneous treatment procedure) and March 2005 were Center of Arizona, 1648 North Country Club Drive, reviewed. Diagnosis of primary hyperparathyroidism was based on phys- Mesa, Arizona 85201. ical examination, phosphorous concentration within or below the reference 70 JOURNAL of the American Animal Hospital Association March/April 2007, Vol. 43 Primary Hyperparathyroidism in Dogs 71 range, repeatable hypercalcemia, PTH concentration within the local veterinarian or by the primary clinician and always or above the reference range, and one or two parathyroid included measurement of a serum calcium concentration. glands visualized on ultrasonography or at surgery.11 All dogs that had surgery had excised tissue evaluated Statistical Analysis histopathologically. All dogs entered in the study were Data are reported as means ± standard deviation (SD). Two- treated for primary hyperparathyroidism and had calcium tailed t-tests were used to compare results between dogs in concentrations evaluated once daily for 6 days and at 90 the different treatment groups. Laboratory data included days after treatment. Dogs were excluded from the study if serum calcium, ionized calcium, and PTH concentrations, metastasis was seen on thoracic radiography. as well as the length of time required for the calcium to fall Medical records for dogs with primary hyperparathy- within reference range after treatment. Fisher’s exact tests roidism were reviewed for signalment, clinical signs, total were used to compare the outcomes of the treatment groups. serum calcium concentrations, plasma ionized calcium con- All analyses were performed with standard statistical soft- centrations, PTH concentrations, diagnostic imaging, treat- ware.h A P value <0.05 was considered significant. ment method, date of treatment, and response to treatment. Routine methods were used to perform serum biochemical Results analyses, CBCs, and urinalyses. Serum total calcium con- A total of 110 dogs were included in the study, and the sig- centration was determined by colorimetric evaluation.b nalment data are presented in Table 1. The most commonly Serum ionized calcium concentration was determined by affected breed was the keeshond (n=21), followed by the ion-selective electrode analysis.c Serum PTH concentration mixed-breed dog (n=18), Labrador retriever (n=9), German was determined by use of a validated, two-site immunora- shepherd dog (n=7), golden retriever (n=6), miniature poo- diometric method that recognizes amino- and carboxy-ter- dle (n=6), shih tzu (n=5), Australian shepherd (n=4), minal ends of the intact molecule.9,10,d All PTH assays were Rhodesian ridgeback (n=3), and American cocker spaniel performed in the clinical chemistry laboratory at the (n=3). The remaining 28 dogs comprised 18 other breeds. University of California, Davis,e or at the endocrine labora- Each treatment group was composed of numerous breeds. tory at Michigan State University.f Ultrasonography of the The most common clinical signs reported in the dogs are neck was performed with a 10-MHz linear, phased-array presented in Table 2. Hypercalcemia was an incidental find- transducer and a standard ultrasonography machine.g ing on routine geriatric or preanesthetic laboratory screen- Arbitrarily, dogs with a parathyroid mass >12 mm at its ings in 42 of the 110 dogs. The pertinent laboratory findings greatest dimension were treated with surgery. Other treat- are presented in Table 3. ments were chosen by the primary clinician after discus- Cervical ultrasonography was performed on all 110 dogs, sions with the owners. and all dogs had one (n=96) or two (n=14) masses visual- ized that were consistent with abnormally enlarged parathy- Therapeutic Techniques roid glands. Of the 14 dogs with two parathyroid nodules Treatments employed for primary hyperparathyroidism identified, nine had bilateral masses and five had two ipsi- associated with parathyroid mass(es) were surgical removal, lateral masses. Twelve dogs had a parathyroid mass that ultrasound-guided alcohol ablation, or ultrasound-guided measured >12 mm. Forty-seven dogs were treated with heat ablation, as previously described.3,14,15,a Alcohol abla- parathyroidectomy, 15 dogs were treated with ethanol abla- tion was performed with the dog under general anesthesia. tion, and 48 dogs were treated with heat ablation. The 47 The parathyroid nodule was located with ultrasonography, dogs treated with surgery had 56 nodules based on ultra- and 96% ethanol was injected into the parathyroid gland via sonography. Thirty-eight dogs had a single nodule, and nine a 27-gauge needle until the entire gland was infiltrated.14 dogs had two nodules (bilateral n=7, ipsilateral n=2). The Heat ablation was performed in a similar manner, with the 15 dogs treated with ethanol ablation all had a single nod- animal under anesthesia while the abnormal parathyroid tis- ule. The 48 dogs treated with heat ablation had 53 nodules; sue was visualized with ultrasonography. With the dog lying 43 dogs had a single nodule, and five dogs had two nodules on a cautery ground pad, a 20-gauge, over-the-needle intra- (bilateral n=3, ipsilateral n=2). The number of successful venous catheter was placed into the parathyroid gland, and and failed treatments and follow-up times after therapy are radiofrequency energy was applied at 10 to 20 W until the presented in Table 4. Fisher’s exact tests showed no signif- entire gland became hyperechoic.15 The needle was occa- icant differences in the outcomes between parathyroidecto- sionally redirected in both procedures to try to ablate the my and heat ablation (P=0.71) and between heat ablation entire gland.14,15 The ultrasound procedures were per- and ethanol ablation (P=0.12). A significant difference in formed by numerous radiology clinicians and residents. outcomes was found between parathyroidectomy and Complications following treatment were recorded from ethanol ablation (P=0.03). the medical record. Treatment was considered successful if Hypercalcemia resolved in 44 of the 47 dogs treated with complete resolution of hypercalcemia was documented at 6 one surgery within 1 to 6 days (mean 1.6±1.1 days). Either and 90 days after therapy. The dates, timing, and chrono- serum total or ionized calcium concentration returned to logical order of the successful and unsuccessful treatments normal within 48 hours in 29 dogs. Hypercalcemia resolved were reviewed. Follow-up examinations were performed by in 3 to 4 days in 13 dogs and in 4 to
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