Non-surgical parathyroid adenoma treatment focuses on minimally invasive procedures and medical management. These methods aim to control elevated calcium and parathyroid hormone levels without open surgery.
Image-guided ablation techniques, including radiofrequency ablation, microwave ablation, and ethanol injection, can effectively destroy adenoma tissue. They provide quick recovery with minimal complications.
Medical management may involve calcimimetic drugs that lower parathyroid hormone secretion. This option is considered for patients who cannot undergo surgical or ablative interventions.
Non-surgical approaches improve quality of life by reducing hypercalcemia symptoms and preventing long-term complications such as kidney stones and osteoporosis.
| Treatment Method | Non-Surgical Parathyroid Adenoma Treatment (Ethanol Ablation) |
| Definition | A minimally invasive treatment method aimed at shrinking the adenoma in patients with an adenoma (benign tumor) in the parathyroid gland, by injecting alcohol (ethanol). |
| Procedure | Under ultrasound guidance, ethanol is injected directly into the adenoma using a fine needle; ethanol destroys adenoma cells, causing them to shrink. |
| Indications | Applied to patients with primary hyperparathyroidism who are not suitable for or do not prefer surgery, and for small and appropriately sized parathyroid adenomas. |
| Treatment Duration | The procedure is usually short and completed in a few minutes; however, multiple sessions may be required for some patients. |
| Advantages | It is a minimally invasive method, does not require hospital stay, has a short recovery period, and is an alternative option for patients who want to avoid surgery. |
| Side Effects | Temporary neck pain, tenderness at the injection site; rarely, side effects such as hoarseness or difficulty swallowing may occur. |
| Success Rate | The success rate is high in small adenomas, but effectiveness may vary depending on the size and location of the adenoma. |
| Follow-up and Monitoring | After the procedure, blood calcium and PTH levels should be monitored; reduction in adenoma size and hormone levels are followed with ultrasound. |
| Contraindications | Large adenomas, multiple adenomas, patients with bleeding disorders, and situations with high procedural risk. |
| Alternative Methods | Parathyroidectomy (surgical removal), medication (calcimimetics), and other minimally invasive methods (radiofrequency ablation), embolization |
| Precautions and Preparation | Anticoagulant medications may need to be discontinued before the procedure and blood calcium levels regulated; a detailed ultrasound evaluation is performed beforehand. |
Prof. Dr. Özgür KILIÇKESMEZ Prof. Dr. Kılıçkesmez holds the Turkish Radiology Competency Certificate, the Turkish Interventional Radiology Competency Certificate, Stroke Treatment Certification, and the European Board of Interventional Radiology (EBIR). In his academic career, he won the Siemens Radiology First Prize in 2008.
Interventional Radiology / Interventional Neuroradiology
What Is a Parathyroid Adenoma and Why Might Non-Surgical Treatments Be Needed?
A parathyroid adenoma is a usually benign tumor that forms in the parathyroid gland. This tumor causes excessive production of parathyroid hormone (PTH), leading to an increase in blood calcium levels, known as primary hyperparathyroidism (PHPT). PHPT can cause serious health problems such as decreased bone density, osteoporosis, and kidney stone formation. In some cases, it is also associated with cardiovascular issues and can reduce patients’ quality of life. Approximately 85% of PHPT cases are caused by a single adenoma.
The definitive solution for PHPT generally requires surgical intervention. However, surgery may be risky for some patients, or their health status may not permit surgery. Especially elderly individuals or those with other health conditions may not be suitable for surgery. In such cases, non-surgical treatment methods play an important role. These treatment options are used to relieve symptoms and reduce the risk of complications.
How Does Ethanol Ablation Work to Treat Parathyroid Adenoma?
Ethanol ablation treats parathyroid adenomas through processes of cellular damage and structural change. With ethanol injection, two main effects are produced in the adenoma tissue: coagulative necrosis and fibrotic transformation.
First, ethanol causes the cells to lose water and their proteins to denature. This leads to irreversible damage and coagulative necrosis in the cells. During necrosis, the cells in the adenoma tissue die and its structure deteriorates. Additionally, ethanol injection leads to clotting of small surrounding blood vessels, reducing blood flow and increasing ischemic necrosis.
Another effect of ethanol ablation is fibrotic transformation. After the cells in the adenoma tissue die, the body transforms this dead tissue into nonfunctional fibrous tissue. This fibrous tissue no longer produces parathyroid hormone (PTH), reducing the hormone imbalance. As the adenoma shrinks over time, PTH levels decrease and serum calcium levels return to normal.
The clinical effects of this process are as follows:
- Significant decrease in PTH and calcium levels.
- Alleviates the symptoms of hyperparathyroidism.
- Most patients improve within 1–3 months.
- High long-term success rate with a low risk of complications.
Ethanol ablation thus offers an effective solution for parathyroid adenomas by controlling hormone imbalance without the need for surgery. *We recommend filling out all fields so we can respond in the best possible way.
Who Are the Best Candidates for Ethanol Ablation?
Ethanol ablation provides a significant treatment alternative, especially for patients with parathyroid adenoma who are not suitable for surgery or have recurrent disease. The most suitable candidates for this treatment have certain criteria and generally fall into different groups:
Patients with primary hyperparathyroidism (PHPT) who have parathyroid adenomas visible by ultrasound: Adenomas that can be localized with ultrasound respond well to this treatment. Especially patients at high surgical risk, such as those not suitable for general anesthesia due to serious health conditions, can benefit from ethanol ablation.
Patients with health risks unsuitable for surgery: Elderly patients or those with cardiovascular and respiratory problems should avoid surgical complications. Ethanol ablation is a safer option for these patients because it is minimally invasive and can be performed with local anesthesia.
Patients with recurrent parathyroid disease associated with multiple endocrine neoplasia type 1 (MEN1): Individuals diagnosed with MEN1 often have multiple parathyroid adenomas. Ethanol ablation offers the advantage of long-term management by avoiding surgery in the treatment of recurrent hyperparathyroidism in these patients.
Patients with recurrent or persistent hyperparathyroidism after surgery: In some patients, hyperparathyroidism may recur after surgery. In this case, ethanol ablation provides a safe and repeatable treatment without the need for additional surgery.
In all these groups, ethanol ablation stands out as an effective method for controlling serum calcium levels and offers an appropriate solution for repeated interventions.
How Effective Is Ethanol Ablation for Parathyroid Adenoma?
Ethanol ablation is considered an effective method for the non-surgical treatment of parathyroid adenoma in primary hyperparathyroidism (PHPT) cases. However, repeated injections may be required, and recurrence of hypercalcemia is common. The overall improvement rates of ethanol ablation range between 73% and 85%.
This procedure usually maintains normocalcemia for up to 24 months. However, about 50% of patients experience a rise in calcium levels within a few years. For optimal results, most patients typically require 2 to 3 sessions. Compared to surgical methods, recurrence rates are higher and cure rates lower with ethanol ablation.
Ethanol ablation is especially preferred in high-risk patients. Recurring hypercalcemia is often related to undetected adenomas that may limit the completeness of the procedure. Therefore, accurate targeting of the adenoma with ultrasound is critical for treatment success. The side effects of ethanol ablation include the following complications:
- Hoarseness
- Temporary hypocalcemia
- Risk of recurrent hypercalcemia after treatment
Despite these limitations, ethanol ablation is a valuable option for patients not suitable for surgery or seeking alternative treatments. It is especially preferred in conditions unsuitable for surgery, such as multiple endocrine neoplasia type 1 (MEN1). In summary, ethanol ablation remains an effective but limited treatment for parathyroid adenoma.
What Are the Risks and Complications of Ethanol Ablation?
Ethanol ablation carries certain risks and complications, which can affect patients’ quality of life and, in some cases, cause permanent damage. The main complications that may be encountered in this treatment method are:
- Vocal Cord Paralysis: The recurrent laryngeal nerve may be damaged during ethanol injection, leading to vocal cord paralysis. This can cause hoarseness, difficulty speaking, and breathing problems. Although rare, vocal cord paralysis is a serious complication and can adversely affect patients’ social life.
- Voice Changes: Even without nerve injury, some patients may experience temporary or permanent changes in their voice. The proximity of the thyroid gland to the vocal cords increases the risk of this complication. Swelling or unwanted injury during the procedure can lead to changes in voice quality.
- Insufficient Destruction and Recurrence: Ethanol ablation may not always completely destroy the nodule. In cases of insufficient destruction, the nodule may regrow and require additional treatment. Studies report recurrence rates ranging from 10% to 20%. Recurrence depends on the structure of the nodule and the experience of the operator.
- Other Risks: Additionally, this procedure involves risks such as pain, bleeding, infection, and temporary swelling in the treated area. Patients may feel discomfort during or after the procedure, but these effects are usually temporary.
Is Ethanol Ablation a Long-Term Solution for Parathyroid Adenoma?
Ethanol ablation provides a limited long-term solution in the treatment of parathyroid adenoma. Studies show that even if normocalcemia is achieved with treatment, this effect may fade over time. Success rates provide promising results in 70% to 84.5% of treated patients for the first 12 months. However, hypercalcemia often recurs within two to three years.
Multiple sessions are usually required for ethanol ablation to be effective in recurrent hyperparathyroidism cases. On average, patients receive about 2.2 sessions to maintain calcium control. Temporary hypocalcemia and, in rare cases, recurrent laryngeal nerve injury have also been observed.
Especially in conditions such as MEN1 syndrome, ethanol ablation is limited as a long-term solution due to the risk of recurrence and non-permanent response of the parathyroid glands. Combination therapy with radiofrequency ablation (RFA) is also being considered as an alternative, aiming to target the remaining hard tissue where ethanol ablation alone may not be fully effective.
Frequently Asked Questions
How is the ablation method performed?
Ablation methods such as radiofrequency ablation (RFA) and microwave ablation (MWA) are minimally invasive options for the treatment of parathyroid adenomas, especially for patients who are not candidates for surgery. With imaging guidance such as ultrasound, the location of the adenoma is identified precisely. Under local anesthesia, a special needle or probe is inserted into the adenoma. Energy is then delivered to generate heat and destroy the targeted tissue. Hydrodissection techniques can be used to prevent thermal damage. Studies show that these ablation methods effectively reduce adenoma size and normalize biochemical markers, with success rates above 85% and minimal complications.
What advantages does this method have compared to surgery?
Ablation techniques such as radiofrequency ablation (RFA) and microwave ablation (MWA) offer various advantages over traditional surgery for the treatment of parathyroid adenomas. Research has shown that ablation significantly reduces procedure and hospital stay durations. For example, the mean procedure time for MWA is about 28 minutes, with an average hospital stay of about 3 days. In contrast, surgery durations are around 92 minutes and hospital stays nearly 6 days. Ablation procedures are also associated with less intraoperative bleeding. Both ablation and surgery effectively reduce serum parathyroid hormone (PTH) and calcium levels, and there is no significant difference in postoperative complications. In addition, RFA provides an 89% reduction in adenoma volume at 6 months follow-up. Ablation methods stand out as a safe and effective alternative treatment due to shorter procedure and hospital times and minimal invasiveness.
What is the risk of complications after ablation?
Complication rates after non-surgical parathyroid adenoma treatment (radiofrequency ablation, RFA) range from 6.7% to 17.6%. Major complications include recurrent laryngeal nerve paralysis (RLN) seen in 5% to 12.6% of cases and Horner’s syndrome seen in 1.1%. Minor complications include hematoma formation in 3.4% of cases. However, most of these complications are temporary, and symptoms such as hoarseness usually resolve within six months. Overall, parathyroid ablation is considered a safe method with a low risk of complications.
How is parathyroid function monitored after the procedure?
After radiofrequency ablation (RFA), parathyroid function is monitored by regular measurement of serum calcium and parathyroid hormone (PTH) levels. These tests are important for detecting hypocalcemia or persistent hyperparathyroidism. Calcium and vitamin D supplementation may be necessary. Regular follow-up visits are held to assess the risk of recurrence and treatment requirements.
Can this treatment method be applied to all parathyroid adenoma patients?
Ablation techniques such as radiofrequency ablation (RFA) provide an effective treatment option for parathyroid adenoma patients not suitable for surgery. In a study involving 60 patients, significant reductions in serum parathyroid hormone and calcium levels and an 89% decrease in adenoma volume within six months were observed after RFA. Similarly, microwave ablation (MWA) achieved significant reduction in adenoma size and calcium levels in three months with a technical success rate of 91% in 35 patients. However, ablation is not suitable for all patients. Secondary or tertiary hyperparathyroidism, suspected malignancy, unsuitable coagulation parameters, and technically inaccessible adenoma locations may preclude ablation. Thus, while ablation therapy can be applied to many patients, it must be evaluated according to individual factors and clinical criteria.
How is the embolization method performed?
In parathyroid adenoma embolization, a catheter is placed in the artery feeding the adenoma, and embolic agents such as autologous clot, gelfoam, or embosphere are injected to block blood flow. This process causes ischemia of the adenoma, reducing hormone secretion and normalizing calcium levels. It is especially effective for ectopic adenomas in surgically hard-to-reach areas like the mediastinum. Studies have reported normalization of calcium and parathyroid hormone levels and long-term remission in some patients. However, effectiveness can vary, and surgical intervention or repeat embolization may be required in some cases.
What advantages does this method have compared to surgery?
Treating parathyroid adenoma by embolization is less invasive than surgery, offers a shorter recovery period, and reduces the risks of hypocalcemia (2.3%) and recurrent laryngeal nerve injury (0.3%). In traditional bilateral neck exploration, these rates are 14% and 0.9%, respectively. Surgeons with high experience (performing more than 20 parathyroid surgeries per year) are associated with lower complication rates and shorter hospital stays. Since embolization is minimally invasive, it can provide fewer complications and faster recovery, but more comparative studies are needed.
What is the risk of complications?
Parathyroid adenoma embolization is a rare procedure, and information on associated complications is quite limited. However, in a case of selective arterial embolization for mediastinal parathyroid adenoma, the procedure was completed without complications, and the patient did not report any pulmonary symptoms at both short-term (2 weeks) and long-term (23 weeks) follow-up. A similar procedure, thyroid artery embolization, has been reported to have minor complications in about 17% of patients and major complications in 1.4%. While these data offer insight into potential risks, individual assessment with a healthcare provider is necessary due to limited comprehensive data.
How is parathyroid function monitored after the embolization procedure?
After parathyroid adenoma embolization, parathyroid function is monitored through serum calcium and parathyroid hormone (PTH) levels to assess the effectiveness of treatment and detect possible hypocalcemia. Since parathyroid function also affects calcium and phosphate balance, kidney function and serum electrolyte levels should be checked regularly. In some cases, additional tests such as urinary cyclic adenosine monophosphate (cAMP) levels may be performed for more detailed evaluation. This comprehensive approach ensures that any post-embolization imbalances are detected and managed promptly.
Can this treatment method be applied to all parathyroid adenoma patients?
Embolization is not suitable for all parathyroid adenoma patients; it is usually reserved for situations where surgery cannot be performed or is contraindicated, such as ectopic adenomas located in the mediastinum. For example, in a case of mediastinal parathyroid adenoma, the patient was successfully treated with embolization after an unsuccessful surgical intervention. Therefore, embolization is only effective in certain cases and is not applied to all patients with parathyroid adenoma.
How do calcimimetic drugs work in parathyroid adenoma treatment and who are they suitable for?
Calcimimetic drugs (such as cinacalcet) act by increasing the sensitivity of calcium-sensing receptors (CaSR) in the parathyroid glands. These drugs stimulate the receptors as if the blood calcium level were higher, resulting in decreased parathyroid hormone (PTH) secretion and therefore lower blood calcium levels. Calcimimetics do not destroy or shrink the adenoma but only suppress hormone production. They are generally used to control hypercalcemia in primary hyperparathyroidism patients who are unsuitable for or do not prefer definitive treatment options such as surgery or ablation (for example, elderly patients with severe comorbidities), or in parathyroid cancer-related hypercalcemia.
What kind of recovery process should patients expect after non-surgical parathyroid adenoma treatment, and what should they pay attention to?
Recovery after non-surgical parathyroid adenoma treatment (ethanol ablation, radiofrequency ablation, etc.) is usually rapid, and most patients can return to normal activities the same day. Mild pain, swelling, or bruising at the procedure site may last for several days but is generally manageable with simple painkillers. Temporary hoarseness or difficulty swallowing may rarely occur. Patients should avoid strenuous exercise for a few days after the procedure, drink plenty of fluids, and attend planned follow-up visits (for blood calcium and PTH monitoring). If unexpected symptoms such as increased pain, fever, or persistent voice changes occur, they should contact their doctor without delay.
What factors are considered when choosing between non-surgical parathyroid adenoma treatments (ethanol ablation, RFA, MWA, embolization)?
The choice of method for non-surgical parathyroid adenoma treatment depends on many factors. The size, structure (cystic or solid), number, and location (easily accessible in the neck or in more difficult regions like the chest cavity) of the adenoma are primary determinants. The patient’s overall health, suitability for anesthesia, comorbidities, and history of previous neck surgery are also important. For example, ethanol ablation may be more suitable for small, predominantly cystic adenomas, while radiofrequency (RFA) or microwave (MWA) ablation may be preferable for solid adenomas. Embolization is generally considered for adenomas inaccessible by other methods. Physician experience and patient preference also influence the decision-making process.
Do patients need a special diet to maintain calcium and vitamin D balance after non-surgical parathyroid adenoma treatment?
After non-surgical parathyroid adenoma treatment, especially while PTH levels are returning to normal, some patients may experience temporary decreases in blood calcium (hypocalcemia). Doctors may recommend calcium and vitamin D supplements in the postoperative period. Dietary intake of calcium-rich foods (such as dairy products, leafy green vegetables, almonds) can be beneficial, but excessive and uncontrolled calcium intake should be avoided. The treating physician will follow calcium and vitamin D levels with regular blood tests and provide personalized nutritional and supplementation recommendations. Overall, maintaining a balanced and healthy diet is important.
If non-surgical parathyroid adenoma treatments (e.g., ethanol ablation or RFA) fail or the adenoma recurs, what are the next treatment options?
Although non-surgical treatments for parathyroid adenoma have high success rates, in some cases, the response may be inadequate or the adenoma may recur over time. In such cases, the reason for failure or recurrence is investigated first. Treatment options include repeated sessions of the previously used non-surgical method (ethanol ablation, RFA, etc.), switching to a different non-surgical treatment (for example, ethanol ablation after RFA), or surgical removal of the adenoma (parathyroidectomy). Surgery is usually the most definitive solution if other methods have failed or are unsuitable. Rarely, calcimimetic drug therapy can also be used to control symptoms.
Interventional Radiology and Neuroradiology Speaclist Prof. Dr. Özgür Kılıçkesmez graduated from Cerrahpaşa Medical Faculty in 1997. He completed his specialization at Istanbul Education and Research Hospital. He received training in interventional radiology and oncology in London. He founded the interventional radiology department at Istanbul Çam and Sakura City Hospital and became a professor in 2020. He holds many international awards and certificates, has over 150 scientific publications, and has been cited more than 1500 times. He is currently working at Medicana Ataköy Hospital.
Vaka Örnekleri