Effects of Parathyroidectomy on Normocalcemic Primary Hyperparathyroidism and the Role of Intraoperative PTH Measurement

2021 ◽  
pp. 000313482110488
Author(s):  
Ehab Alameer ◽  
Mahmoud Omar ◽  
Marcus Hoof ◽  
Hosam Shalaby ◽  
Mohamed Abdelgawad ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Cure Rate ◽  
Tertiary Hyperparathyroidism ◽  
Intraoperative Pth ◽  
Intraoperative Parathyroid Hormone ◽  
Cure Rates ◽  
Current Guidelines ◽  
Normocalcemic Hyperparathyroidism

Background Normocalcemic primary hyperparathyroidism (NCpHPT) and normohormonal primary hyperparathyroidism (NHpHPT) are recently recognized variants of primary hyperparathyroidism. Current guidelines for the management hyperparathyroidism recognize NCpHPT as one of the areas that are recommended for more research due to limited available data. Methods A retrospective review of patients who had parathyroidectomy between 2014 and 2019. We excluded patients with multiple endocrine neoplasia syndromes and secondary and tertiary hyperparathyroidism. Included patients were classified based on the biochemical profile into classic or normocalcemic hyperparathyroidism group. Collected data included demographics, preoperative localizing imaging, intraoperative parathyroid hormone levels, and postoperative cure rates. Results 261 patients were included: 160 patients in the classic and 101 patients in the normocalcemic group. Patients in the normocalcemic group had significantly more negative sestamibi scans (n = 58 [8.2%] vs 78 [51.3%], P = <.01), smaller parathyroid glands (mean weight 436.0 ± 593.0 vs 742.4 ± 1109.0 mg, P = .02), higher parathyroid hyperplasia rates (n = 51 [50.5%] vs 69 [43.1%]), and significantly higher intraoperative parathyroid hormone at 10 minutes (78.1 ± 194.6 vs 43.9 ± 62.4 1, P = .04). Positive predictive value of both intraoperative parathyroid hormone and cure rate was lower in the normocalcemic group (84.2% vs 95.7%) and (80.5% vs 95%), respectively. Conclusion Normocalcemic hyperparathyroidism is a challenging disease. Surgeons should be aware of the lower cure rate in this group, interpret intraoperative parathyroid hormone with caution, and have a lower threshold for bilateral neck exploration and 4 glands visualization.

A Successful Application of the Intraoperative Parathyroid Hormone Assay in Tertiary Hyperparathyroidism

2007 ◽  
Vol 73 (3) ◽  
pp. 281-283 ◽  
Author(s):  
Leila Thanasoulis ◽  
Juliane Bingener ◽  
Kenneth Sirinek ◽  
Melanie Richards
Keyword(s):  
Parathyroid Hormone ◽  
Success Rates ◽  
Tertiary Hyperparathyroidism ◽  
Equivalent Rate ◽  
Parathyroid Hormone Assay ◽  
The Mean ◽  
Intraoperative Parathyroid Hormone ◽  
Intraoperative Parathyroid Hormone Assay

The role of the intraoperative parathyroid hormone (IOPTH) assay in patients with tertiary hyperparathyroidism (3HPT) is not well defined. To evaluate the utility of the IOPTH in 3HPT, we compared its use in 72 patients with primary hyperparathyroidism (1HPT) and 3HPT undergoing parathyroidectomy. Sixty-three patients with 1HPT and nine patients with 3HPT were identified. There were 30 men and 42 women (mean age, 58 years). The mean serum calcium and preoperative intact PTH levels in 1HPT were 11.1 mg/dL and 214 pg/mL compared with 11.2 mg/dL and 849 pg/mL in 3HPT (Ca, non significant; PTH, P < 0.05). Intraoperatively, a solitary abnormal gland was found in 62 of 72 (86%) patients. Seven patients with 3HPT had three- or four-gland hyperplasia. The two groups were compared to determine if a 10-minute postexcision IOPTH decline >50 per cent would have similar success rates. Seventy-one of 72 (98.6%) patients had a >50 per cent decline from the baseline IOPTH at the end of the operation. The average reduction from baseline was 85.3 per cent in 1HPT and 88.6 per cent in 3HPT (not significant). Average follow-up was 9.8 months for 1HPT and 11.1 months in 3HPT. Three of 63 patients (4.8%) with 1HPT and five of nine patients (55.6%) with 3HPT had inappropriate elevations in PTH ( P < 0.05). All patients with 3HPT were normocalcemic compared with 62 of 64 (97%) patients with 1HPT (not significant). The IOPTH assay can be used in 3HPT in an identical fashion with an equivalent rate of normocalcemia compared with its applications in 1HPT.

Primary Hyperparathyroidism: Redefining Cure

2019 ◽  
Vol 85 (2) ◽  
pp. 214-218 ◽  
Author(s):  
Anatoliy V. Rudin ◽  
Travis J. McKenzie ◽  
Roberta Wermer ◽  
Geoffrey B. Thompson ◽  
Melanie L. Lyden
Keyword(s):  
Primary Hyperparathyroidism ◽  
Inclusion Criteria ◽  
Cure Rate ◽  
Tertiary Hyperparathyroidism ◽  
Gland Weight ◽  
Significant Difference ◽  
Intraoperative Pth ◽  
Multiple Endocrine Neoplasia Syndrome ◽  
History Of

Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or pre-operative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15–65 pg/mL) can be considered cured and may need less frequent follow-up.

scholarly journals Clinical impact of two different intraoperative parathyroid hormone assays in primary and renal hyperparathyroidism

2009 ◽  
Vol 160 (2) ◽  
pp. 275-281 ◽  
Author(s):  
Sonja-Kerstin Meyer ◽  
Markus Zorn ◽  
Karin Frank-Raue ◽  
Markus W Büchler ◽  
Peter Nawroth ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Clinical Impact ◽  
Renal Hyperparathyroidism ◽  
Normal Range ◽  
Persistent Disease ◽  
Intraoperative Pth ◽  
Intraoperative Parathyroid Hormone

BackgroundIntraoperative parathyroid hormone (PTH) monitoring predicts successful surgery for primary hyperparathyroidism (pHPT). In renal HPT, intraoperative PTH assays can define whether parathyroid resection is adequate.MethodsIntraoperative PTH was measured with two different immunometric assays (Immulite Turbo DPC and ADVIA Centaur assay) in 91 patients undergoing parathyroidectomy for primary (n=57) and renal (n=34) hyperparathyroidism. PTH was monitored preoperatively, 10, 20, and 30 min after parathyroidectomy and 24 h postoperatively.ResultsTen minutes after parathyroidectomy, intraoperative PTH dropped into the normal range (<7.6 pmol/l) in 84% of patients with pHPT and tertiary HPT as measured with the ADVIA Centaur assay (PTH-A), compared with 100% of the samples measured with the Immulite Turbo DPC assay (PTH-I; P=0.0082). Twenty minutes after parathyroidectomy for secondary HPT, intraoperative PTH decreased to the normal range in 100% measured with PTH-I compared with 50% measured with PTH-A (P=0.009). Then, 24 h postoperatively, PTH-I and PTH-A levels were within the normal range in all of the successfully treated patients. Both assays correctly identified six patients with persistent disease and another patient with a double adenoma in pHPT.ConclusionsIn patients undergoing parathyroidectomy for primary or renal HPT, PTH levels decreasing to the normal range indicated successful surgery in all of the patients as measured with the PTH-I assay. Comparing the two assays, PTH-I was able to quantify the intraoperative PTH decay more quickly than PTH-A.

Novel Criteria for Parathyroid Hormone Levels in Parathyroid Hormone–Guided Parathyroid Surgery

2007 ◽  
Vol 131 (12) ◽  
pp. 1800-1804
Author(s):  
Robert de Vos tot Nederveen Cappel ◽  
Nicole Bouvy ◽  
Wouter de Herder ◽  
Yolanda de Rijke ◽  
Hans van Toor ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
False Positive ◽  
Parathyroid Surgery ◽  
Cure Rate ◽  
True Negative ◽  
Tertiary Hyperparathyroidism ◽  
Negative Results ◽  
Future Evaluation ◽  
Positive Results

Abstract Context.—Novel criteria for decrease of perioperative parathyroid hormone measurement may improve the accuracy of perioperative quick parathyroid hormone (qPTH)–guided parathyroidectomy. Objective.—To assess overall cure rate based on conventional criteria (50% decline of qPTH). Perioperative qPTH levels were evaluated to determine novel criteria for successful parathyroid surgery. Design.—Analysis of perioperative qPTH measurement findings of all consecutive patients undergoing parathyroidectomy for hyperparathyroidism (72 with primary hyperparathyroidism and 28 with secondary or tertiary hyperparathyroidism or multiple endocrine neoplasia I/IIa disease). Results.—Measurement of qPTH (based solely on the criterion of greater than 50% decline of parathyroid hormone) in 72 patients with primary hyperparathyroidism (77 procedures) showed true-positive results in 69, false-positive results in 4, and true-negative results in 4 procedures. In our series, false-positive and true-negative results were associated with high postexcision levels. However, when qPTH declines of greater than 70% and 80% were used in cases of postexcision qPTH levels of 100 to 200 ng/L and greater than 200 ng/L, respectively, no false-positive results were observed. Conclusions.—Through adherence to these novel criteria, reexploration of the neck could have been prevented in 29% of patients with primary hyperparathyroidism due to multiple gland disease. These novel criteria demand future evaluation to establish their value.

scholarly journals Retrospective analysis of the role of intra-operative parathyroid hormone monitoring during parathyroidectomy for primary hyperparathyroidism; a single center experience over 2 decades

2021 ◽  
Author(s):  
Yehonatan Adler ◽  
Sharon Tzelnick ◽  
Yoni Shopen ◽  
Ella Reifen ◽  
Gideon Bachar ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Retrospective Analysis ◽  
Operating Room ◽  
Parathyroid Hormone Monitoring ◽  
Significant Difference ◽  
Cure Rates ◽  
Room Time ◽  
Operating Room Time

Background: The role of intra-operative parathyroid hormone (IOPTH) monitoring during parathyroidectomy for primary hyperparathyroidism has long been debated. Objectives: Our main goal was to investigate the cure rates of parathyroidectomy for primary hyperparathyroidism with and without IOPTH monitoring. Our secondary goal was to investigate if operating room time can be saved when not using IOPTH monitoring. Design: A retrospective analysis of patients who underwent parathyroidectomy for PHPT for a single adenoma between 2004-2019 was performed. Cure rates and operating room time were compared. Results: 423 patients were included. IOPTH was used in 248 patients (59%). Four patients were not cured, two from each group, with no significant difference between the groups (98.8% vs. 99.1%, p=0.725). Surgery time was significantly longer in the IOPTH group, p<0.001. Conclusions: There is no advantage for using IOPTH during parathyroidectomy in suitable clinical setting. A focused procedure may be safely performed without IOPTH while achieving non-inferior success rates and reducing operative time.

scholarly journals A 10-Year Experience in Intraoperative Parathyroid Hormone Measurements for Primary Hyperparathyroidism: A Prospective Study of 91 Previous Unexplored Patients

2012 ◽  
Vol 2012 ◽  
pp. 1-6 ◽  
Author(s):  
M. C. Neves ◽  
M. N. Ohe ◽  
M. Rosano ◽  
M. Abrahão ◽  
O. Cervantes ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
False Negative ◽  
True Positive ◽  
Tertiary Institution ◽  
True Negative ◽  
Technological Advances ◽  
Intraoperative Pth ◽  
Intraoperative Parathyroid Hormone ◽  
A Prospective Study

Introduction. Primary hyperparathyroidism (PHP) is characteristically determined by high levels of calcium and high or inappropriate levels of parathyroid hormone (PTH). Technological advances have dramatically changed the surgical technique over the years once intraoperative parathyroid hormone (IOPTH) assay had allowed for focused approaches.Objective. To evaluate our 10-year experience in employing a rapid intraoperative PTH assay for PHP.Methods. A prospective cohort of 91 PHP-operated patients in a tertiary institution in São Paulo, Brazil, from June 2000 to April 2011.Results. We had 85 (93.4%) successful parathyroidectomies, 6 (6.6%) failed parathyroidectomies in 91 previous unexplored patients, and 5 (100%) successful remedial surgeries. The IOPTH was true-positive in 88.5%, true-negative in 7.3%, false-positive in 2.1%, and false-negative in 2.1% of the procedures. IOPTH was able to obviate additional exploration or to ask for additional exploration in 92 (95.8%) procedures.Conclusion. The IOPTH revealed to be an important technological adjunct in the current parathyroid surgery for PHP.

Multimodal Preoperative Localization Improves Outcomes in Reoperative Parathyroidectomy: A 25-Year Surgical Experience

2019 ◽  
Vol 85 (9) ◽  
pp. 939-943 ◽  
Author(s):  
Snehal G. Patel ◽  
Neil D. Saunders ◽  
Salman Jamshed ◽  
Collin J. Weber ◽  
Jyotirmay Sharma
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Preoperative Localization ◽  
Preoperative Imaging ◽  
Complication Rates ◽  
Recurrent Nerve ◽  
Cure Rate ◽  
Recurrent Nerve Palsy ◽  
Preoperative Serum ◽  
Cure Rates

Reoperative parathyroid surgery (REOPS) is often associated with lower cure rates and greater risk of nerve injury and hypoparathyroidism. The aim of this study was to evaluate cure rates, pathology, complications, and the efficacy of preoperative localization in patients requiring REOPS. Between 1992 and 2017, 2491 consecutive patients underwent parathyroidectomy for primary hyperparathyroidism. With Institutional Review Board approval, our prospectively collected parathyroidectomy outcomes database was queried for operative findings, outcomes, pathology, and localization methodology. Three hundred forty-six patients had REOPS (111 men/32% and 235 women/68%), with an overall cure rate of 91 per cent and a mean follow-up of 1.9 ± 0.7 years. The average preoperative serum calcium and parathyroid hormone were 11 ± 1 mg/dL and 373 ± 796 pg/mL, respectively. Normalization of intraoperative parathyroid hormone occurred in 248 patients and it was predictive of cure in 98.8 per cent of patients. A single adenoma was resected in 253 patients (75%), and the superior gland location was most common at 57 per cent. Ectopic glands were identified in only 33 patients. When preoperative imaging localized a lesion, a tumor was identified in that location in 75.4 per cent of sestamibi or SPECT/CTscans, 57.8 per cent of CT, 61.2 per cent of MRI, and 46.2 per cent of US. When at least two imaging modalities were concordant, sensitivity improved to 91.6 per cent ( P < 0.001). Complication rates of permanent hypoparathy-roidism and recurrent nerve palsy occurred in 0.03 per cent of patients. REOP for recurrent or persistent primary hyperparathyroidism has a cure rate of 91 per cent. Most missed parathyroid tumors are in the neck, and multimodal imaging improves preoperative localization and success.

scholarly journals Surgery for Primary Hyperparathyroidism in Patients with Preoperatively Negative Sestamibi Scan and Discordant Imaging Studies: The Usefulness of Intraoperative Parathyroid Hormone Monitoring

2013 ◽  
Vol 6 ◽  
pp. CMED.S13114 ◽  
Author(s):  
Pietro Giorgio Caló ◽  
Giuseppe Pisano ◽  
Giulia Loi ◽  
Fabio Medas ◽  
Alberto Tatti ◽  
...  
Keyword(s):  
Parathyroid Hormone ◽  
Primary Hyperparathyroidism ◽  
Preoperative Imaging ◽  
Imaging Studies ◽  
Parathyroid Hormone Monitoring ◽  
Intraoperative Pth ◽  
Group A ◽  
Group B ◽  
Intraoperative Parathyroid Hormone ◽  
The Impact

The aim of this study was to evaluate the impact of intraoperative parathyroid hormone (PTH) monitoring on surgical strategy, intraoperative findings, and outcome in patients with negative sestamibi scintigraphy and with discordant imaging studies. We divided our 175 patients into 3 groups: group A was methoxyisobutylisonitrile (MIBI)-positive and ultrasonography positive and was concordant (114 patients), group B was MIBI-positive and ultrasonography-negative (50 patients), and group C was MIBI–-and ultrasonography-negative (11 patients). The overall operative success was 99.12% in group A, 98% in group B, and 90.91% in group C, with an incidence of multiglandular disease of 3.5% in group A, 12% in group B, and 9.09% in group C. Intraoperative PTH monitoring changed the operative management in 2.63% of patients in group A and 14% in group B. The use of intraoperative PTH achieves to obtain excellent results in the treatment of primary hyperparathyroidism in high-volume centers, even in the most difficult cases, during MIBI-negative and discordant preoperative imaging studies.

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