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Utility of Intraoperative PTH for Primary Hyperparathyroidism Due to Multigland Disease

  • Endocrine Tumors
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Surgical resection is the only curative therapy for patients with primary hyperparathyroidism (1HPT). Although cure rates of parathyroidectomy are generally high, failure is most often due to unrecognized multigland disease (MGD), which compromises 15–20% of patients with 1HPT. The use of intraoperative PTH (ioPTH) monitoring is well established for single-gland disease. Controversy remains over the utility of ioPTH in MGD, with concern for false-positive results leading to prematurely concluding the operation and leaving behind abnormal parathyroid tissue, risking future recurrence. The aim of this study was to determine the utility of ioPTH monitoring for MGD.

Methods

Between November 2000 and March 2008, data were prospectively collected on 755 patients with 1HPT who underwent parathyroidectomy. PTH samples were collected pre-incision, and then at 5, 10, and 15 min after excision of suspected abnormal parathyroid gland(s). Surgical cure was defined as a drop of greater than 50% in PTH level. Patients were clinically cured if they became normocalcemic postoperatively and remained so for 6 months. The data were analyzed to determine how accurately ioPTH predicted success or failure of parathyroidectomy.

Results

Of the 755 patients, 163 (21.5%) were found to have MGD on pathology. Intraoperative PTH monitoring was used in 161 of these cases. In 146/161 cases (90.7%), the ioPTH level fell by at least 50% after removal of all suspected abnormal glands. All of these patients (100%) remained normocalcemic postoperatively. In 15/161 cases (9.3%), the PTH level did not fall by >50%. For 11/15 cases (73%), patients remained hypercalcemic postoperatively or had recurrence. However, in the remaining four cases, the patients became normocalcemic postoperatively despite failure of the PTH to fall by >50%. In each of these patients, PTH levels fell by 40–50%.

Conclusions

ioPTH monitoring accurately predicted success or failure of parathyroidectomy in 97.5% (157/161) of patients with MGD. A fall of ioPTH by >50% can be used as a highly accurate predictor of cure in patients with MGD. Therefore, ioPTH monitoring is a very useful tool in patients with 1HPT and MGD.

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References

  1. Chen H, Mack E, Starling JR. Radioguided parathyroidectomy is equally effective for both adenomatous and hyperplastic glands. Ann Surg. 2003;238(3):332–7 (discussion 337–8).

    PubMed  Google Scholar 

  2. Chen H, Zeiger MA, Gordon TA, Udelsman R. Parathyroidectomy in Maryland: effects of an endocrine center. Surgery. 1996;120(6):948–52 (discussion 952–3).

    Article  CAS  PubMed  Google Scholar 

  3. Udelsman R. Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg. 2002;235(5):665–70 (discussion 670–2).

    Article  PubMed  Google Scholar 

  4. Bergenfelz A, Lindblom P, Tibblin S, Westerdahl J. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: a prospective randomized controlled trial. Ann Surg. 2002;236(5):543–51.

    Article  PubMed  Google Scholar 

  5. Chen H. Radioguided parathyroid surgery. Adv Surg. 2004;38:377–92.

    PubMed  Google Scholar 

  6. Chen H, Sokoll LJ, Udelsman R. Outpatient minimally invasive parathyroidectomy: a combination of sestamibi–SPECT localization, cervical block anesthesia, and intraoperative parathyroid hormone assay. Surgery. 1999;126(6):1016–21 (discussion 1021–2).

    Article  CAS  PubMed  Google Scholar 

  7. Delbridge LW, Dolan SJ, Hop TT, Robinson BG, Wilkinson MR, Reeve TS. Minimally invasive parathyroidectomy: 50 consecutive cases. Med J Aust. 2000;172(9):418–22.

    CAS  PubMed  Google Scholar 

  8. Irvin GL 3rd, Molinari AS, Figueroa C, Carneiro DM. Improved success rate in reoperative parathyroidectomy with intraoperative PTH assay. Ann Surg. 1999;229(6):874–8 (discussion 878–9).

    Article  PubMed  Google Scholar 

  9. Irvin GL,3rd, Prudhomme DL, Deriso GT, Sfakianakis G, Chandarlapaty SK. A new approach to parathyroidectomy. Ann Surg. 1994;219(5):574–9 (discussion 579–81).

    Article  PubMed  Google Scholar 

  10. Irvin GL 3rd, Solorzano CC, Carneiro DM. Quick intraoperative parathyroid hormone assay: surgical adjunct to allow limited parathyroidectomy, improve success rate, and predict outcome. World J Surg. 2004;28(12):1287–92.

    Article  PubMed  Google Scholar 

  11. Nichol PF, Mack E, Bianco J, Hayman A, Starling JR, Chen H. Radioguided parathyroidectomy in patients with secondary and tertiary hyperparathyroidism. Surgery. 2003;134(4):713–7 (discussion 717–9).

    Article  PubMed  Google Scholar 

  12. Westerdahl J, Bergenfelz A. Unilateral versus bilateral neck exploration for primary hyperparathyroidism: 5-year follow-up of a randomized controlled trial. Ann Surg. 2007;246(6):976–80 (discussion 980–1).

    Article  PubMed  Google Scholar 

  13. Westerdahl J, Bergenfelz A. Sestamibi scan-directed parathyroid surgery: potentially high failure rate without measurement of intraoperative parathyroid hormone. World J Surg. 2004;28(11):1132–8.

    Article  PubMed  Google Scholar 

  14. Goldstein RE, Blevins L, Delbeke D, Martin WH. Effect of minimally invasive radioguided parathyroidectomy on efficacy, length of stay, and costs in the management of primary hyperparathyroidism. Ann Surg. 2000;231(5):732–42.

    Article  CAS  PubMed  Google Scholar 

  15. Udelsman R, Aruny JE, Donovan PI, et al. Rapid parathyroid hormone analysis during venous localization. Ann Surg. 2003;237(5):714–9 (discussion 719–21).

    Article  PubMed  Google Scholar 

  16. Caron NR, Sturgeon C, Clark OH. Persistent and recurrent hyperparathyroidism. Curr Treat Options Oncol. 2004;5(4):335–45.

    Article  PubMed  Google Scholar 

  17. Alexander HR,Jr, Chen CC, Shawker T, et al. Role of preoperative localization and intraoperative localization maneuvers including intraoperative PTH assay determination for patients with persistent or recurrent hyperparathyroidism. J Bone Miner Res. 2002;17(Suppl 2):N133–40.

    PubMed  Google Scholar 

  18. Norman J, Denham D. Minimally invasive radioguided parathyroidectomy in the reoperative neck. Surgery. 1998;124(6):1088–92 (discussion 1092–3).

    Article  CAS  PubMed  Google Scholar 

  19. Chen H, Pruhs Z, Starling JR, Mack E. Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. Surgery. 2005;138(4):583–7 (discussion 587–90).

    Article  PubMed  Google Scholar 

  20. Chen H, Mack E, Starling JR. A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable? Ann Surg. 2005;242(3):375–80 (discussion 380–3).

    PubMed  Google Scholar 

  21. Sugg SL, Krzywda EA, Demeure MJ, Wilson SD. Detection of multiple gland primary hyperparathyroidism in the era of minimally invasive parathyroidectomy. Surgery. 2004;136(6):1303–9.

    Article  PubMed  Google Scholar 

  22. Arciero CA, Peoples GE, Stojadinovic A, Shriver CD. The utility of a rapid parathyroid assay for uniglandular, multiglandular, and recurrent parathyroid disease. Am Surg. 2004;70(7):588–92.

    CAS  PubMed  Google Scholar 

  23. Stratmann SL, Kuhn JA, Bell MS, et al. Comparison of quick parathyroid assay for uniglandular and multiglandular parathyroid disease. Am J Surg. 2002;184(6):578–81 (discussion 581).

    Article  CAS  PubMed  Google Scholar 

  24. Haciyanli M, Lal G, Morita E, Duh QY, Kebebew E, Clark OH. Accuracy of preoperative localization studies and intraoperative parathyroid hormone assay in patients with primary hyperparathyroidism and double adenoma. J Am Coll Surg. 2003;197(5):739–46.

    Article  PubMed  Google Scholar 

  25. Siperstein A, Berber E, Barbosa GF, et al. Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone: analysis of 1158 cases. Ann Surg. 2008;248(3):420–8.

    PubMed  Google Scholar 

  26. Weber CJ, Ritchie JC. Retrospective analysis of sequential changes in serum intact parathyroid hormone levels during conventional parathyroid exploration. Surgery. 1999;126(6):1139–43 (discussion 1143–4).

    Article  CAS  PubMed  Google Scholar 

  27. Carneiro-Pla DM, Romaguera R, Nadji M, Lew JI, Solorzano CC, Irvin GL 3rd. Does histopathology predict parathyroid hypersecretion and influence correctly the extent of parathyroidectomy in patients with sporadic primary hyperparathyroidism? Surgery. 2007;142(6):930–5 (discussion 930–5).

    Article  PubMed  Google Scholar 

  28. Clerici T, Brandle M, Lange J, Doherty GM, Gauger PG. Impact of intraoperative parathyroid hormone monitoring on the prediction of multiglandular parathyroid disease. World J Surg. 2004;28(2):187–92.

    Article  PubMed  Google Scholar 

  29. Randhawa PS, Mace AD, Nouraei SA, Stearns MP. Primary hyperparathyroidism: do perioperative biochemical variables correlate with parathyroid adenoma weight or volume? Clin Otolaryngol. 2007;32(3):179–84.

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI, USA

    Ashley K. Cayo MD, Rebecca S. Sippel MD, Sarah Schaefer NP & Herbert Chen MD FACS

Authors
  1. Ashley K. Cayo MD
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  2. Rebecca S. Sippel MD
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  3. Sarah Schaefer NP
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  4. Herbert Chen MD FACS
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Corresponding author

Correspondence to Herbert Chen MD FACS.

Additional information

Accepted for presentation at the 62nd annual meeting of the Society for Surgical Oncology, Phoenix March 2009.

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Cayo, A.K., Sippel, R.S., Schaefer, S. et al. Utility of Intraoperative PTH for Primary Hyperparathyroidism Due to Multigland Disease. Ann Surg Oncol 16, 3450–3454 (2009). https://doi.org/10.1245/s10434-009-0699-7

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  • DOI: https://doi.org/10.1245/s10434-009-0699-7

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