Intraoperative Parathyroid Hormone Monitoring Research Articles

Persistent/Recurrent Primary Hyperparathyroidism: Does the Number of Abnormal Glands Play a Role?

BackgroundPersistent/recurrent hyperparathyroidism occurs in 2%-5% of patients with sporadic primary hyperparathyroidism (PHPT). In this study, the incidence and time to recurrence in patients with single-gland disease (SGD), double adenomas (DAs), or four-gland hyperplasia (FGH) at initial parathyroidectomy were compared. MethodsThis retrospective review included adult patients with sporadic PHPT who underwent initial parathyroidectomy with intraoperative parathyroid hormone monitoring (IOPTH) from 1/2000 to 12/2016 with ≥6 mo follow-up. An abnormal parathyroid was defined by a gland weight of ≥50 mg. A concurrent serum calcium >10.2 mg/dL and parathyroid hormone >40 pg/mL was defined as persistent PHPT if present <6 mo and recurrent PHPT if present ≥6 mo postoperatively after initial normocalcemia. ResultsOf 1486 patients, 1203 (81%) had SGD, 159 (11%) DA, and 124 (8%) FGH. Among the 3 groups, there was no difference in the percent decrease from the baseline or time of excision to final postexcision IOPTH levels between groups (79% versus 80% versus 80%, respectively; P = 0.954) or in the proportion of patients with a final IOPTH ≥40 (22% versus 18% versus 14%; P = 0.059). Overall, 22 (1.5%) had persistent PHPT and 26 (1.7%) had recurrent PHPT. Persistent PHPT was more frequent with DAs (6; 3.8%) than other groups (SGD: 16, 1.3%; FGH: 0; P = 0.02). At median follow-up of 33 mo (IQR, 18-60), there was no difference in recurrence rate (1.6% versus 2.5% versus 2.4%; P = 0.57) or median time (mo) to recurrence (SGD: 59 [IQR, 21-86], DAs: 36 [IQR, 29-58], FGH: 23 [IQR, 17-40]; P = 0.46). ConclusionsRecurrent PHPT occurred in 1.7% of patients who underwent curative initial parathyroidectomy, with no difference in incidence or time to recurrence between groups based on the number of glands removed. Patients with DA more commonly had persistent PHPT, raising the possibility of unrecognized FGH.

Efficacy of Intra-Operative PTH Monitoring in Determining Potential Cure in Patients undergoing Parathyroid Surgery

Efficacy of Intra-Operative PTH Monitoring in Determining Potential Cure in Patients undergoing Parathyroid Surgery

Increasing trend of bilateral neck exploration in primary hyperparathyroidism

BackgroundBilateral neck exploration was the standard operation for primary hyperparathyroidism. With improvements in preoperative localization and use of intraoperative PTH (ioPTH) monitoring, minimally invasive unilateral neck exploration has been widely adopted. This study evaluates the trend in parathyroidectomies for primary hyperparathyroidism. MethodsParathyroidectomy for sporadic primary hyperparathyroidism was analyzed from 2010 to 2017. Exclusion criteria included previous neck surgery and concomitant procedures. The operations were classified as unilateral exploration (UE), UE converted to bilateral exploration (BE), or BE. Variables included preoperative and intraoperative factors. Outcomes included persistence, recurrence, permanent hypocalcemia and recurrent laryngeal nerve (RLN) injury. ResultsFour hundred thirty-one patients were reviewed. Since 2010, the rate of BE has increased from 30% to 50%. Disease duration, presence of bone disease, negative localization, baseline ioPTH <100, and ≥2 abnormal glands have increased. Mean operative time has not changed over time. Two percent of patients had persistent disease, <1% had recurrent disease, and 2% have had reoperation. Nine percent had temporary hypoparathyroidism, and 15 patients had temporary RLN injury. ConclusionsThis study shows an increasing trend in BE for primary hyperparathyroidism. This increase was associated with lower baseline intraoperative parathyroid hormone (ioPTH) levels and smaller gland size. The operative approach for parathyroidectomy should be individualized and surgeons should not hesitate to perform BE when needed.

Confirmation of Parathyroid Tissue: Are Surgeons Aware of New and Novel Techniques?

BackgroundEx vivo aspiration of parathyroid glands for the measurement of intraoperative parathyroid hormone (IOPTH) levels is a rapid point-of-care method to confirm parathyroid tissue during parathyroidectomy and an alternative to frozen section (FS). This study sought to determine the awareness and utilization of this technique among endocrine surgeons. Materials and methodsA de-identified 12-question survey regarding techniques for intraoperative identification/confirmation of parathyroid tissue and the use of IOPTH monitoring was distributed to all 608 members of the American Association of Endocrine Surgeons. ResultsAmong the 182 (30%) respondents, FS was the most common primary technique utilized by 115 (63%) respondents to confirm parathyroid tissue; only 12 (7%) utilized ex vivo aspiration, although 78 (42%) were familiar with the technique. Availability and familiarity were the principal reasons for use of the primary technique; the most common barrier was time. Serum IOPTH monitoring was routinely used by 124 (74%). Of respondents who utilized FS, serum IOPTH monitoring was routinely used by 75% (86/115), including 71% (45/63) who reported time as a barrier to FS. Of these 45, only 15 (33%) were familiar with ex vivo parathyroid aspiration. Only 48% of surgeons knew how PTH samples were charged. ConclusionsFS was the most common method of identification/confirmation of parathyroid tissue. Although most respondents routinely performed IOPTH monitoring, relatively few utilized ex vivo aspiration as a technique for parathyroid identification and less than 50% were familiar with this technique. Broader dissemination about novel techniques such as ex vivo aspiration and cost awareness are recommended.

Biochemical Profile Affects IOPTH Kinetics and Cure Rate in Primary Hyperparathyroidism.

Recently, normocalcemic (NC) and normohormonal (NH) variants of primary hyperparathyroidism (pHPT) have been described, with distinct biochemical profiles from the typical high serum calcium and parathyroid hormone (PTH) levels. Here, we investigate whether biochemical profile affects cure rate, as well as the kinetics of intraoperative PTH (IOPTH). This is a single-center, retrospective study of pHPT patients undergoing parathyroidectomy. Patients were grouped based on preoperative calcium and PTH levels into typical, NC (normal calcium, elevated PTH, no evidence of secondary hyperparathyroidism), and NH (elevated calcium, unsuppressed PTH) biochemical profiles. All patients had IOPTH monitoring and ≥6-month post-op serum studies to confirm surgical cure. Patient variables were analyzed with Kruskal-Wallis test and Chi-square analysis. IOPTH kinetic curves were analyzed using a linear mixed model. From June 2006 to October 2014, 646 patients met inclusion criteria. Biochemical profile was typical in 460 patients (71%), NC in 101 (16%), and NH in 85 (13%). IOPTH levels were higher at all time points in typical patients, p < 0.001. Surgical cure rates were significantly lower for NC patients (90.1%) than for typical (98.5%) or NH patients (97.7%), p < 0.001, although a stricter criteria for cure was used in this group(normal calcium AND normal PTH). In a multivariable linear mixed model, NC patients had a significantly slower rate of IOPTH decline (p < 0.001 at 10min). Here, we better characterize the atypical variants of pHPT. Using a stricter definition of cure in the NC variant, these patients have a lower surgical cure rate than typical or NH variants in pHPT. The IOPTH curve is affected by biochemical profile, with both NC and NH patients having lower absolute values and NC patients having a slower decline.

Surgical treatment in patients with single and multiple gland primary hyperparathyroidism with the use of intraoperative parathyroid hormone monitoring: extensive single-center experience.

To evaluate a single-center extensive experience and effectiveness in surgical treatment of primary hyperparathyroidism (pHPT) with the use of rapid intraoperative parathyroid hormone (ioPTH) monitoring in patients with single gland (SGpH) or multiple gland (MGpH) disease. This retrospective, single-center cohort study included 214 patients with pHPT treated from January 2010 to June 2017. In total, 172 patients fulfilled the inclusion criteria having at least one preoperative localization image study and measurement of ioPTH. Statistical analysis was made by the chi-square test and Student's t tests. Of the 172 patients, 146 were women (85%) and 26 men (15%), with a mean age of 56.9years; 153 (89%) had SGpH and 19 (11%) MGpH. The mean follow-up was 41.8months. A total of 153 surgical procedures were performed as minimal invasive parathyroidectomy (MIP) based on a SGpH diagnosis; operative success was achieved in 150 cases (98%), according to ioPTH concentrations. The remainder (19 procedures) were performed as bilateral neck exploration (BNE) based on a MGpH diagnosis; operative success was achieved in 16 cases (84%). ioPTH correctly modified the initially planned operation in 26.3% of patients with MGpH. ioPTH enables the surgical treatment of patients with pHPT with focused approaches and excellent results, as it helps the surgeon to identify cases of MGpH. ioPTH adds value to cases where preoperative imaging failed to detect the affected gland or the results are inconclusive. According to the literature, its application seems to be of marginal benefit in cases in which there are two concordant preoperative imaging studies.

Intraoperative Parathyroid Hormone Monitoring in Parathyroidectomy for Tertiary Hyperparathyroidism

BackgroundTertiary hyperparathyroidism (THPT) is characterized by hypercalcemia and hyperparathyroidism after renal allograft. Limited data exist regarding the use of intraoperative parathyroid hormone (IOPTH) for THPT. We examined our series of parathyroidectomies performed for THPT to determine clinical outcomes with respect to IOPTH. Materials and methodsPatients who underwent parathyroidectomy for THPT (1999-2017) were identified for inclusion. Retrospective chart review was performed. Cure was defined as eucalcemia ≥6 mo after surgery. Statistical analysis was performed. ResultsOf 41 patients included in the study, 41% (n = 17) were female. The median duration of dialysis before renal allograft was 34 mo (interquartile interval [IQI]:6-60). Preoperatively, the median calcium level was 10.4 mg/dL (IQI:10.0-11.2), median parathyroid hormone was 172 pg/mL (IQI:104-293), and renal function was minimally abnormal with median glomerular filtration rate 58 mL/min/1.73 m2 (IQI:49-71). At surgery, the median final IOPTH was 40 pg/mL (IQI:29-73), and median decrease in IOPTH was 78% (IQI:72-87), with 88% (n = 36) of patients demonstrating >50% decrease. Median calcium level ≥6 mo after surgery was 9.4 mg/dL (IQI:8.8-9.7), and only one patient had recurrent hypercalcemia. Failure to achieve >50% decrease in IOPTH was not significantly associated with recurrent hypercalcemia (P = 1.000). With a median follow-up time of 41 mo (IQI:25-70), only three patients had graft failure. The positive predictive value of IOPTH for cure was 89% (95% confidence interval: 0.752-0.971), with 0% negative predictive value and 87% accuracy (95% confidence interval: 0.726-0.957). ConclusionsSubtotal parathyroidectomy is a successful operation with durable cure of THPT. IOPTH fails to predict long-term cure in THPT despite minimally abnormal renal function.

Intraoperative parathyroid hormone levels ≤40 pg/mL are associated with the lowest persistence rates after parathyroidectomy for primary hyperparathyroidism

BackgroundIntraoperative parathyroid hormone (IOPTH) monitoring is used to predict biochemical cure during parathyroidectomy for primary hyperparathyroidism; however, there is variability in the intraoperative parathyroid hormone criteria used by surgeons to predict normocalcemia after parathyroidectomy. This study sought to determine the intraoperative parathyroid hormone criteria correlated with the lowest rates of persistent hyperparathyroidism after parathyroidectomy for primary hyperparathyroidism. Materials and MethodsThis is a retrospective cohort study of 2,654 patients with primary hyperparathyroidism who underwent parathyroidectomy with intraoperative parathyroid hormone monitoring at a single institution from 1999 to 2014. Multivariate logistic regression analysis was used to measure the association between the lowest intraoperative parathyroid hormone level and the persistence of primary hyperparathyroidism after parathyroidectomy. ResultsA total of 66 patients (2.5%) had persistent hyperparathyroidism after parathyroidectomy. Using the traditional intraoperative parathyroid hormone criteria of a ≥50% decrease from the baseline level, the rate of persistent primary hyperparathyroidism was greater when intraoperative parathyroid hormone did not decrease to ≥50% from the baseline level (17 of 180 patients [9.4%] vs 49 of 2,474 [2.0%], [OR 5.9, 95% CI 3.2–10.5, P < .001]). Regardless of whether intraoperative parathyroid hormone decreased ≥50%, patients with a lowest intraoperative parathyroid hormone above the normal range (10–65 pg/mL) had greater persistence rates compared with patients with an intraoperative parathyroid hormone <65 pg/mL (30 of 350 [8.6%] vs 36 of 2,304 [1.6%], [OR 6.6, 95% CI 3.4–12.7, P < .001]). Furthermore, patients with a lowest intraoperative parathyroid hormone 40 to 65 pg/mL had increased rates of adjusted persistence compared with patients with lowest intraoperative parathyroid hormone ≤40 pg/mL (13 of 385 [3.4%] vs 23 of 1,919 [1.2%], [OR 4.2, 95% CI 2.0–8.7, P < .001]). Patients with lowest intraoperative parathyroid hormone <5 to 20 pg/mL did not have decreased rates of persistence compared with patients with lowest intraoperative parathyroid hormone 20 to 40 pg/mL (9 of 996 [0.9%] vs 14 of 923 [1.5%], [OR 0.5, 95% CI 0.2–1.2, P = .14]). ConclusionPatients with a lowest intraoperative parathyroid hormone ≤40 pg/mL compared with the traditional criteria of a ≥50% decrease from baseline and a final parathyroid hormone in the normal range (<65 pg/mL) had the lowest rates of persistent primary hyperparathyroidism after parathyroidectomy for primary hyperparathyroidism. The single criteria of a lowest intraoperative parathyroid hormone level ≤40 pg/mL may best predict the lowest persistent disease rates after parathyroidectomy for primary hyperparathyroidism.

Detectability and surgical outcomes in parathyroid surgery – a single-centre experience

The incidence of primary hyperparathyroidismand referrals for the removal of parathyroid adenomas are increasing. Factors that improve the detectability, and ultimately the surgical outcome, are the focus of this retrospective study. We included 117 patients who had parathyroid operations with intraoperative monitoring of parathyroid hormone (PTH). Sestamibi, ultrasound and, in selected cases, fusion with computed tomograms (CT), were done to locate the lesion preoperatively. Concentrations of calcium and PTH before and after operation, specimen weight, and preoperative vitamin D concentrations, were assessed. The sensitivity of sestamibi and ultrasound for the preoperative location of adenomas was 92% and 80%, respectively. Sestamibi located them more accurately in patients with low preoperative concentrations of vitamin D (p = 0.037) and with heavier adenomas (p < 0.001). We found no significant association between the preoperative concentrations of PTH and detectability on preoperative scans (p = 0.058). Postoperative follow up showed that 97% of the 117 patients were biochemically cured. Accurate location helps to lower morbidity as it facilitates a targeted approach. Further studies are needed to explore the role of vitamin D in the location of parathyroid adenomas before parathyroidectomy.

Primary Hyperparathyroidism

Primary hyperparathyroidism is defined. Key components of the diagnostic work-up including symptoms, family history, laboratory examination, and imaging techniques are reviewed. Indications for surgery, including a discussion of the latest guidelines, are emphasized. Controversies such as when to operate on asymptomatic primary hyperparathyroidism are discussed. This review contains 4 figures, 1 table, and 29 references. Key Words: hypercalcemia, hypercalcemic crisis, intraoperative parathyroid hormone monitoring, multiple endocrine neoplasia, normocalcemic primary hyperparathyroidism, parathyroid adenoma, parathyroid hyperplasia, primary hyperparathyroidism, sestamibi scan

Primary Hyperparathyroidism

Primary hyperparathyroidism is defined. Key components of the diagnostic work-up including symptoms, family history, laboratory examination, and imaging techniques are reviewed. Indications for surgery, including a discussion of the latest guidelines, are emphasized. Controversies such as when to operate on asymptomatic primary hyperparathyroidism are discussed. This review contains 4 figures, 1 table, and 29 references. Key Words: hypercalcemia, hypercalcemic crisis, intraoperative parathyroid hormone monitoring, multiple endocrine neoplasia, normocalcemic primary hyperparathyroidism, parathyroid adenoma, parathyroid hyperplasia, primary hyperparathyroidism, sestamibi scan

Operative Approach to Primary Hyperparathyroidism

We review the key components of the embryology and anatomy of the parathyroid glands. Here, minimally invasive parathyroidectomy with intraoperative adjuncts such as intraoperative parathyroid hormone monitoring, four-gland exploration, subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and cyropreservation are described. The incidence of postoperative complications and the technical aspects of parathyroid surgery are delineated. This review contains 3 figures, 1 tables, and 17 references. Key Words: cryopreservation, hyperparathyroidism, minimally invasive parathyroidectomy parathyroidectomy, pharyngeal pouch, recurrent laryngeal nerve, subtotal parathyroidectomy, total parathyroidectomy

Operative Approach to Primary Hyperparathyroidism

We review the key components of the embryology and anatomy of the parathyroid glands. Here, minimally invasive parathyroidectomy with intraoperative adjuncts such as intraoperative parathyroid hormone monitoring, four-gland exploration, subtotal parathyroidectomy, total parathyroidectomy with autotransplantation, and cyropreservation are described. The incidence of postoperative complications and the technical aspects of parathyroid surgery are delineated. This review contains 3 figures, 1 tables, and 17 references. Key Words: cryopreservation, hyperparathyroidism, minimally invasive parathyroidectomy parathyroidectomy, pharyngeal pouch, recurrent laryngeal nerve, subtotal parathyroidectomy, total parathyroidectomy

Intraoperative Parathyroid Hormone Monitoring in the Surgical Management of Sporadic Primary Hyperparathyroidism.

Intraoperative parathyroid hormone monitoring (IPM) has been shown to be a useful adjunct during parathyroidectomy to ensure operative success at many specialized medical centers worldwide. Using the Miami or “>50% intraoperative PTH drop” criterion, IPM confirms the complete excision of all hyperfunctioning parathyroid tissue before the operation is finished, and helps guide the surgeon to identify additional hyperfunctioning parathyroid glands that may necessitate further extensive neck exploration when intraoperative parathyroid hormone (PTH) levels do not drop sufficiently. The intraoperative PTH assay is also used to differentiate parathyroid from non-parathyroid tissues during operations using fine needle aspiration samples and to lateralize the side of the neck harboring the hypersecreting parathyroid through differential jugular venous sampling when preoperative localization studies are negative or equivocal. The use of IPM underscores the recognition and understanding of sporadic primary hyperparathyroidism (SPHPT) as a disease of function rather than form, where the surgeon is better equipped to treat such patients with quantitative instead of qualitative information for durable long-term operative success. There has been a significant paradigm shift over the last 2 decades from conventional to focused parathyroidectomy guided by IPM. This approach has proven to be a safe and rapid operation requiring minimal dissection performed in an ambulatory setting for the treatment of SPHPT.

Minimally invasive parathyroidectomy in a community based teaching hospital: The role of dual-phase parathyroid scintigraphy and surgeon experience

Aim: In a community based teaching hospital setting, to explore role of dual-phase parathyroid scintigraphy and surgeon experience in minimally invasive parathyroidectomy.Material and Methods: During 4-year period, from January 2013 to December 2016, 136 of 170 patients those were diagnosed with primary hyperparathyroidism were selected for this retrospective study. For detection of hyper-functioning parathyroid tissue, routine neck ultrasound and 99mTc-MIBI dual phase parathyroid scintigraphy were performed. All scintigraphy scans were evaluated by nuclear medicine physicians and surgeons together. Patients with suspected multiglandular diseases and familial cases were excluded. Enlarged glands were identified by surgeons intraoperatively. Specimens were sent for frozen section analysis.Results: Without using intraoperative parathormone monitoring or gamma probe, combination of neck ultrasound, surgeon-nuclear physician evaluated parathyroid scintigraphy scan and resection of surgeon-identified diseased gland resulted in 100% cure rate for this group of patients. Conclusion: Operative experience of surgeon and review of preoperative parathyroid scintigraphy scan had remarkable impact on outcomes. Minimally invasive parathyroidectomy can be held successfully at community-based hospitals under specific conditions without using intraoperative parathormone or gamma probe.

Additional 20-Minute Intraoperative Parathormone Measurement Can Minimize Unnecessary Bilateral Neck Exploration

BackgroundParathyroidectomy guided by intraoperative parathormone (ioPTH) monitoring for primary hyperparathyroidism (pHPT) confirms removal of all hyperfunctioning parathyroid glands. This study evaluates the utility of an additional 20-min ioPTH measurement in patients who fail to meet the >50% ioPTH drop criterion. MethodsA retrospective review of prospectively collected data of 706 patients with pHPT who underwent parathyroidectomy guided by ioPTH monitoring was performed. When a >50% ioPTH decrease from the highest either preincision or preexcision level was achieved after 10 min, parathyroidectomy was completed. If this criterion was not met, further exploration was performed or an additional 20-min ioPTH measurement was obtained. ResultsOf 706 patients, 72 (10%) patients did not meet the >50% ioPTH drop criterion at 10 min. Of these patients, 67% (48/72) underwent immediate bilateral neck exploration (BNE). For the other 33% of patients (24/72), a 20-min parathormone (PTH) measurement was drawn. Of patients with an additional 20-min PTH measurement, 46% (11/24) had a >50% ioPTH decrease at 20 min where BNE was avoided and parathyroidectomy completed, whereas 54% (13/24) did not. Compared to patients with insufficient ioPTH drop at 10 min and subsequent BNE, there was a statistically significant 46% reduction of BNE in patients with a 20-min PTH level (P < 0.01). ConclusionsA 20-min ioPTH measurement is useful in preventing unnecessary BNE in some patients who undergo focused parathyroidectomy with a delayed >50% ioPTH drop.

Stricter ioPTH criterion for successful parathyroidectomy in stage III CKD patients with primary hyperparathyroidism

The effects of underlying renal insufficiency on intraoperative parathormone monitoring during parathyroidectomy (PTX) for primary hyperparathyroidism remain unclear. This study evaluates operative outcomes in patients undergoing parathyroidectomy using classic or stricter >50% intraoperative parathormone decrease criterion for primary hyperparathyroidism with mild or moderate renal insufficiency. A retrospective review of prospectively collected data in 577 patients undergoing parathyroidectomy guided by intraoperative parathormone monitoring for primary hyperparathyroidism was performed. Patients were stratified by stages I to III of chronic kidney disease; those with overt secondary hyperparathyroidism (chronic kidney disease stages IV and V) were excluded. Patients were further subdivided into subgroups based on the classic criterion of a >50% intraoperative parathormone decrease and a stricter criterion of a >50% intraoperative parathormone decrease e to a normal range (<65 pg/mL). Long-term operative outcomes were compared across the 3 chronic kidney disease groups. Of 577 patients, 38% (221) had normal renal function or stage I chronic kidney disease, 44% (251) had stage II chronic kidney disease, and 18% (105) had stage III chronic kidney disease. In stages I and II chronic kidney disease patients, there were no differences in operative success, failure, recurrence, bilateral neck exploration, and multiglandular disease between classic and stricter criterion groups. In contrast, in stage III chronic kidney disease patients, operative success was greater using the stricter intraoperative parathormone criterion than the classic intraoperative parathormone criterion (100% vs 92%, respectively, P < .05). No other outcome differences were identified between classic and stricter intraoperative parathormone criterion subgroups in stage III chronic kidney disease patients. In patients with primary hyperparathyroidism and concurrent stage III chronic kidney disease, a stricter criterion of a >50% intraoperative parathormone decrease to a normal range should be used for successful parathyroidectomy.

Applicability of ashortened interpretation model for intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism in an endemic goiter region.

SummaryBackgroundIn primary hyperparathyroidism (pHPT), quick intraoperative parathyroid hormone monitoring (IOPTH) is performed to predict complete excision of hyperfunctioning tissue and therefore cure. In recent years, efforts have been made to make this prediction more accurate and to shorten the duration of the test, respectively, and therefore reduce waiting and total operating time. The aim of this study was to evaluate the practicability and safety of a time-reduced criterion (decline ≥ 35% after 5 min) in a large cohort of patients.MethodsIn an 11-year period, all patients operated for pHPT were analyzed. After preoperative localization studies, hyperfunctioning parathyroid tissue was removed and IOPTH monitoring was performed. Intraoperatively, a decline of ≥50% from baseline 10 min after excision of the gland predicted cure. The performance of an interpretation model, using an earlier PTH level was analyzed retrospectively (decline ≥ 35% from baseline 5 min after excision). Differences in sensitivity, specificity, positive/negative predictive value and accuracy were calculated.ResultsAccording to the inclusion criteria, 1018 patients were analyzed. IOPTH predicted cure in 854 patients (83.9%) 10 min after gland excision with a false positive decline in 13 patients (1.5%). Applying the modified criterion (≥35% decline within 5 min), 814 patients (80%) showed an appropriate decline (false positive in 18 [2.2%]). Overall, multiple gland disease would have been missed in 7 patients. McNemar’s test showed a significantly lower sensitivity, specificity and accuracy applying the “35%” criterion.ConclusionsIn an endemic goiter region, a criterion, demanding a ≥ 35% decline 5 min after excision can not be recommended for IOPTH monitoring in patients with pHPT.

Targeted surgical parathyroidectomy in end-stage renal disease patients and long-term metabolic control: A single-center experience in the current era.

The long-term results of surgical parathyroidectomy (PTX) in end-stage renal disease (ESRD) patients are less well known in the modern era of newer activated vitamin-D analogs, calcimimetics and intraoperative monitoring of parathyroid hormone (PTH). We performed a retrospective chart review of all ESRD patients undergoing PTX at the University of Mississippi Medical Center between January 2005 and August 2011, with follow-up data as available up to 4 years. All PTXs were performed with intraoperative second-generation PTH monitoring and targeted gland size reduction. The cohort (N = 37) was relatively young with a mean (±SD) age of 48.4 ± 13.9. 94.6% of the subjects were African American and 59.5% female. Preoperatively, 45.9% received cinacalcet (CNC) at a mean dose of 63.5 ± 20.9 mg. The size of the largest removed glands measured 1.7 ± 0.8 cm and almost all (94.6%) glands had hyperplasia on histology. The mean length of inpatient stay was 5.5 ± 2.4 days. Preoperative calcium/phosphorus measured 9.6 ± 1.2/6.6 ± 1.7 mg/dL with PTH concentrations of 1589 ± 827 pg/mL. Postoperative PTH values measured 145.4 ± 119.2 pg/mL. Preoperative PTH strongly correlated (P < 0.0001) with both alkaline phosphatase (ALP) levels (r: 0.596) and the number of inpatient days (r: 0.545), but not with CNC administration. Independent predictors for the duration of hospitalization were preoperative ALP (beta 0.469; P = 0.001) and age (beta -0.401; P = 0.005) (R2 0.45); for postoperative hypocalcemia, age (beta: -0.321; P = 0.006) and preoperative PTH (beta: 0.431; P = 0.036) were significant in linear regression models with stepwise selection. Gland-sparing PTX achieved acceptable control of ESRD-associated hyperparathyroidism in most patients from a socioeconomically challenged, underserved population of the United States.

Clinical usefulness of intraoperative parathyroid hormone monitoring for primary hyperparathyroidism

PurposeThe availability of intraoperative parathyroid hormone (IOPTH) monitoring allows successful focused parathyroidectomy for primary hyperparathyroidism (pHPT). The objective of this study was to report our initial experience in IOPTH monitoring during parathyroid surgery for primary hyperparathyroidsim.MethodsBetween May 2011 and February 2013, 37 patients underwent focused parathyroidectomy due to pHPT. IOPTH monitoring based on Miami criteria was used to confirm complete excision of hyperfunctioning parathyroid gland during surgery. Medical records of patients were reviewed retrospectively.ResultsPreoperative mean maximal calcium level was 11.7 ± 0.9 mg/dL. Preoperative technetium (99mTc) sestamibi scan and ultrasonography identified 32 of 37 (86.5%) and 29 of 37 (78.4%) of abnormal parathyroid glands, retrospectively. Results of the 2 imaging modalities were discordant for 8 cases (21.6%). The mean pre-excision PTH level was 147.2 ± 201.5 pg/mL. At 5- and 10-minute post tumor resection, PTH levels were 65.3 ± 25.4 pg/mL and 47.5 ± 24.3 pg/mL, respectively. In all cases, IOPTH levels fell by at least 50% after removing all suspected abnormal glands. All patients had a successful return to normocalcemia after surgery (mean follow-up period: 60.2 ± 15.4 months).ConclusionSurgeon could confirm complete excision of abnormal hyperfunctioning parathyroid glands by IOPTH monitoring during surgery for pHPT. IOPTH monitoring can maximize performance of successful focused para thyroidectomy for pHPT, especially when preoperative imaging results are discordant.