The Value of Intraoperative Parathyroid Hormone Monitoring in Localized Primary Hyperparathyroidism: A Cost Analysis

Background  

Minimally invasive parathyroidectomy (MIP) is the preferred approach to primary hyperparathyroidism (PHPT) when a single adenoma can be localized preoperatively. The added value of intraoperative parathyroid hormone (IOPTH) monitoring remains debated because its ability to prevent failed parathyroidectomy due to unrecognized multiple gland disease (MGD) must be balanced against assay-related costs. We used a decision tree and cost analysis model to examine IOPTH monitoring in localized PHPT.     

Prospective Evaluation of the Rate and Impact of Hemolysis on Intraoperative Parathyroid Hormone (IOPTH) Assay Results

Background  

Intraoperative parathyroid hormone (IOPTH) is commonly used during minimally invasive parathyroidectomy. Retrospective evidence suggested that hemolysis may artificially lower IOPTH results. Falsely decreased IOPTH measurements could result in either failed parathyroidectomy or unnecessary bilateral neck exploration.     

The impact of vitamin D status and tumor size on the intraoperative parathyroid hormone dynamics in patients with symptomatic primary hyperparathyroidism

Purpose

The intraoperative parathyroid hormone (IOPTH) monitoring is a useful adjunct for predicting whether a cure has been obtained during parathyroidectomy. We studied the influence of vitamin D status and parathyroid tumor weight on the IOPTH dynamics for predicting a cure in patients with symptomatic primary hyperparathyroidism.

Methods

Fifty-nine primary hyperparathyroidism patients with a single adenoma underwent curative surgery. Patients were grouped according to their serum 25-hydroxy vitamin D levels (deficient, insufficient and sufficient) and tumor weights (small, large and giant). The IOPTH results in patient groups were compared, and the percentage of the IOPTH decrease was examined for a correlation with the serum 25-hydroxy vitamin D level and tumor weight.

Results

The sensitivity, specificity and overall accuracy of IOPTH in predicting a cure of hyperparathyroidism were 94.8, 100 and 93.2%, respectively. The percentage decrease in the IOTPH was significantly higher in the vitamin D deficient, compared to the vitamin D sufficient patients (p?=?0.012); and in the patients with larger tumors, compared to those with smaller parathyroid tumors (p?=?0.02). A statistically significant correlation was found between the percentage decrease in the IOPTH at 10?min post-tumor excision and the serum 25-hydroxy vitamin D level (p?=?0.037), but not with the tumor weight (p?=?0.208).

Conclusions

The IOPTH can accurately predict a cure in patients with severe primary hyperparathyroidism. The percentage of decrease in the IOPTH is steeper in patients with lower serum 25-hydroxy vitamin D levels and larger parathyroid tumors.     

A spike in parathyroid hormone during neck exploration may cause a false-negative intraoperative assay result

HYPOTHESIS: We hypothesize that false-negative results using the rapid intraoperative parathyroid hormone (IOPTH) assay can be caused by spikes in the level of parathyroid hormone that occur during mobilization of the adenoma. DESIGN: Retrospective analysis of a case series. SETTING: University tertiary care center. PATIENTS: Ten consecutive patients with primary hyperparathyroidism. INTERVENTIONS: All patients underwent neck exploration with IOPTH monitoring. Using a sampling protocol described in the literature, IOPTH values were checked at the time of incision, during mobilization of the adenoma, and 10 minutes after resection of the adenoma. MAIN OUTCOME MEASURES: Patients were evaluated for adequate parathyroid tissue excision as determined by IOPTH levels and examination of ipsilateral glands. All patients had normal serum calcium values documented postoperatively. Parathyroid hormone half-life was calculated assuming first-order kinetic decay. RESULTS: Nine patients had an appropriate decline in IOPTH with a mean +/- SD parathyroid hormone half-life of 3.9 +/- 1.08 minutes. Mobilization of the adenoma resulted in a spike in the IOPTH value, with 1 patient's value increasing from a baseline of 95.5 pg/mL (10.1 pmol/L) to 751 pg/mL (79.1 pmol/L). Another patient who was confirmed to have a solitary adenoma had a false-negative postexcision value. A spike in IOPTH that occurred during neck dissection was not detected by the sampling protocol and explains the false-negative value. A literature review revealed that most protocols check baseline values early in the operation and are at risk for false-negative results due to a spike from mobilization of the adenoma. CONCLUSIONS: These data demonstrate that false-negative IOPTH assay findings can result from a spike in parathyroid hormone level during exploration, which may go unrecognized if baseline values are measured during the early stages of mobilization of the adenoma. We have altered our assay protocol and have begun measuring IOPTH at the time of neck incision, at the time the adenoma is completely removed (time zero [t(0)]), and 10 minutes after excision.     

Parathyroidectomy for primary hyperparathyroidism: A retrospective analysis of localization,surgical characteristics,and treatment outcomes

ObjectiveTo evaluate parathyroidectomy for primary hyperparathyroidism (PHPT) regarding localization, surgical characteristics, and treatment outcomes.MethodsSeventy-eight patients who underwent parathyroidectomy for PHPT were retrospectively reviewed. The results were analyzed according to intraoperative localization technique (IOLT), intraoperative parathyroid hormone (IOPTH) monitoring, and intraoperative nerve monitoring (IONM). The localization accuracy of ultrasonography (US), computed tomography (CT), and single-photon emission computed tomography (SPECT)-CT with sestamibi Tc99m was evaluated.ResultsParathyroidectomy was successfully completed in all 78 patients, achieving 100% surgical cure. For 60 patients with IOPTH monitoring, 10-min IOPTH decreased >50% from baseline in 57 (95.0%), and they achieved surgical cure. In the remaining three (5.0%) patients with ≤50% decrease in 10-min IOPTH, 20-min IOPTH decreased >50% from baseline in two (3.3%) patients, achieving surgical cure without additional neck exploration. There were no differences in surgical cure and complications as a function of IOLT use or IOPTH monitoring. Operating time was significantly shorter with IOLT and IOPTH monitoring than without (IOLT: 70.9 min vs. 88.0 min, p = 0.013; IOPTH: 74.9 min vs. 91.9 min, p = 0.037). All 78 patients had adenoma including one patient with a double adenoma. Vocal cord paralysis was not observed in our series, regardless of IONM. US, CT, and SPECT-CT localized the pathological parathyroid gland accurately in 88.1%, 85.5%, and 86.8% of patients, respectively (p = 0.894).ConclusionThe surgical outcomes of parathyroidectomy for PHPT were excellent regardless of IOLT and IOPTH monitoring. However, these techniques can maximize the performance of parathyroid surgery by reducing operating time and rescuing challenging cases.     

Operative Failure in Minimally Invasive Parathyroidectomy Utilizing an Intraoperative Parathyroid Hormone Assay

Background

Minimally invasive parathyroidectomy (MIP) is a targeted operation to cure primary hyperparathyroidism utilizing intraoperative parathyroid hormone monitoring (IOPTH). The purpose of this study was to quantify the operative failure of MIP.

Methods

Utilizing institutional parathyroid surgery database, demographic, operative, and biochemical data were analyzed for successful and failed MIP. Operative failure was defined as <6 months of eucalcemia after operation.

Results

Five hundred thirty-eight patients (96.6 %) had successful MIP with mean follow-up of 13 months, and 19 (3.4 %) had operative failure. The major cause of operative failure (11 of 19) was the result of surgeons’ inability to identify all abnormal parathyroid glands. The remaining eight operative failures were the result of falsely positive IOPTH results. Eleven of 19 patients whose MIP had failed underwent a second parathyroid surgery. All but one of these patients achieved operative success, and 9 patients had missed multigland disease. Only 46 (8.3 %) of 557 patients had conversion to bilateral cervical exploration (BCE). Eighty percent of patients had more than 70 % IOPTH decrease, and all had successful operations. Patients with a marginal IOPTH decrease (50–59 %) had a treatment failure rate of 20 %.

Conclusions

The most common cause of operative failure in MIP utilizing IOPTH was the result of surgeons’ failure to identify all abnormal parathyroid glands. Falsely positive IOPTH is rare, and a targeted MIP utilizing IOPTH can achieve an excellent operative success rate without routine BCE. Selective BCE on patients with marginal IOPTH decrease may improve surgical outcome.     

Estudios preoperatorios coincidentes para el diagnóstico de hiperparatiroidismo primario por adenoma simple: ¿podemos evitar la PTH intraoperatoria?

IntroductionWe aim to determine the utility of intraoperative parathyroid hormone (IOPTH) monitoring in patients with matching preoperative ultrasound and mibi SPECT for primary hyperparathyroidism for a single adenoma.MethodsAll patients who underwent minimally invasive parathyroidectomy (MIP) for pseudohypoparathyroidism (PHP) for a single parathyroid adenoma, were included. An Ultrasound and mibi SPECT were performed in all patients. We defined matching studies when both coincided in the localization of the adenoma. IOPTH was performed in all patients and analyzed in three occasions: a baseline measurement at the anesthetic induction, immediately before, and 15 minutes after gland excision. Success was defined during the third measurement as a drop of IOPTH of at least 50%compared to the previous maximum value after gland excision. Demographics, intraoperative, postoperative variables and the utility of IOPTH monitoring were analyzed.ResultsA total of 218 MIP were performed. The average age was 60.1 years and 85% were female. Preoperative ultrasound and mibi SPECT coincided 100%. When the adenoma was localized, 15 minutes after its excision, IOPTH did not decrease in 9 patients (4.2% OR 1.9% - 7.69%); all of them underwent a bilateral neck exploration. The added-value of IOPTH accuracy for disease cure was 3.6%. There was a 99% of cure rate. The mean surgical time was 66.4 minutes and the waiting time for the third IOPTH result was 31minutes. Performing IOPTH monitoring made the surgery about twice more expensive.ConclusionsPreoperative matching ultrasound and mibi SPECT for parathyroid adenoma localization in PHP, could avoid IOPTH monitoring in minimally invasive parathyroidectomies.     

Intraoperative PTH May Not Be Necessary in the Management of Primary Hyperparathyroidism Even with Only One Positive or Only Indeterminate Preoperative Localization Studies

Background

Intraoperative PTH (IOPTH) monitoring has been widely used to confirm the removal of the culprit lesion during operation. However, the true benefit of IOPTH in patients with preoperatively well-localized single adenoma has been questioned. The aim of this study was to examine how or if IOPTH changes the surgical management and outcomes in patients with only one positive or only indeterminate localization studies.

Methods

This is a retrospective review of data from a parathyroid surgery database and patient records from July 2004 to June 2014, including patients with primary hyperparathyroidism with a planned MIP by two experienced endocrine surgeons after ≥1 positive/indeterminate preoperative localization study by ultrasound and/or sestamibi.

Results

A total of 482 patients with positive (342: 259 only 1, 83 with ≥2) or indeterminate (140: 105 only 1, 35 with ≥2) preoperative imaging studies were included. IOPTH changed the management in only 16 (3%) patients, with an additional lesion found in 12 of them. Surgical cure was achieved in 471 (98%) of patients (98% in the positive vs. 97% in the indeterminate group, p 0.58). With or without IOPTH, the cure rate would not have been significantly different in patients with only 1 positive preoperative imaging (96 vs. 98%, p 0.12). Similar results were seen in those with ≥2 indeterminate (100% cure rate with or without IOPTH).

Conclusion

Our study suggests that MIP may be safely and successfully performed without IOPTH for patients with ≥1 positive or ≥2 indeterminate preoperative imaging studies. This study is retrospective within inherent biases, and future prospective study is warranted.

     

Does the Final Intraoperative PTH Level Really Have to Fall into the Normal Range to Signify Cure?

Background

Intraoperative parathyroid hormone (IOPTH) helps shorten the duration of surgery and increase the likelihood of surgical cure. Although general consensus agrees that the IOPTH should fall by 50%, there is much debate as to whether the IOPTH needs to fall into the normal range.

Methods

We retrospectively reviewed a prospective database of patients undergoing surgery for treatment of primary hyperparathyroidism. We included all patients with an IOPTH that fell by >50% by 10 or 15?min, but that did not fall into the normal range (parathyroid hormone remained ??60?pg/ml). We excluded patients who had undergone prior neck surgery or had known multiple endocrine neoplasia 1 or 2.

Results

A total of 1,231 patients underwent a parathyroidectomy, 155 of whom met the study??s inclusion/exclusion criteria (12.6%). A total of 117 patients had an IOPTH fall by 50% by 10?min, and 38?patients?? IOPTH fell by 50% by 15?min. Overall surgical cure rate was 98.7%. One patient from the 10-minute group and one patient from the 15-minute group had persistent disease on follow-up. One patient in the 15-minute group had recurrent disease. With a mean?±?SEM 18.1?±?2.1?months?? follow-up, the recurrence rate in this cohort was 0.6%. The average calcium at last follow-up was 9.4?±?0.0?mg/dl.

Conclusions

Allowing the IOPTH to fall by 50% by 15?min, regardless of whether the IOPTH falls into the normal range, results in a high success rate when performed by experienced surgeons. This helps reduce intraoperative time used waiting for additional parathyroid hormone levels and the risks associated with unnecessary bilateral neck exploration.     

Feasibility of Rapid Parathormone Assay for Enabling Minimally Invasive Parathyroid Excision

There is no doubt that the success of minimally invasive parathyroidectomy (MIP) has changed the whole treatment of patients with primary hyperparathyroidism, especially the approach towards traditional bilateral neck exploration. A single adenoma is the most common cause of primary hyperparathyroidism and its removal results in cure. Hence, it is worth the effort to localise and excise the single adenoma using modern technologies such as high-quality sestamibi scans and to confirm complete excision using rapid intra operative parathormone (IOPTH) assays. The objective of the study was to evaluate the feasibility of rapid IOPTH assay in successfully facilitating minimally invasive parathyroid excision. This research involved the retrospective study of seven patients, who underwent MIP at Sagar Hospital in Bengaluru, India, for parathyroid adenoma. All patients with evidence of unifocal disease on sestamibi scanning and cervical ultrasonography, underwent MIP via 2–3 cm lateral incision. Blood samples for measurement of IOPTH were taken at the time of induction of anaesthesia and 10 min after the adenoma excision. Reduction of parathormone (PTH) levels of more than 50 % in the postexcision sample was taken as evidence for complete extirpation of parathyroid adenoma. A solitary adenoma was identified in all the seven patients. After MIP, IOPTH levels fell in six of the seven patients. Following the surgery, all the cases were followed up for a period of 1 month. During this time, except for one patient, six patients remained asymptomatic and blood tests revealed normal serum calcium levels. A histopathological examination confirmed the diagnosis of parathyroid adenoma in six of the seven patients. After accurate preoperative localisation of the adenoma in patients with primary hyperparathyroidism, MIP with IOPTH measurement offers a safe and successful outcome.     

Intraoperative Parathyroid Hormone Monitoring in Patients with Recognized Multiglandular Primary Hyperparathyroidism

Background  

Intraoperative parathyroid hormone (IOPTH) monitoring reliably predicts cure of primary hyperparathyroidism (PHPT) due to single-gland disease. However, its utility in PHPT caused by multiple-gland disease (MGD) is still debated, for both detection and prediction of adequate resection. Our hypothesis is that once MGD is encountered during an operation, more stringent criteria for determining adequate resection can improve cure rates.     

Utility of Intraoperative Parathyroid Hormone Monitoring in Patients with Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism Undergoing Initial Parathyroidectomy

Background

Intraoperative parathyroid hormone monitoring (IOPTH) is a widely used adjunct for primary hyperparathyroidism (pHPT). However, the benefit of IOPTH in familial pHPT, such as in multiple endocrine neoplasia type I (MEN1), remains unclear.

Methods

We performed a retrospective analysis of 52 patients with MEN1-associated pHPT undergoing initial parathyroidectomy with IOPTH monitoring at our institution. Parathyroid hormone (PTH) levels were measured before skin incision and 10 min after resection of the last parathyroid gland. Variables analyzed included percent drop of PTH from baseline and the final PTH level compared to the normal reference range (RR).

Results

A total of 52 patients underwent initial subtotal parathyroidectomy with IOPTH. An IOPTH decrease cutoff of ≥75 % from baseline had the highest biochemical cure rate (87 %). In the remaining 13 % who met this cutoff, all had persistent pHPT, with ≥90 % drop of PTH from baseline. The remaining patients, who did not meet the ≥75 % cutoff, were cured. Follow-up was available for three of four patients with final IOPTH levels above the RR: one had persistent pHPT, two had hypoparathyroidism (50 %). When a postresection PTH level was within the RR, 88 % of patients were cured. While considered cured from pHPT, 7 % of patients in this group developed permanent hypoparathyroidism. When the final PTH level dropped below the RR, 28 % developed permanent hypoparathyroidism.

Conclusions

A cutoff in IOPTH decrease of ≥75 % from baseline has the highest biochemically cure rate in patients with pHPT associated with MEN1. However, a 75 % cutoff in IOPTH decrease does not exclude persistent pHPT. The absolute IOPTH value does not accurately predict postoperative hypoparathyroidism.     

The Final Intraoperative Parathyroid Hormone Level: How Low Should It Go?

Background

In minimally invasive surgery for primary hyperparathyroidism (HPT), intraoperative parathyroid hormone (IOPTH) monitoring assists in obtaining demonstrably better outcomes, but optimal criteria are controversial.

Methods

The outcomes of 1,108 initial parathyroid operations for sporadic HPT using IOPTH monitoring from 1997 to 2011 were stratified by final post-resection IOPTH level. All patients had adequate follow-up to verify cure.

Results

With mean follow-up of 1.8 years (range 0.5–14.3 years), parathyroidectomy using IOPTH monitoring failed in 1.2 % of cases, with an additional 0.5 % incidence of long-term recurrence at a mean of 3.2 years (range 0.8–6.8 years) postoperatively. Operative success was equally likely with a final IOPTH drop to 41–65 pg/mL vs ≤40 pg/mL (p = 1). In the 76 patients with an elevated baseline IOPTH level that did not drop to ≤65 pg/mL, surgical failure was 43 times more likely than with a drop into normal range (13 vs. 0.3 %; p < 0.001). When the final IOPTH level dropped by >50 % but not into the normal range, surgical failure was 19 times more likely (3.8 vs. 0.2 %; p = 0.015). Long-term recurrence was more likely in patients with a final IOPTH level of 41–65 pg/mL than with a level ≤40 pg/mL (1.2 vs. 0; p = 0.016).

Conclusions

Adjunctive intraoperative PTH monitoring facilitates a high cure rate for initial surgery of sporadic primary hyperparathyroidism. A final IOPTH level that is within the normal range and drops by >50 % from baseline is a strong predictor of operative success. Patients with a final IOPTH level between 41–65 pg/mL should be followed beyond 6 months for long-term recurrence.     

Contemporary surgical treatment of primary hyperparathyroidism without intraoperative parathyroid hormone measurement

Introduction

Primary hyperparathyroidism (pHPT) is usually the result of a single adenoma that can often be accurately located preoperatively and excised by a focused operation. Intraoperative parathyroid hormone (IOPTH) measurement is used occasionally to detect additional abnormal glands. However, it remains controversial as to whether IOPTH monitoring is necessary. This study presents the results of a large series of focused parathyroidectomy without IOPTH measurement.

Methods

Data from 2003 to 2014 were collected on 180 consecutive patients who underwent surgical treatment for pHPT by a single surgeon. Preoperative ultrasonography and sestamibi imaging was performed routinely, with computed tomography (CT) and/or selective venous sampling in selected cases. The preferred procedure for single gland disease was a focused lateral approach guided by on-table surgeon performed ultrasonography. Frozen section was used selectively and surgical cure was defined as normocalcaemia at the six-month follow-up appointment.

Results

Focused surgery was undertaken in 146 patients (81%) and 97% of these cases had concordant results with two imaging modalities. In all cases, an abnormal gland was discovered at the predetermined site. Of the 146 patients, 132 underwent a focused lateral approach (11 of which were converted to a collar incision), 10 required a collar incision and 4 underwent a mini-sternotomy. At 6 months following surgery, 142 patients were normocalcaemic (97% primary cure rate). Three of the four treatment failures had subsequent surgery and are now biochemically cured. There were no complications or cases of persistent hypocalcaemia.

Conclusions

This study provides further evidence that in the presence of concordant preoperative imaging, IOPTH measurement can be safely omitted when performing focused parathyroidectomy for most cases of pHPT.     

Utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing in guiding patients with a negative sestamibi scan for minimally invasive parathyroidectomy—a randomized controlled trial

Background and aims  The purpose of this study was to determine the utility of bilateral internal jugular venous sampling with rapid parathyroid hormone assay (BIJV–IOPTH) in comparison to endocrine surgeon-performed ultrasonography of the neck as an alternative localizing modality in guiding patients with primary hyperparathyroidism (pHPT) and negative sestamibi scans for minimally invasive parathyroidectomy (MIP). Patients and methods  Seventy eight consenting patients with a negative subtraction sestamibi scan planned for parathyroidectomy underwent additional ultrasound parathyroid imaging and were randomized to undergo surgery without vs. with additional BIJV–IOPTH; n = 39 in each group. The patients with a positive alternative imaging test were qualified for video-assisted MIP, whereas the others underwent open neck explorations. The primary outcome measure was the number of patients with true-positive results of alternative imaging tests. Results  Of the 78 patients, 50 (64%) had a single adenoma, eight (10.3%) had double adenomas, and 20 (25.7%) demonstrated four-gland hyperplasia. Ultrasonography alone vs. combined with BIJV–IOPTH was true positive in detecting a solitary parathyroid adenoma in 8/24 (33.3%) vs. 17/26 (65.4%) patients, respectively (p = 0.023). Curative video-assisted MIP was successfully performed in all the patients with true-positive results. The remaining individuals were cured by more extensive open neck explorations (unilateral—4/39 vs. 4/39, respectively; p = 1.0 or bilateral—27/39 vs. 18/39, respectively; p = 0.039). Conclusions  Most patients with pHPT and a negative subtraction sestamibi scan (64%) have a single adenoma. BIJV–IOPTH as an addition to a surgeon-performed ultrasound of the neck allows for more accurate guiding for MIP in patients with a solitary parathyroid adenoma and negative subtraction sestamibi scans. Presented at the 3rd Workshop of the European Society of Endocrine Surgeons (ESES), “Modern techniques in primary hyperparathyroidism surgery: An evidence based perspective”, 19-21 of March 2009, Lund, Sweden. “Best of Endocrine Surgery in Europe 2009”     

Hemolysis falsely decreases intraoperative parathyroid hormone levels

Background

Intraoperative parathyroid hormone (IOPTH) measurement is used to confirm biochemical cure during parathyroidectomy. Falsely decreased IOPTH measurements could result in false-negative or false-positive results and lead to failed parathyroidectomy or unnecessary additional exploration.

Study design

The records of all patients who underwent parathyroidectomy with IOPTH between May and August 2007 were retrospectively reviewed, and the frequency of hemolysis of IOPTH samples was determined. Separately, 10 split-samples were hemolyzed using the freeze-thaw technique.

Results

Forty-seven patients underwent parathyroidectomy, and 226 IOPTH samples were sent. Seventeen (7.5%) specimens from 9 (18.8%) patients were hemolyzed. In 8 split-samples, the range of decrease caused by hemolysis was 24.5% to 53.8% compared with nonhemolyzed controls.

Conclusions

Hemolysis of IOPTH samples occurs commonly and falsely decreases IOPTH levels. Unrecognized hemolysis in pre-excision specimens could result in false-negative IOPTH results and lead to unnecessary continued exploration. Unrecognized hemolysis in postexcision specimens could lead to false-positive IOPTH results and lead to failed parathyroidectomy and the need for reoperation. Thus, hemolysis may be an easily preventable cause of erroneous IOPTH measurements.     

Molecular Genetics of Parathyroid Disease

Background  

Primary hyperparathyroidism (HPT) is often caused by a benign parathyroid tumor, adenoma; less commonly by multiglandular parathyroid disease/hyperplasia; and rarely by parathyroid carcinoma. Patients with multiple tumors require wider exploration to avoid recurrence and have increased risk for hereditary disease. Secondary HPT is a common complication of renal failure. Improved knowledge of the molecular background of parathyroid tumor development may help select patients for appropriate surgical treatment and can eventually provide new means of treatment. The present contribution summarizes more recent knowledge of parathyroid molecular genetics.     

Focused parathyroid surgery with intraoperative parathyroid hormone measurement as a day-case procedure

BACKGROUND: This study assessed the feasibility, efficacy and safety of focused parathyroidectomy combined with intraoperative parathyroid hormone (IOPTH) measurement in a day-case setting. METHODS: Over 28 months 50 consecutive patients (mean age 63 (range 33-92) years) with clear evidence of unifocal disease on sestamibi scanning or ultrasonography underwent unilateral neck exploration via a small lateral incision. Blood samples for measurement of IOPTH were taken at induction of anaesthesia, before adenoma excision and after adenoma excision (at 5, 10 and 20 min). Ten patients were discharged within 23 h and 40 patients on the day of surgery. RESULTS: A solitary adenoma was identified in all but one patient, with a mean operating time of 30 (range 16-57) min. After parathyroidectomy, IOPTH levels fell appropriately except in one patient with multiglandular hyperplasia. No patient developed symptomatic hypocalcaemia during the 2 weeks after operation, enabling cessation of oral supplements. All patients remained normocalcaemic on follow-up (mean 26 (range 8-84) weeks) and histological examination confirmed parathyroid adenoma (48 patients), hyperplasia (one) or carcinoma (one). CONCLUSION: After accurate preoperative localization of uniglandular disease, patients with primary hyperparathyroidism may be managed successfully and safely by focused parathyroidectomy with IOPTH measurement as a day-case procedure.     

Radio-guided parathyroidectomy in patients with primary hyperparathyroidism and concomitant multinodular goiter

Purpose  

We investigated possible instances where the standard bilateral neck exploration for parathyroid adenoma may be omitted in primary hyperparathyroidism (pHPT) if preoperative diagnostics for the location have been performed.     

A successful application of the intraoperative parathyroid hormone assay in tertiary hyperparathyroidism

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.