Efficacy of intraoperative parathyroid hormone monitoring to predict success of parathyroidectomy for secondary hyperparathyroidism

Abstract

Purpose In secondary hyperparathyroidism (sHPT), it is unclear which criterion for intraoperative parathyroid hormone (ioPTH) decline performs best and whether ioPTH monitoring is sufficiently efficacious in predicting postoperative surgical cure by retrospective review. Methods In 80 parathyroidectomies for sHPT, patients with ioPTH monitoring and follow-up PTH assay were categorized into physiologically accepted and failed groups. Receiver operating characteristic (ROC) curves were used to identify the criterion with the best performance and to determine the regression equation for prediction of surgical success. Results There was a statistically significant difference in the percentage reduction of ioPTHs between the two groups (P < 0.05). With our criterion, cure was predicted with a sensitivity of 86% and specificity that could be improved to 60% using an 85% ioPTH decrease as cut-off level when this value was compared to the Miami Criterion. There was a slightly negative correlation between the natural logarithm of percentage reduction of ioPTH and percentage reduction of PTH at follow-up (R 2 = 0.109, P = 0.003). Conclusion ioPTH measurements are a useful tool for improvement of the cure rate of operations for sHPT. Because this study aimed at 40 minutes (ioPTH3) as an optimal process in the operation, we recommend using a criterion of more than 85% ioPTH decline at 40 minutes by use of the ROC curve, and the use of the presently calculated regression equation may enable prediction of success.

Intrathyroidal parathyroid hyperplasia in tertiary hyperparathyroidism

“…These efforts are not commonly used. It is known that intraoperative iPTH monitoring is a good predictor of a successful parathyroidectomy in secondary hyperparathyroidism [10]. In our case, we knew that immediate parathyroidectomy had failed though intraoperative iPTH monitoring and frozen biopsy.…”

Tratamiento quirúrgico del hiperparatiroidismo asociado a insuficiencia renal crónica: Experience in 71 patients

“…En nuestros pacientes, una caída de PTHop ≥ 75% del valor basal, predijo curación en 98% y en 100% de los casos de HPT 2° e HPT 3° respectivamente. Sin embargo, con la evidencia actualmente disponible, no existe consenso sobre el nivel de descenso de PTHop asociado a éxito de la cirugía ni a predicción de curación posterior en pacientes con HPT renal [8][9][10][11] .…”

“…En el caso del HPT 3°, la cirugía es el tratamiento de elección 4 . La medición de PTH intraoperatoria (PTHop), método ampliamente validado en la cirugía de pacientes con HPT primario, está menos estudiada en este tipo de pacientes [8][9][10][11] . Nuestro objetivo primario fue evaluar la presentación clínica y resultados del tratamiento quirúrgico de los pacientes con HPT 2° y terciario operados en nuestra institución.…”

Intraoperative Parathyroid Hormone Testing: Who Should Be the Target?

“…Gasparri et al [60] found iPTH to be a useful adjunct to MIBI and parathyroid weight in these patients by helping the surgeon to know that no ectopic tissue is present (i.e., if after removing four glands, iPTH remains elevated, the surgeon should search for an additional gland). Kim et al [21] recommend an 85 % decline from baseline at 40 min post-subtotal thyroidectomy for the best prediction of cure, while Sharma et al [61] advocate a near-total parathyroidectomy, leaving a vascularized remnant of one gland that approximates the size of two normal parathyroid glands and aims for an absolute final iPTH level of 100 pg/mL.…”

“…Others conclude that when MIBI alone localizes a single adenoma, iPTH does not add value [18]. Still others argue in favor of routine bilateral exploration [19,20], and others have explored its use in secondary and tertiary hyperparathyroidism [21,22].…”