Justified Follow-Up: A Final Intraoperative Parathyroid Hormone (ioPTH) Over 40 pg/mL is Associated with an Increased Risk of Persistence and Recurrence in Primary Hyperparathyroidism

Abstract

Introduction After parathyroidectomy for sporadic primary hyperparathyroidism (PHPT), overall rates of persistence/recurrence are extremely low. A marker of increased risk for persistence/recurrence is needed. We hypothesized that final intraoperative parathyroid hormone (FioPTH) ≥40 pg/mL is indicative of increased risk for disease persistence/recurrence, and can be used to selectively determine degree of follow up. Method A retrospective review of PHPT patients undergoing parathyroidectomy with ioPTH monitoring was performed. An ioPTH decline of 50% was the only criteria for operation termination. Patients were grouped based on FioPTH of <40pg/mL, 40 to 59, and >60. Results Between 2001 and 2012, 1371 patients were included. Mean age was 61±0.4 years.78% were female. Overall persistence rate was 1.4%, with 2.9% recurrence rate. 976 (71%) had FioPTH<40, 228 (16.6%) had FioPTH 40-59, and 167 (12.2%) had FioPTH≥60. Mean follow-up was 21±0.6 months. FioPTH<40 were younger, with lower preoperative serum calcium, PTH and creatinine (all p≤0.001). FioPTH<40 had the lowest persistence rate (0.2%) versus FioPTH 40-59 (3.5%) or FioPTH≥60 (5.4%, p<0.001). Recurrence rate was also lowest in FioPTH<40 (1.3% vs. 5.9% vs. 8.2% respectively, p<0.001). Disease free status was greatest in FioPTH<40 at 2 years (98.5% vs. 96.8% vs. 90.5%) and 5 years (95.7% vs. 72.3% vs. 74.8%, p<0.01). Conclusion Patients with FioPTH<40 pg/mL had lower rates of persistence and recurrence, than FioPTH 40-59, or ≥60. Differences became more apparent after 2 years of follow-up. Patients with FioPTH ≥40 pg/mL warrant close and prolonged follow-up.

Simultaneous Incidental Parathyroid Carcinoma and Intrathyroid Parathyroid Gland in Suspected Renal Failure Induced Hyperparathyroidism

“…Rajaei et al followed PTH levels in 1,371 patients following parathyroidectomy, finding that patients with final intraoperative PTH levels of <40 pg/mL versus >60 pg/mL were more likely to be disease-free at 5 years, 95.7 versus 74.8%, respectively. 5 In our case, after identifying only three parathyroid glands following complete left central compartment exploration, and an initial 20-minute postresection intraoperative PTH level returned 179 PTH pg/mL, following this guideline, our index of suspicion for an intrathyroidal parathyroid gland was high. This led to our decision to perform a left thyroid lobectomy, which revealed the intrathyroid parathyroid, allowing for a successful completion of the case, marked by a final PTH level of 23 pg/mL.…”

Primer hiperparatiroidizmin cerrahi tedavisinde tek merkez deneyimi

“…Hatta Rajei ve ark. [20] tarafından yapılan çalışmada intraoperatif PTH >40 pg/dL'nin üzerinde olan hastaların ilk iki yıl içerisinde persistant hastalık veya rekürrens açısından yakın takip edilmesi gerektiği vurgulanmıştır.…”

Measurement of intact parathormone during operation for primary hyperparathyroidism

“…The blood sample is taken before the surgical incision and after the parathyroid gland removal (Riss et al, 2007a). Some authors report the association of intraoperative parathormone level over 4.24 pmol/ /mL with an increased risk of persistence and recurrence in primary hyperparathyroidism (Rajaei et al, 2015). The persistence of an increased intact parathormone has been reported to occur in 8-40 % of cases.…”