The Necessity and Reliability of Intraoperative Parathyroid Hormone (PTH) Testing in Patients with Mild Hyperparathyroidism and PTH Levels in the Normal Range

Alhefdhi, Amal; Pinchot, Scott N.; Davis, Ruth J.; Sippel, Rebecca S.; Chen, Herbert

doi:10.1007/s00268-011-1179-3

Cited by 26 publications

(49 citation statements)

References 16 publications

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“…There was a 96% cure rate approximately 9 months after surgery with normalized biochemical profiles. Similarly, Alhefdhi et al [25] reported on a series of 142 patients with NHHPT and found that 100% were cured with normal serum calcium after 6 months. Amin et al [38] demonstrated similar cure rates and complication rates for the classic and NHHPT groups.…”

Section: Persistence/recurrence Of Diseasementioning

confidence: 99%

“…50% drop from the highest ioPTH level at 10 minutes after gland excision and a final ioPTH level less than the preincision value [65], .50% drop from the highest ioPTH level at 10 minutes after gland excision and a final ioPTH level within the reference range [66], .50% drop after 5 minutes from highest ioPTH [67], and .50% drop in ioPTH from the preexcision level after 10 minutes [68]. Alhefdhi et al [25] did find that a 50% decline of the preincision value even of patients with NHHPT values is reliable 96.5% of the time, although it takes a longer period of time for this decline to occur in these patients, as well as NCHPT patients [26].…”

Section: Surgicalmentioning

confidence: 99%

“…Siperstein et al [39] NCHPT, intermittent hypercalcemic pHPT, and classic pHPT patients benefitted equally from surgery when comparing biochemical and symptom profiles. Alhefdhi et al [25] In patients who had NHHPT, a 50% decline in intraoperative PTH is reliable to predict a cure 96.5% of the time. In a series of 142 of these patients, 100% were cured with normal serum calcium 6 months after surgery.…”

Section: Persistence/recurrence Of Diseasementioning

confidence: 99%

“…Of all patients diagnosed with pHPT, 5%-28% have the mild form of the disease [19][20][21][22][23][24][25]. In a large series, the distribution of all patients with mild pHPT was 68.6% NHHPT and 31.4% NCHPT [26].The NIH has had three international workshops on asymptomatic hyperparathyroidism [10,27,28].…”

Section: Introductionmentioning

confidence: 99%

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Mild Primary Hyperparathyroidism: A Literature Review

Applewhite

Schneider

2014

The Oncologist

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The biochemical profile of classic primary hyperparathyroidism (pHPT) consists of both elevated calcium and parathyroid hormone levels. The standard of care is parathyroidectomy unless prohibited by medical comorbidities. Because more patients are undergoing routine bone density evaluation and neck imaging studies for other purposes, there is a subset of people identified with a biochemically mild form of the pHPT that expresses itself as either elevated calcium or parathyroid hormone levels. These patients often do not fall into the criteria for operation based on the National Institutes of Health consensus guidelines, and they can present a challenge of diagnosis and management. The purpose of this paper is to review the available literature on mild pHPT in an effort to better characterize this patient population and to determine whether patients benefit from parathyroidectomy. Evidence suggests that there are patients with mild pHPTwho have overt symptoms that are found to improve after parathyroidectomy. There is also a group of patients with biochemically mild pHPT who are found to progress to classic pHPT over time; however, it is not predictable which group of patients this will be. Early intervention for this group with mild pHPT may prevent progression of bone, psychiatric, and renal complications, and parathyroidectomy has proven safe in appropriately selected patients at high volume centers. The Oncologist 2014;19:919-929 Implications for Practice: Mild primary hyperparathyroidism (pHPT) is a disease that is being diagnosed with increased frequency; however, recommendations for treatment are not uniform. Current NIH guidelines do not recommend parathyroidectomy for these patients if they are asymptomatic; however, upon focused questioning, many of these patients are found to have subtle symptoms.The biochemically mild nature of the disease has been found to delay diagnosis and treatment, but after it is identified, surgery has shown to provide an improvement in quality of life and bone health. Although the current body of literature suggests that patients with mild pHPT benefit from parathyroidectomy, careful patient and surgeon selection is critical to ensuring safety and efficacy. Universal acceptance of parathyroidectomy in this subset of patients will require more high quality, prospective studies and improved definitions of long-term cure.

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Section: Persistence/recurrence Of Diseasementioning

confidence: 99%

Section: Surgicalmentioning

confidence: 99%

Section: Persistence/recurrence Of Diseasementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Mild Primary Hyperparathyroidism: A Literature Review

Applewhite

Schneider

2014

The Oncologist

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“…When PTH levels remain elevated after an excision of the suspected gland, a bilateral neck exploration may be necessary to locate the remaining hypersecreting tissue [56,57]. The IoPTH test is also reliable in mild cases, even if PTH is not elevated [59].…”

Section: Differential Diagnosis and Work-upmentioning

confidence: 99%

Current Concepts in the Presentation, Diagnosis and Management of Primary Hyperparathyroidism

Alhefdhi¹

2015

Surgery

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Review ArticleOpen Access IntroductionPrimary hyperparathyroidism (PHPT) is defined by an abnormal increase in the intrinsic activity of the parathyroid gland(s) that result in elevated parathyroid hormone (PTH) levels [1,2]. It is one of the most common endocrine disorders and is the most common cause of hypercalcemia. PHPT is one of the most common endocrine disorders and is the most common cause of hypercalcemia, which increases morbidity and mortality that result from cardiovascular, renal, and musculoskeletal pathologies. PHPT affects 1 in 500 females and 1 in 2,000 males aged >40 years, with a peak incidence in post-menopausal women. In the US, Europe, and Australia, the reported estimated incidence rates range from 25 to 30 per 100,000 person years, and the prevalence range from 1 to 21 per 1,000 individuals [1][2][3][4].PHPT has been a recognizable disease since the 1920s in both Europe and the US [5]. The first parathyroidectomy was performed in 1925 by Felix Mandl in Vienna, Austria; since then, the diagnosis and management of PHPT have progressed [5]. The purpose of this article is to review the current trends of PPT presentation, work-up, and management. Anatomy and PhysiologyHumans typically have four parathyroid glands located at the posterior capsule of the thyroid gland; in up to 15% of individuals have more than four and up to 3% have three identifiable glands [6]. The superior parathyroid glands arise from the IV pharyngeal pouch and migrate to the cephalad thyroid gland; they are usually located at the cricothyroid junction, 1 cm from the recurrent laryngeal nerve and the inferior thyroid artery. Inferior parathyroid glands arise from the III pharyngeal pouch and migrate caudally with the thymus; they are usually located on the posterolateral aspect of the inferior pole of the thyroid gland. Normal parathyroid glands are yellow or brown in color, oval in shape, 3-7 mm in length, and 30-40 mg in weight [7,8].A parathyroid gland consists of chief cells, oxyphilic cells, a thin fibrous capsule, and a network of adipose tissue, blood vessels, and glandular parenchyma [8]. Chief cells secrete PTH, which consists of 84 amino acid polypeptides. The normal serum PTH level range is 15-72 pg/mL, with a half-life of 2-4 min. Seventy percent of PTH metabolism occurs in the liver and 30% in the kidneys [9][10][11]. PTH is regulated by serum calcium, phosphorus, and vitamin D metabolites. The total normal calcium level should be 8.8-10.2 mg/dL (ionized calcium 2.2-2.6 mmol/L) to ensure optimum physiological functions [9][10][11]. PTH levels are inversely proportional to serum calcium levels, as high serum calcium levels decrease PTH release [5][6][7] and low serum calcium levels increase PTH secretion. This relationship enhances renal tubular calcium reabsorption, urinary phosphate excretion, osteoclastmediated bone resorption, and the conversion of 25-hydroxyvitamin D3 into 1,25-hydroxyvitamin D3, which increases calcium absorption from the bowel [9-11]. EtiologyNinety-five percent of PHPT cases are spora...

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Intraoperative Parathyroid Hormone Monitoring In Normohormonal Primary Hyperparathyroidism: How Low Do You Go?

Law,

Larrabee,

Stefan

et al. 2023

The Laryngoscope

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ObjectiveThe primary goal of this study was to determine in patients with normohormonal primary hyperparathyroidism (NHHPT) what percent reduction in post‐excision intraoperative parathyroid hormone (IOPTH) from baseline would yield a rate of cure comparable to that in patients with classical primary hyperparathyroidism (PHPT).MethodsThis is a retrospective cohort study of patients who underwent parathyroidectomy between July 2013 and February 2020. Demographic data, preoperative, intraoperative, and postoperative metrics were collected. Patients with NHHPT were compared to those with classical PHPT. Subgroup analyses were performed.ResultsOf the 496 patients included in the study, 66 (13.3%) were of the normohormonal variant based on preoperative intact parathyroid hormone (PTH) levels and 28 (5.6%) based on baseline IOPTH levels. The cure rates in the two normohormonal groups were not significantly different from their classical counterparts (98.4% and 100.0% vs. 97.1%, p = 1.000). The median percent decline in post‐excision IOPTH from baseline that achieved cure in the normohormonal groups were 82.6% and 80.4% compared to their respective controls at 87.3%, p = 0.011 and p = 0.001. Although the rate of multiglandular disease was higher in one of the normohormonal variant groups, this difference was due to a higher rate of double adenomas, not four‐gland hyperplasia.ConclusionPatients with NHHPT undergoing parathyroidectomy can expect cure rates similar to that in patients with classical PHPT. The results of this study indicate that achieving an 80% drop or more in IOPTH levels predicts a high likelihood of cure. This is true irrespective of whether the patient is deemed normohormonal based on preoperative or intraoperative testing.Level of EvidenceLevel 3 Laryngoscope, 2023

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The Necessity and Reliability of Intraoperative Parathyroid Hormone (PTH) Testing in Patients with Mild Hyperparathyroidism and PTH Levels in the Normal Range

Cited by 26 publications

References 16 publications

Mild Primary Hyperparathyroidism: A Literature Review

Mild Primary Hyperparathyroidism: A Literature Review

Current Concepts in the Presentation, Diagnosis and Management of Primary Hyperparathyroidism

Intraoperative Parathyroid Hormone Monitoring In Normohormonal Primary Hyperparathyroidism: How Low Do You Go?

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