Impact of autofluorescence for detection of parathyroid glands during thyroidectomy on postoperative parathyroid hormone levels: parallel multicentre randomized clinical trial

Abstract

Background Techniques for autofluorescence have been introduced to visualize the parathyroid glands during surgery and to reduce hypoparathyroidism after thyroidectomy. Methods This parallel multicentre RCT investigated the use of Fluobeam® LX to visualize the parathyroid glands by autofluorescence during total thyroidectomy compared with no use. There was no restriction on the indication for surgery. Patients were randomized 1 : 1 and were blinded to the group allocation. The hypothesis was that autofluorescence enables identification and protection of the parathyroid glands during thyroidectomy. The primary endpoint was the rate of low parathyroid hormone (PTH) levels the day after surgery. Results Some 535 patients were randomized, and 486 patients received an intervention according to the study protocol, 246 in the Fluobeam® LX group and 240 in the control group. Some 64 patients (26.0 per cent) in the Fluobeam® LX group and 77 (32.1 per cent) in the control group had low levels of PTH after thyroidectomy (P = 0.141; relative risk (RR) 0.81, 95 per cent c.i. 0.61 to 1.07). Subanalysis of 174 patients undergoing central lymph node clearance showed that 15 of 82 (18 per cent) in the Fluobeam® LX group and 31 of 92 (33 per cent) in the control group had low levels of PTH on postoperative day 1 (P = 0.021; RR 0.54, 0.31 to 0.93). More parathyroid glands were identified during operation in patients who had surgery with Fluobeam® LX, and fewer parathyroid glands in the surgical specimen on definitive histopathology. No specific harm related to the use of Fluobeam® LX was reported. Conclusion The use of autofluorescence during thyroidectomy did not reduce the rate of low PTH levels on postoperative day 1 in the whole group of patients. It did, however, reduce the rate in a subgroup of patients. Registration number: NCT04509011 (http://www.clinicaltrials.gov).

Autofluorescence-Guided Total Thyroidectomy in Low-Volume, Nonparathyroid Institutions

“…Both Dip et al and Benmiloud et al showed a reduction in immediate hypocalcemia, but not in permanent hypocalcemia. In the studies by DiMarco et al, Lykke et al, and Bergenfelz et al, no statistically significant change was reported for either immediate or permanent hypoPT. The overall absence of reduction in the rates of permanent hypoPT in these studies can probably be ascribed to the fact that their permanent hypoPT rates were relatively low.…”

Hypoparathyroidism following total thyroidectomy: high rates at a low-volume, non-parathyroid institution

“…Other studies ( 36 ) consider low PTH levels at POD1 as being indicative of immediate postoperative hypoPT. According to that definition, the rate of immediate hypoPT in our study would be 49.4%, yielding a transient hypoPT rate of 27.9%.…”

How to Manage Advanced Differentiated Thyroid Cancer: Step-by-Step Analysis from Two Italian Tertiary Referral Centers

“…The use of near-infrared (NIR) autofluorescence of the parathyroid glands and more recently the combination of autofluorescence with fluorescence imaging using indocyanine green (ICG) angiography were proposed as a means of identification and protection of the parathyroid glands during thyroid surgery. It was demonstrated that the preservation of at least one well-vascularized parathyroid gland, as assessed by ICG angiography, predicted the absence of postoperative hypoparathyroidism [34].…”