Intraoperative parathyroid hormone levels ≤40 pg/mL are associated with the lowest persistence rates after parathyroidectomy for primary hyperparathyroidism

Claflin, Jake; Dhir, Apoorv; Espinosa, Nicolas M.; Antunez, Alexis G.; Cohen, Mark S.; Gauger, Paul G.; Miller, Barbra S.; Hughes, David T.

doi:10.1016/j.surg.2019.01.024

Cited by 15 publications

(9 citation statements)

References 15 publications

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“…The latter criterion has enhanced, among the rules, the achievement of the maximum threshold value of normality 11 . Finally, a recent study demonstrated the extremely low likelihood of disease persistence in patients in whom an ioPTH value of 40 pg/mL was reached within 15 min 18 .…”

Section: Discussionmentioning

confidence: 98%

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Interpretation of intraoperative parathyroid hormone monitoring according to the Rome criterion in primary hyperparathyroidism

Graceffa

Cipolla

Calagna

et al. 2022

Sci Rep

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Intraoperative parathyroid hormone dosage allows real-time monitoring of the decrease in PTH levels during parathyroidectomy and verify procedure’s efficacy. Currently, none of the interpretative criteria used has absolute accuracy. The aim of this study is to evaluate diagnostic accuracy of the Rome criterion verifying diagnostic significance of the individual assays. A total of 205 patients with primary hyperparathyroidism from a single adenoma were retrospectively evaluated and monitored with baseline PTH, PTH at 10 min and PTH at 20 min after adenoma excision. The accuracy of the latter two assays compared with baseline was compared by ROC curves. In addition, was evaluated the influence on these data of localization diagnostics (ultrasounds and scintigraphy), definitive histology, and type of surgery performed. The ratio of 20-min sampling to baseline in the Rome criterion showed highest diagnostic significance. This finding was not influenced by the type of surgery performed, definitive histologic examination, or intraoperative localization of the adenoma. The Rome criterion has shown its high reliability in detecting persistence. The ratio of sampling at 20 min to baseline is by far the best performing. Further studies are needed to evaluate whether sampling at 10 min after adenoma excision can be considered not mandatory.

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Section: Discussionmentioning

confidence: 98%

“…Overall, the routine use of ioPTH is justified by the usefulness shown in decision making in HPT1 surgery 18 .…”

Section: Introductionmentioning

confidence: 99%

Interpretation of intraoperative parathyroid hormone monitoring according to the Rome criterion in primary hyperparathyroidism

Graceffa

Cipolla

Calagna

et al. 2022

Sci Rep

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“…While traditionally surgeons looked for a decline in IOPTH levels ≥50% at 10 min post‐excision, many now seek a post‐excision IOPTH reduced by ≥50%, which is in the normal range 3,24,25 . Some prefer even stricter criteria based on recent studies which have shown lower rates of persistence or recurrence when the IOPTH falls to <40 pg/mL 23,26,27 . However, NHHPT potentially poses a unique clinical challenge for IOPTH monitoring given the normal starting values.…”

Section: Discussionmentioning

confidence: 99%

“…Other studies recommended a more stringent criterion to assure high rates of cure in patients with NHHPT 12,15 . Calflin et al suggested a post‐excision IOPTH level ≤40 pg/mL is associated with low rates of persistence for all patients with HPT, regardless of phenotype 23 . The cure rates for the NHHPT groups in the current study were not significantly different than that of their classic counterparts, with high cure rates in all groups (NH Preop 98.4%, NH Intraop 100%, Classical 97.1%).…”

Section: Discussionmentioning

confidence: 99%

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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“…IPM is considered to indicate successful parathyroidectomy when 10 min after excision it is decreased by ≥ 50% from its highest value before excision (Miami sole criterion, often used) or the latter plus a drop to a normal value (dual criteria)[ 63 , 64 ]. IPM ≤ 40 pg/mL minimizes persistence as the final PTH will fall ≤ 65 pg/mL[ 65 ]. Intraoperative PTH monitoring can safely predict the outcome (accuracy at six months 98% at least), even in patients with normohormonal HPT (8%)[ 6 ].…”

Section: Intraoperative Tools For Parathyroid Identificationmentioning

confidence: 99%

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Pavlidis¹,

Pavlidis²

2023

World J Clin Cases

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Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.

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Intraoperative parathyroid hormone levels ≤40 pg/mL are associated with the lowest persistence rates after parathyroidectomy for primary hyperparathyroidism

Cited by 15 publications

References 15 publications

Interpretation of intraoperative parathyroid hormone monitoring according to the Rome criterion in primary hyperparathyroidism

Interpretation of intraoperative parathyroid hormone monitoring according to the Rome criterion in primary hyperparathyroidism

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

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

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