Surgery for Primary Hyperparathyroidism with Normal Non‐suppressed Parathyroid Hormone can be Both Challenging and Successful

Orr, Lauren; McKenzie, Travis J.; Thompson, Geoffrey B.; Farley, David R.; Wermers, Robert A.; Lyden, Melanie L.

doi:10.1007/s00268-017-4323-x

Cited by 14 publications

(11 citation statements)

References 29 publications

(26 reference statements)

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“…Our earlier work investigated the effect of biochemical profile on IOPTH and demonstrated a slower rate of IOPTH decline in NC 25,26 and NH 27 patients compared with typical profile patients. Surgical resection of adenomatous glands has been demonstrated to be beneficial in both NC 28e30 and NH 31 groups. In detailed analyses of long-term cure with respect to IOPTH criteria, Trinh et al 26 demonstrated comparable outcomes for NC patients as long as a >50% IOPTH decrease was achieved.…”

Section: Discussionmentioning

confidence: 99%

The effect of chronic kidney disease on intraoperative parathyroid hormone: A linear mixed model analysis

Graves

Hwang

McManus

et al. 2021

Surgery

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Background: Reduced creatinine clearance is an indication for surgery in asymptomatic primary hyperparathyroidism, and a significant proportion of patients undergoing parathyroidectomy have chronic kidney disease. The purpose of this study was to evaluate the kinetics of intraoperative parathyroid hormone decline during parathyroidectomy in patients who have chronic kidney disease compared with those with who have normal renal function. Methods: This is a single-center, retrospective study of patients with primary hyperparathyroidism undergoing parathyroidectomy (n ¼ 646). Patients were grouped based on estimated glomerular filtration rate greater than (normal renal function) or less than (chronic kidney disease) 60 mL/min/ 1.73m 2 . All patients had intraoperative parathyroid hormone monitoring and 6-month postoperative serum studies to confirm surgical cure. Intraoperative parathyroid hormone kinetic curves were analyzed using a linear mixed model. Results: Despite similar pre-excision values, patients with chronic kidney disease had significantly higher intraoperative parathyroid hormone values at 5 minutes (76 vs 58 pg/mL, P ¼ .02) and 10 minutes (54 vs 37 pg/mL, P ¼ .004) postexcision. No significant difference was observed in whether patients met Miami criterion by 5 minutes (chronic kidney disease 71%, normal renal function 78%, P ¼ .255) or by 10 minutes (chronic kidney disease 95%, normal renal function 96%, P ¼ .751) postexcision. Using a linear mixed model, glomerular filtration rate did not have a significant effect on the change in intraoperative parathyroid hormone over time. Conclusion:Patients with chronic kidney disease had significantly higher postexcision intraoperative parathyroid hormone levels. However, renal function did not affect the change in intraoperative parathyroid hormone over time, nor did renal function ultimately affect the likelihood of meeting the Miami criterion. Intraoperative parathyroid hormone monitoring remains useful in this population, although additional time points may be needed to observe normalization of values.

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Section: Discussionmentioning

confidence: 99%

The effect of chronic kidney disease on intraoperative parathyroid hormone: A linear mixed model analysis

Graves

Hwang

McManus

et al. 2021

Surgery

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“…Finally, there may be an increasing rate of operations for patients with mild disease such as those with normal non-suppressed parathyroid hormone levels which is known to correlate with increased likelihood of negative imaging and MG resection. 17 In our series, 6 patients had an unsuccessful operation with documented persistence of postoperative hypercalcemia. All of these cases started with a focused exploration at the most obvious site of disease and then 5 of the cases were converted to a bilateral exploration due to an inadequate drop in IOPTH.…”

Section: Discussionmentioning

confidence: 68%

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization

Foster

Rocco

et al. 2021

The American Surgeon

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Background In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT. Methods Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization. Results From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings. Discussion Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.

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“…These patients are more likely to have negative imaging, multiglandular disease, and a PTH decline that does not meet standard curative criteria. 19 Only 75 per cent of patients with normal PTH levels will have a 50 per cent decline, and cure rates are less (88% vs 96%). 19 There may be a subset of these patients in whom the diagnosis is equivocal.…”

Section: Discussionmentioning

confidence: 99%

“…19 Only 75 per cent of patients with normal PTH levels will have a 50 per cent decline, and cure rates are less (88% vs 96%). 19 There may be a subset of these patients in whom the diagnosis is equivocal. These are challenging patients at a primary operation, and perhaps patients should be further classified based on postoperative risk of failure and follow-up tailored accordingly.…”

Section: Discussionmentioning

confidence: 99%

Primary Hyperparathyroidism: Redefining Cure

Rudin

McKenzie

Wermer

et al. 2019

The American Surgeon

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Primary hyperparathyroidism is the most common cause of hypercalcemia. Follow-up can be resource-intensive and costly. The aim of this study was to determine if there is a subset of patients who can be defined cured earlier than six months. This was a retrospective study of patients who underwent parathyroidectomy between January 2012 and March 2014. Patients with a history of multiple endocrine neoplasia syndrome, and secondary or tertiary hyperparathyroidism were excluded. Patients with normal preoperative calcium and parathyroid hormone (PTH) and those without six months follow-up were excluded. Patients were divided into two groups: cured and not cured. Data analysis was performed between the two groups. A total of 509 patients were screened, and 214 met our inclusion criteria: 202 in the cured category and 12 in the not cured category (94% cure rate). There was no significant difference between age, gland weight, or pre-operative PTH. There was a statistically significant difference between final intraoperative PTH (IOPTH) (37 vs 55, P = 0.008) and per cent PTH decrease (69 vs 43%, P < 0.0001). There was a significant difference between intraoperative cure rate (P < 0.0006), imaging concordance (P = 0.0115), and solitary versus multiglandular disease (P = 0.0151). Subgroup analysis in patients with concordant imaging, solitary parathyroid adenoma, and IOPTH decrease by 50 per cent to normal or near-normal correlated with a six-month cure rate of 97 per cent. Patients with primary hyperparathyroidism with concordant imaging, single-adenoma pathology, and IOPTH decrease by 50 per cent to normal or near-normal levels (15–65 pg/mL) can be considered cured and may need less frequent follow-up.

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Surgery for Primary Hyperparathyroidism with Normal Non‐suppressed Parathyroid Hormone can be Both Challenging and Successful

Abstract: Parathyroidectomy can have a high cure rate in the context of normal PTH levels despite an increased likelihood of negative imaging and multigland resection. Operative success is equivalent to classic PHPT when PTH levels are > 55 pg/mL.

Cited by 14 publications

References 29 publications

The effect of chronic kidney disease on intraoperative parathyroid hormone: A linear mixed model analysis

The effect of chronic kidney disease on intraoperative parathyroid hormone: A linear mixed model analysis

Routine Use of Preoperative Neck Ultrasound in Primary Hyperparathyroidism Identifies Coexisting Thyroid Disease and Improves Parathyroid Localization

Primary Hyperparathyroidism: Redefining Cure

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