Lombardi CP, Rafaelli M, Traini E, et al. Intraoperative PTH monitoring during parathyroidectomy: the need for stricter criteria to detect multiglandular disease

Division of Endocrine Surgery, Università Cattolica del S. Cuore, Policlinico A. Gemelli, L.go A Gemelli 8, 00168, Rome, Italy.
Langenbeck s Archives of Surgery (Impact Factor: 2.19). 09/2008; 393(5):639-45. DOI: 10.1007/s00423-008-0384-5
Source: PubMed


Usefulness of rapid intraoperative parathyroid hormone assay (RI-PTH) for diagnosis of multiglandular disease during parathyroidectomy is still debated.
Two hundred seven patients were selected for focused parathyroidectomy for a suspicious single adenoma. RI-PTH results were interpreted on the basis of our criteria for prediction of multiglandular disease (a < 50% drop from the highest pre-excision level and/or a T20 concentration higher than reference range and/or >7.5 ng/L higher than the T10). The results of these criteria were compared with the Miami Criterion (MC).
One hundred ninety-seven uniglandular disease and ten multiglandular disease were found. Our criteria identified all but one patient with multiglandular disease (false positive (FP) rate 0.5%; specificity 90%). On the basis of MC, RI-PTH monitoring would have resulted in five FP results, with a specificity of 50%.
Despite the higher rate of unnecessary bilateral exploration, our criteria results in a lower FP, markedly reducing the risk of missing multiglandular disease.

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    • "Prolonged PTH monitoring at 20 min was suggested by some authors which found that the best predictors of operative failure and persistent (multiglandular) disease are a PTH drop of <50% at 20 min and/or a residual (at 20 min) PTH level above the normal range and/or a significant increase of the PTH levels between the sample obtained 20 min after gland excision with the respect to the 10-min samples [3,4,17,18]. "
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    ABSTRACT: Parathyroid hormone (PTH) monitoring during the surgical procedure can confirm the removal of all hyperfunctioning parathyroid tissue, as the half-life of PTH is approximately 5 min. The commonly applied Irvin criterion is reported to correctly predict post-operative calcium levels in 96-98% of patients. However, the PTH baseline reference concentration is markedly influenced by surgical manipulations during preparation of the affected glands, interindividual variability of the PTH half-life and modifications in the physiological state of the patient during surgery. The aim of this study was to evaluate the possible impact of the measurement of intraoperative PTH 20 minutes after surgery. Between 2003 and 2012, 188 patients underwent a focused parathyroidectomy associated to rapid intraoperative PTH assay monitoring. Blood samples were collected: 1) at pre-incision time, 2) at 10 min after gland excision and 3) at 20 min after excision, if a sufficient reduction of PTH value was not observed. On the bases of the Irvin criterion, an intra-operative PTH drop>50% from the highest either pre-incision or pre-excision level after parathyroid excision was considered a surgical success. A >50% decrease of PTH after gland excision compared to the highest pre-excision value occurred in 156/188 patients (83%) within 10 min and in further 12/188 after 20 minutes (6.4%). In the remaining 20 patients (10.6%) values of PTH remained substantially unchanged or decreased less than 50% and for this reason bilateral neck exploration was performed. An additional pathologic parathyroid was removed in 9 cases, a third in one. In the other 10 cases further neck exploration by a standard cervical approach was negative and in four of these persistent postoperative hypercalcemia was demonstrated. The overall operative success was 97.3%. Intraoperative PTH monitoring was accurate in predicting operative success or failure in 96.3% of patients. The 20 minutes PTH measurement appears very useful, avoiding unnecessary bilateral exploration and the related risk of complications with only a slight increase of the duration of surgery and of the costs. PTH values decreasing appeared to be influenced by surgical manipulations during minimally invasive parathyroidectomy.
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    ABSTRACT: Die intraoperative Parathormonschnellbestimmung (IOPTH) hat vor allem zur weiten Verbreitung der fokussierten und minimal-invasiven Operationsverfahren beim primären Hyperparathyreoidismus beigetragen. Durch die IOPTH-Bestimmung lässt sich mit hoher Sicherheit zum Zeitpunkt der Operation eine vorliegende Mehrdrüsenerkrankung ausschließen, ohne dass alle vier Nebenschilddrüsen dargestellt werden müssen. Dabei ist für die Prognose des operativen Erfolgs („biochemische Heilung“) die Wahl des Cut-off-Wertes der IOPTH-Bestimmung, das sogenannte Erfolgskriterium, entscheidend. Die Vorzüge und Einschränkungen der vielen beschriebenen Erfolgskriterien sind unübersichtlich und werden zudem unterschiedlich bewertet. Insbesondere unter Kosten-Nutzen-Aspekten wird die standardmäßige Anwendung der IOPTH-Bestimmung als „biochemischer Schnellschnitt“, auch bei der konventionellen Parathyreoidektomie, kontrovers diskutiert. Im vorliegenden Beitrag soll der aktuelle Kenntnisstand zur IOPTH-Bestimmung und eine praxisrelevante Empfehlung zum klinischen Einsatz der Methode gegeben werden. Intraoperative parathyroid hormone measurement (IOPTH) has proved to be an important promoter for focused and minimally invasive parathyroidectomy procedures in primary hyperparathyroidism. IOPTH enables multiglandular disease to be excluded with a high degree of certainty at the time of operation. The choice of the cut-off value for IOPTH as the criterion for success is of utmost importance with respect to the prognosis for operative success (biochemical healing). Advantages and disadvantages of the variety of existing IOPTH success criteria are confusing and their assessment is contradictory. Particularly with respect to cost-benefit aspects the standard application of IOPTH as „biochemical frozen section“ even in conventional open parathyroidectomy remains a matter of controversy. This article gives an up-date on current knowledge and provides practical guidelines for clinical use of IOPTH. SchlüselwörterPrimärer Hyperparathyreoidismus-Intraoperative Parathormonbestimmung-Erfolgskriterium-Hyperparathyreoidismuschiurgie-Kosten-Nutzen-Aspekt KeywordsPrimary hyperparathyroidism-Intraoperative parathyroid hormone assay-Success criteria-Parathyroidectomy-Cost-benefit aspects
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