Relationship Between Parathormone Concentration During Surgery and the Post-Operative Outcome of Primary Hyperparathyroidism

Article information

Abstract

Introduction

The relationship between the intra-operative concentration of parathyroid hormone (IOPTH) and the long-term outcome of patients intervened due to primary hyperparathyroidism (PHPT).

Patients and methods

A prospective observational study was performed with 120 patients. Three determinations were made of PTH in blood: baseline, when the diseases gland was located, and 10minutes after its extirpation. The calcium, PTH and vitamin D (25-OH-D3) levels were measured during follow up.

Results

A decrease in IOPTH>50% was observed in 96 (80%) patients, and the postextirpation value returned to the normal range (Group I), in 18 (15%) a decrease of >50% but the final value remained higher than normal (Group II) and in 6 (5%) the decrease was<50% (Group III). Persistent PHPT was detected during follow up in 6 patients (5%): one in Group I (1%), 3 (16.7%) in II and 2 (33.3%) in group III (P<.001). The risk of persistent PHPT was higher in Group II (odds ratio: 19; 95% CI: 1.85–194) and in Group III (odds ratio: 47; 95% CI: 3.53–639). There were no cases of recurrent PHPT. A normal calcium with an increased PTH was detected in 20 patients of Group I (20.8%), 11 (61.1%) in II and 3 (50%) in III (P<.001). These patients had a lower concentration of post-operative vitamin D (17ng/ml, range: 24; compared to 28ng/ml, range: 21) (P=.008) and higher frequency of hypovitaminosis D (70.6% compared to 26.2%) (P>.001).

Conclusion

The risk of persistent PHPT is higher when the IOPTH decreases more than 50% but still remains high.

Keywords:

Primary hyperparathyroidism

Intra-operative parathormone

Adenoma

Parathyroids

Persistence

Recurrence

Vitamin D

Resumen

Introducción

Se analiza la relación entre la concentración intraoperatoria de parathormona (IOPTH) y la evolución a largo plazo de pacientes intervenidos por hiperparatiroidismo primario (HPTP).

Pacientes y métodos

Estudio prospectivo observacional que incluye 120 pacientes. Se realizaron tres determinaciones de PTH en sangre: basal, en el momento de localizar la glándula patológica y a los 10 minutos tras su extirpación. Se determinaron las concentraciones de calcio, PTH y vitamina D (25-OH-D3) durante el seguimiento.

Resultados

En 96 (80%) pacientes se observó disminución de IOPTH>50% y el valor postextirpación volvió al rango normal (Grupo I), en 18 (15%) disminución>50% pero el valor final se mantuvo superior al nivel normal (Grupo II) y en 6 (5%) la disminución fue<50% (Grupo III). Durante el seguimiento se detectó HPTP persistente en 6 pacientes (5%): uno en el Grupo I (1%), 3 (16,7%) en el II y 2 (33,3%) en el III (p<0,001). El riesgo de HPTP persistente fue superior en el Grupo II (odds ratio: 19; IC 95%: 1,85–194) y en el III (odds ratio: 47; IC 95%: 3,53–639). No se observaron casos de HPTP recidivado. Se detectó calcemia normal con PTH elevada en 20 pacientes del Grupo I (20,8%), 11 (61,1%) en el II y 3 (50%) en el III (p<0,001). Estos pacientes presentaron menor concentración de vitamina D postoperatoria (17ng/ml, rango: 24; frente a 28ng/ml, rango: 21) (p=0,008) y mayor frecuencia de hipovitaminosis D (70,6% frente a 26,2%) (p>0,001).

Conclusión

El riesgo de persistencia del HPTP es superior cuando la IOPTH disminuye más del 50% pero se mantiene en niveles elevados.

Palabras clave:

Hiperparatiroidismo primario

Parathormona intraoperatoria

Adenoma

Paratiroides

Persistencia

Recurrencia

Vitamina D

Full text is only aviable in PDF

References

[1.]

S.R. Nussbaum, A.R. Thompson, K.A. Hutcheson, R.D. Gaz, C.A. Wang.

Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism.

Surgery, 104 (1988), pp. 1121-1127

Medline

[2.]

G.L. Irving, D.L. Prudhomme, G.T. Deriso, G. Sfakianakis, S.K. Chandarlapaty.

A new approach to parathyroidectomy.

Ann Surg, 219 (1994), pp. 574-581

Medline

[3.]

G.L. Irving, D.M. Carneiro, C.C. Solorzano.

Progress in the operative management of sporadic primary parathyroidism over 34 years.

Ann Surg, 239 (2004), pp. 704-711

Medline

[4.]

J.L. Ponce, M. Meseguer, C. Sebastián.

Avances en el tratamiento del hiperparatiroidismo primario.

Cir Esp, 74 (2003), pp. 4-9

[5.]

J.M. Nuño, J. Suso, C. Fernández, E. Fernández, M. Carreira, J. Seoane.

Influencia de la determinación rápida intraoperatoria de la paratirina intacta en la cirugía del hiperparatiroidismo primario.

Cir Esp, 80 (2006), pp. 289-294

Medline

[6.]

A. Gómez-Palacios, M.A. Taibo, M.T. Gutiérrez, O. Gómez, J. Gómez-Zabala, B. Barrios, et al.

La determinación peroperatoria de PTHi como factor predictivo de curación en el hiperparatiroidismo.

Cir Esp, 79 (2006), pp. 114-119

Medline

[7.]

T. Clerici, M. Brandle, J. Lange, G.M. Doherty, P.G. Gauger.

Impact of intraoperative parathyroid hormone monitoring on the prediction of multiglandular parothyroid disease.

World J Surg, 28 (2004), pp. 187-192

http://dx.doi.org/10.1007/s00268-003-7255-6 | Medline

[8.]

T. Wang, S. Ostrower, K. Heller.

Persistently elevated parathyroid hormone levels after parathyroid surgery.

Surgery, 138 (2005), pp. 1130-1136

http://dx.doi.org/10.1016/j.surg.2005.08.026 | Medline

[9.]

S. Rodgers, J. Lew, C. Solorzano.

Primary hyperparathyroidism.

Curr Opin Oncol, 20 (2008), pp. 52-58

http://dx.doi.org/10.1097/CCO.0b013e3282f2838f | Medline

[10.]

C. Solorzano.

Surgical management of primary hyperparathyroidism: state of the art.

Surg Clin North Am, 89 (2009), pp. 1205-1225

http://dx.doi.org/10.1016/j.suc.2009.06.014 | Medline

[11.]

D. Carneiro-Pla.

Recent findings in the use of intraoperative parathyroid hormone monitoring in parathyroid disease.

Curr Opin Oncol, 21 (2008), pp. 18-22

Medline

[12.]

D. Carneiro-Pla, C. Solorzano, M. Nader, M. Ramírez, G.L. Irving.

Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: Which criterion is the most accurate?.

Surgery, 134 (2003), pp. 973-981

http://dx.doi.org/10.1016/j.surg.2003.06.001 | Medline

[13.]

I. Ning, R. Sippel, S. Schaefer, H. Chen.

What is the clinical significance of an elevated parathyroid.hormone level after curative surgery for hyperparatiroidism?.

Ann Surg, 249 (2009), pp. 469-472

http://dx.doi.org/10.1097/SLA.0b013e31819a6ded | Medline

[14.]

K.S. Heller, S.N. Blumberg.

Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy.

Arch Otolaryngol Head Neck Surg, 135 (2009), pp. 1103-1107

http://dx.doi.org/10.1001/archoto.2009.155 | Medline

[15.]

D. Carneiro-Pla, C. Solorzano, J.I. Lew, G.L. Irvin.

Long-term outcome of patients with intraoperative parathyroid level remaining above the normal range during parathyroidectomy.

Surgery, 144 (2008), pp. 989-994

http://dx.doi.org/10.1016/j.surg.2008.08.026 | Medline

[16.]

B.S. Miller, B.G. England, M. Nehs, R.E. Burney, G.M. Doherty, P.G. Gauger.

Interpretation of intraoperative parathyroid hormone monitoring in patients with baseline parathyroid hormone levels of <100pg/ml.

Surgery, 140 (2006), pp. 883-890

http://dx.doi.org/10.1016/j.surg.2006.07.016 | Medline

[17.]

P. Riss, K. Kaczirek, G. Heinz, C. Bieglmayer, B. Niederle.

A “defined baseline” in PTH monitoring increases surgical success in patients with multiple gland disease.

Surgery, 142 (2007), pp. 398-404

http://dx.doi.org/10.1016/j.surg.2007.05.004 | Medline

[18.]

B. Chiu, C. Sturgeon, P. Angelos.

Which intraoperative parathyroid hormone assay criterion best predicts operative success?.

Arch Surg, 141 (2006), pp. 483-488

http://dx.doi.org/10.1001/archsurg.141.5.483 | Medline

[19.]

M. Barczynski, A. Konturek, A. Hubalewska-Dydejczyk, S. Cichon, W. Nowak.

Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy.

Langenbecks Arch Surg, 394 (2009), pp. 843-849

http://dx.doi.org/10.1007/s00423-009-0510-z | Medline

[20.]

A. Sitges-Serra, F.J. Díaz-Aguirregoitia, N. de la Quintana, J. Gil-Sánchez, J. Jimeno, R. Prieto, J.J. Sancho.

Weight difference between double parathyroid adenomas is the cause of falsepositive IOPTH test after resection of the first lesion.

World J Surg, 34 (2010), pp. 1337-1342

http://dx.doi.org/10.1007/s00268-010-0413-8 | Medline

[21.]

A. Siperstein, E. Berber, G.F. Barbosa, M. Tsinberg, A. Greene, J. Mitchell, et al.

Predicting the success of limited exploration for primary hyperparathyroidism using ultrasound, sestamibi, and intraoperative parathyroid hormone.

Ann Surg, 248 (2008), pp. 420-428

http://dx.doi.org/10.1097/SLA.0b013e3181859f71 | Medline

[22.]

P. Mazzaglia, M. Milas, E. Berber, A. Siperstein, J. Monchick.

Normalization of 2-week postoperative parathyroid hormone values in patients with primary hyperparathyroidism: four-gland exploration compared to focused-approach surgery.

World J Surg, 34 (2010), pp. 1318-1324

http://dx.doi.org/10.1007/s00268-010-0557-6 | Medline

[23.]

B. Untch, M. Barfield, M. Dar, D. Dixit, G. Leight, J. Olson.

Impact of 25-hidroxyvitamin D deficiency on perioperative parathyroid hormone kinetics and results in patients with primary hyperparathyroidism.

Surgery, 142 (2007), pp. 1022-1026

http://dx.doi.org/10.1016/j.surg.2007.09.026 | Medline

[24.]

B. Hung-Hin, L. Chung-Yau.

Vitamin D3 deficiency is associated with late-onset hypocalcemia after minimally invasive parathyroidectomy in a vitamin D bordeline area.

World J Surg, 34 (2010), pp. 1350-1355

http://dx.doi.org/10.1007/s00268-009-0377-8 | Medline