Citation Information :
Cvasciuc T, Lansdown M, Fraser S. Focused Parathyroidectomy without Intraoperative Parathyroid Hormone Testing: Acceptability after Preoperative Localization with SPECT-CT. World J Endoc Surg 2019; 11 (1):1-5.
Introduction: Intraoperative parathyroid hormone (IOPTH) monitoring is used to confirm the success of parathyroidectomy for primary hyperparathyroidism (PHPT). The aim of this study is to find out if IOPTH is useful during parathyroidectomy for patients with PHPT and positive single photon emission computed tomography (SPECT-CT) imaging.
Materials and methods: A retrospective study of parathyroidectomies for PHPT between 2011 and 2016 in a teaching hospital was performed. Patients' characteristics (demographics and gender), biochemistry, imaging [ultrasound parathyroids (USSs) and SPECT-CT], type of operation, histology, and persistent disease were identified. Patients were divided into four subgroups according to preoperative imaging, use of IOPTH, and failure rate.
Results: Two hundred and fifty-eight patients were enrolled. About 44.6% of patients had positive and concordant preoperative imaging. Multi-gland disease (MGD) was found in 13.18% of patients on histology. Patients were divided into four subgroups: group 1 (140 patients): positive imaging and focused parathyroidectomy (FP); group 2 (53 patients): positive imaging and nonfocused approach; group 3 (6 patients): disconcordant imaging [negative SPECT-CT but positive ultrasound (US)] and FP; group 4 (57 patients): negative imaging and no FP. The cure rates were 97.86, 94.34, 100, and 87.71%. The overall cure rate was 95%. Within groups 1 and 2, the failure rate was similar if IOPTH was used. IOPTH was used in all patients in groups 3 and 4.
Conclusion: The selective use of IOPTH is an effective operative strategy. Positive SPECT-CT imaging can guide an FP without the need for IOPTH. IOPTH is useful for SPECT-CT-negative patients who are at risk of multi-gland disease (MGD) or to guide FP if single positive imaging.
Clinical significance: Our results and suggestions can guide the use of IOPTH in clinical practice. The selective use of IOPTH suggested by preoperative imaging can be cost-effective and reduce unnecessary time in theater.
Wachtel H, Cerullo I, et al. What can we learn from intraoperative parathyroid hormone levels that do not drop appropriately? Ann Surg Oncol 2015;22:1781–1788. DOI: 10.1245/s10434-014-4201-9.
Bobanga ID, McHenry CR. Is intraoperative parathyroid hormone monitoring necessary for primary hyperparathyroidism with concordant preoperative imaging? Am J Surg 2017;213(3):484–488. DOI: 10.1016/j.amjsurg.2016.11.035.
Dobrinja C, Santandrea G, et al. Effectiveness of intraoperative parathyroid monitoring (ioPTH) in predicting a multiglandular or malignant parathyroid disease. Int J Surg 2017;41Suppl 1:S26–S33. DOI: 10.1016/j.ijsu.2017.02.063.
Nelson CM, Victor NS. Rapid intraoperative parathyroid hormone assay in the surgical management of hyperparathyroidism, Perm J 2007 Winter;11(1):3–6.
Khan AA, Khatun Y, et al. Role of intraoperative PTH monitoring and surgical approach in primary hyperparathyroidism. Ann Med Surg 2015;4(3):301–305. DOI: 10.1016/j.amsu.2015.08.007.
Thielmann A, Kerr P. Validation of selective use of intraoperative PTH monitoring in parathyroidectomy. J Otolaryngol Head Neck Surg 2017;46(1):10. DOI: 10.1186/s40463-017-0188-0.
Guerin C, Paladino NC, et al. Persistent and recurrent hyperparathyroidism. Updates Surg 2017;69(2):161–169. DOI: 10.1007/ s13304-017-0447-7.
Yeh MW, Wiseman JE, et al. Population-level predictors of persistent hyperparathyroidism. Surgery 2011;150(6):1113–1119. DOI: 10.1016/j. surg.2011.09.025.
Hessman O, Stalberg P, et al. High success rate of parathyroid reoperation may be achieved with improved localization diagnosis. World J Surg 2008;32(5):774–781. DOI: 10.1007/s00268-008-9537-5.
Lew JI, Solorzano CC. Surgical management of primary hyperparathyroidism: state of the art. Surg Clin North Am 2009;89:1205–1225. DOI: 10.1016/j.suc.2009.06.014.
Singh Ospina NM, Rodriguez-Gutierrez R, et al. Outcomes of parathyroidectomy in patients with primary hyperparathyroidism: a systematic review and meta-analysis. World J Surg 2016;40(10): 2359–2377. DOI: 10.1007/s00268-016-3514-1.
Lee S, Ryu H, et al. Operative failure in minimally invasive parathyroidectomy utilizing an intraoperative parathyroid hormone assay. Ann Surg Oncol 2014;21(6):1878–1883. DOI: 10.1245/s10434-013-3479-3.
Bergenfelz AOJ, Hellman P, et al. Positional statement of the European Society of Endocrine Surgeons (ESES) on modern techniques in pHPT surgery. Langenbecks Arch Surg 2009;394:761–764. DOI: 10.1007/ s00423-009-0533-5.
Chen H, Pruhs Z, et al. Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. Surgery 2005;138(4):583–587. DOI: 10.1016/j. surg.2005.06.046.
Caixàs A, Bernà L, et al. Efficacy of preoperative diagnostic imaging localization of technetium 99m-sestamibi scintigraphy in hyperparathyroidism. Surgery 1997;121(5):535–541.
Malhotra A, Silver C, et al. Preoperative parathyroid localization with sestamibi. Am J Surg 1996;172:637–640.
O'Doherty MJ, Kettle AG, et al. Parathyroid imaging with technetium- 99m-sestamibi: preoperative localization and tissue uptake studies. J Nucl Med 1992;33(3):313–318.
Richards ML, Thompson GB, et al. Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 2008;196(6):937–942. DOI: 10.1016/j.amjsurg.2018.12.057.
Heineman TE, Kutler DI, et al. Is intraoperative parathyroid hormone monitoring warranted in cases of 4D-CT/ultrasound localized single adenomas? Otolaryngol Head Neck Surg 2015;153(2):183–188. DOI: 10.1177/0194599815590597.
Guerrero MA, Clark OH. A comprehensive review of intraoperative parathyroid hormone monitoring. World J Endocr Surg 2010;2(1): 21–27.
Alhefdhi A, Ahmad K, et al. Five minute intraoperative parathyroid hormone levels can identify multigland disease. Ann Surg Oncol 2017;24(3):733–738. DOI: 10.1245/s10434-016-5617-1.
Zawawi F, Mlynarek AM, et al. Intraoperative parathyroid hormone level in parathyroidectomy: which patients benefit from it? J Otolaryngol Head Neck Surg 2013;42(1):56. DOI: 10.1186/1916- 0216-42-56.
Najafian A, Kahan S, et al. Intraoperative PTH may not be necessary in the management of primary hyperparathyroidism even with only one positive or only indeterminate preoperative localization studies. World J Surg 2017;41(6):1500–1505. DOI: 10.1007/s00268-017-3871-4.
Shawky MS. Intraoperative parathyroid hormone monitoring in primary hyperparathyroidism; resolving controversies and debates. J Parathyroid Dis 2017;5(1);3–10.
Garbutt L, Sigvaldason H, et al. What is the most appropriate intraoperative baseline parathormone? A prospective cohort study. Int J Surg 2016;25:49–53. DOI: 10.1016/j.ijsu.2015.11.044.
Calò PG, Pisano G, et al. Intraoperative parathyroid hormone assay during focused parathyroidectomy: the importance of 20 minutes measurement. BMC Surg 2013 Sep 18;13:36. DOI: 10.1186/1471-2482- 13-36.
Perrier ND, Ituarte PHG, et al. Parathyroid surgery: separating promise from reality. J Clin Endocrinol Metab 2002;87(3):1024–1029. DOI: 10.1210/jcem.87.3.8310.
Strichartz SD, Giuliano AE. The operative management of coexisting thyroid and parathyroid disease. Arch Surg 1990;125:1327–1331.
Kim HG, Kim WY, et al. Minimally invasive parathyroidectomy with or without intraoperative parathyroid hormone for primary hyperparathyroidism. Ann Surg Treat Res 2015;89(3):111–116. DOI: 10.4174/astr.2015.89.3.111.
Wong W, Foo FJ, et al. Simplified minimally invasive parathyroidectomy: a series of 100 cases and review of the literature. Ann R Coll Surg Engl 2011;93:290–293. DOI: 10.1308/003588411X571836.