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The role of intraoperative parathyroid hormone (IOPTH) determination for identification and surgical strategy of sporadic multiglandular disease in primary hyperparathyroidism (pHPT)

https://doi.org/10.1016/j.beem.2019.101310Get rights and content

Intraoperative PTH monitoring (IOPTH) made minimally invasive parathyroidectomy in patients with primary HPT possible. However, with the increasing accuracy of preoperative localization studies there is a growing discussion if IOPTH is necessary in patients with localized single gland disease (concordant preoperative localization studies). Different interpretation criteria have been developed – each with their particular advantages and disadvantages, but the “perfect” criterion is still missing.

Despite several pitfalls, which can be recognized intraoperatively and do not necessarily lead to a more extensive surgery, IOPTH seems to be a useful adjunct in surgery for PHPT. However, according to current guidelines, selected patients may be operated without IOPTH but need to be informed about the possibly increased risk of recurrent disease.

Introduction

Before the introduction of intraoperative PTH (IOPTH) monitoring, bilateral neck exploration with visualization of at least four parathyroid glands was the standard surgical procedure. It was therefore possible to directly detect all macroscopically enlarged parathyroid glands and thus to remove them. In 1991, Irvine et al. described the technique of IOPTH determination using a PTH assay with a reduced turnover time [1]. The IOPTH- values were available to the surgeon intraoperatively and, due to the short half-life of PTH, the curve of the PTH decay was analyzed almost in “real-time”. This made the intraoperative prediction of cure possible or, otherwise, the recognition of multiple gland disease which was the prerequisite for minimally invasive techniques. In the last 20 years, the IOPTH- assays have been enhanced, new interpretation models developed and endoscopic techniques (like video assisted, transoral endoscopic and/or robotic surgery) established. However, the technique and the underlying concept has not been changed much but the accuracy of preoperative localization studies using modern techniques like PET-CT have been improved enormously. Consequently, there is an emerging discussion about the value of IOPTH monitoring. This article aims to clarify if, according to the latest literature, IOPTH- monitoring is still of value for patients with PHPT to detect multiple gland disease intraoperatively.

Section snippets

Technical aspects of IOPTH- determination

Blood samples are regularly drawn after induction of anesthesia, right after excision of the enlarged gland, 5 min and 10 min later. Different assays are reported to be comparable and have a turnover time of 15–45 min [2]. A promising new assay based on a handheld system with results within 10 min has, unfortunately, never been commercially available [3]. Besides the assay turnover time, the lab is not next to the OR in most institutions and additional transportation time has to be taken into

Criteria for interpretation

The intraoperative parathyroid hormone (IOPTH) determination is highly valuable in surgery of primary hyperparathyroidism (PHPT) as it rules out the presence of a multiple-gland disease. The macroscopic presentation of all parathyroid glands is generally waived in minimally invasive surgical procedures and unilateral explorations for which IOPTH is particularly important. Although, IOPTH enables to reflect the current biochemical picture intraoperatively, it is unable to make long-term

Guidelines

The ideal situation in surgery is, when the surgeon is able to remove an image-identified abnormal gland without an additional dissection. In image-guided surgery, positive preoperative localization study directs where to start exploration and the results of IOPTH monitoring, which relies on real-time assessment of gland function, help to determine the success. However, such focused operations preceded by solely imaging studies without IOPTH determination might miss multiglandular disease in up

Renal insufficiency

PTH is degenerated in the liver to fragment of different sizes c- and n-terminal which are subsequently excreted renally. In patients with renal insufficiency, particular c-terminal fragments cannot be excreted, accumulate and cross-react with the commercially available IOPTH- assays. Thus, the PTH- decay is prolonged and the results have to be interpreted with caution [42]. Nevertheless, IOPTH seems to be a useful adjunct even in patients with chronic kidney disease and renal impairment [43],

Conclusions

Preoperative 99mTc-Sestamibi-scintigraphy and ultrasound are the widely used standard localization studies and correctly identify the enlarged gland concordantly in 66% [54]. Multiple gland disease, however, can often not be correctly identified. Methionine- or 18F-Cholin-PET/CT are promising new modalities but cannot be performed in all patients by standard. Nevertheless, due to modern ultrasound-technique and SPECT-CT, the widely used localization studies are of increasing accuracy.

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