Endocrinol Metab.  2019 Dec;34(4):327-339. 10.3803/EnM.2019.34.4.327.

Intraoperative Parathyroid Hormone Monitoring in the Surgical Management of Sporadic Primary Hyperparathyroidism

• Khan ZF
• Lew JI

• KMID: 2466251
• DOI: http://doi.org/10.3803/EnM.2019.34.4.327

Abstract

Intraoperative parathyroid hormone monitoring (IPM) has been shown to be a useful adjunct during parathyroidectomy to ensure operative success at many specialized medical centers worldwide. Using the Miami or ">50% intraoperative PTH drop" criterion, IPM confirms the complete excision of all hyperfunctioning parathyroid tissue before the operation is finished, and helps guide the surgeon to identify additional hyperfunctioning parathyroid glands that may necessitate further extensive neck exploration when intraoperative parathyroid hormone (PTH) levels do not drop sufficiently. The intraoperative PTH assay is also used to differentiate parathyroid from non-parathyroid tissues during operations using fine needle aspiration samples and to lateralize the side of the neck harboring the hypersecreting parathyroid through differential jugular venous sampling when preoperative localization studies are negative or equivocal. The use of IPM underscores the recognition and understanding of sporadic primary hyperparathyroidism (SPHPT) as a disease of function rather than form, where the surgeon is better equipped to treat such patients with quantitative instead of qualitative information for durable long-term operative success. There has been a significant paradigm shift over the last 2 decades from conventional to focused parathyroidectomy guided by IPM. This approach has proven to be a safe and rapid operation requiring minimal dissection performed in an ambulatory setting for the treatment of SPHPT.

Keyword

Humans; Parathyroidectomy; Minimally invasive surgical procedures; Hyperparathyroidism, primary; Monitoring, intraoperative; Parathyroid glands; Parathyroid Hormone; Surgeons

MeSH Terms

Biopsy, Fine-Needle
Humans
Hyperparathyroidism, Primary*
Minimally Invasive Surgical Procedures
Monitoring, Intraoperative
Neck
Parathyroid Glands
Parathyroid Hormone*
Parathyroidectomy
Surgeons
Parathyroid Hormone

Figure

• 

  Fig. 1 Intraoperative parathyroid hormone (PTH) dynamics after successful excision of a single hyperfunctioning parathyroid gland. With a drop at the 10-minute post-excision interval of 79% from the highest PTH level, this hormone dynamic predicts a postoperative return to eucalcemia and successful parathyroidectomy. Dotted line shows time of gland excision.

• 

  Fig. 2 Intraoperative parathyroid hormone (PTH) dynamics during successful parathyroidectomy in a patient presenting with multiglandular disease. An intraoperative pre-incision level of 122 pg/mL, excision of an abnormal left inferior parathyroid gland led to a rise of PTH level to 179 pg/mL. After excision of this hypersecreting gland, the PTH assay showed no decrease at 5 minutes (120 pg/mL) and 10 minutes (98 pg/mL). Continued neck exploration revealed another abnormal hypersecreting parathyroid gland. The third and fourth glands appeared grossly normal. The expected hormone level did not decrease significantly until excision of the second hyperfunctioning parathyroid gland. With a 77% decrease in the 10-minute sample (24 pg/mL) compared with the second pre-excision plasma sample (105 pg/mL), no remaining hypersecreting parathyroid tissue was present. Dotted line shows time of gland excision.

• 

  Fig. 3 Intraoperative parathyroid hormone (PTH) dynamics in a patient where the intraoperative >50% PTH decrease criterion is not met at 10 minutes after parathyroid gland excision or if the decline dynamics are equivocal (e.g., borderline PTH drop at 50%). In the majority of patients, the “>50% intraoperative PTH drop” criterion is achieved with an additional 20-minute PTH measurement that excludes a false negative result, accurately predicts postoperative success and prevents unnecessary bilateral neck exploration. Dotted line shows time of gland excision.

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