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Reassessment of PTH Monitoring during Parathyroidectomy for Primary Hyperparathyroidism after Two Preoperative Localization Studies

Atul A Gawande1, Jack M Monchik2, Thomas A Abbruzzese1, Jason D Iannuccilli2, Shahrul I Ibrahim1, Francis D Moore, Jr.1
1Brigham and Women's Hospital, Boston, MA;2Brown Medical School, Providence, RI

Objective: To assess the role of intraoperative-PTH (ioPTH) measurement in patients with primary hyperparathyroidism (PHPT) undergoing minimally invasive parathyroidectomy (MIP) after two preoperative imaging studies.
Design: Retrospective cohort study.
Setting: Experience of two academic centers over five years (Center A) and three years (Center B).
Patients: 569 patients with PHPT.
Interventions: Sestamibi parathyroid imaging (MIBI) and neck ultrasound (US) followed by MIP.
Main Outcome Measures: Incidence of correct prediction of location and extent of disease.
Results: In 57% (n=322), MIBI and US identified the same, single site of disease. In 99.1% (319/322) of these patients, concordant studies predicted correct disease location and extent, with normalized calcium and PTH concentrations on follow-up. In 0.9% (3/322), ioPTH identified unsuspected additional disease. In another 0.9% (3/319), ioPTH-guided removal of a single adenoma failed to correct hypercalcemia. Therefore, the failure rate of surgery in MIBI+, US+ patients was 0.9% with ioPTH and 1.8% without ioPTH (p=0.50). In 201 (35%) of the 569 patients, only one of the two studies recognized an abnormality or the studies disagreed on location. In these, either MIBI or US (if MIBI was negative) failed to predict correct site or extent of disease in 38% (n=76, p<0.001 vs. concordant studies).
Conclusions: In PHPT, concordant preoperative localization with MIBI and US is highly accurate. Use of ioPTH in these cases adds only marginal benefit.

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