Pitfalls of intraoperative quick parathyroid hormone monitoring and gamma probe localization in surgery for primary hyperparathyroidism.
OBJECTIVE
Intraoperative quick parathyroid hormone (qPTH) monitoring and gamma probe (GP) localization greatly aid the surgeon.


METHODS
Prospective case series of patients undergoing parathyroidectomy (PTX) with preoperative localization studies, operative data (including intraoperative qPTH values and GP localization), and outcomes. Follow-up was complete (mean, 4.2 months).


METHODS
University teaching hospital.


METHODS
We studied 57 consecutive patients with primary hyperparathyroidism from December 1, 1999, through November 30, 2000. Of these, 51 underwent first-time PTX, and 6, reoperative PTX (rePTX).


METHODS
Cure rate and morbidity after PTX or rePTX; sensitivity and accuracy of preoperative localization studies; prediction of cure from results of qPTH monitoring (comparing Nichols [>50% fall from the highest baseline level and lower than the lowest baseline] or normal-limit [>50% fall from first baseline level and lower than upper limit of the reference range] criteria); and value of GP localization.


RESULTS
Patients were cured in 50 (98%) of 51 PTX and 6 (100%) of 6 rePTX for single adenomas (n = 49), double adenomas (n = 4), and multigland hyperplasia (n = 3). Nichols criteria for qPTH monitoring correctly categorized 45 (92%) of 49 cured single adenomas 10 minutes after excision. Only 35 (71%) of these adenomas were correctly categorized as cured by means of the normal-limit criteria. In double adenomas, both sets of criteria in the 10-minute samples indicated unresected glands in only 2 of 4 cases. Preoperative sestamibi parathyroid scans correctly localized 38 (76%) of 50 single adenomas. The GP was used in 54 of 57 cases. All adenomas measured greater than 20% of background ex vivo, but 6 thyroid nodules also measured greater than 20% ex vivo. In double adenomas, the GP helped locate the second adenoma in only 1 of 4 cases. The GP was graded as crucial in 2 cases with dense scar (both rePTX), helpful in 12 (22%) of 54 cases (particularly in retroesophageal glands), confirmatory in 32 (59%), and not helpful in 8 (15%). The GP helped localize 3 (43%) of 7 glands not seen on sestamibi parathyroid scans.


CONCLUSIONS
Intraoperative qPTH monitoring confirmed cure in most cases. For single adenomas, use of the Nichols criteria for qPTH assessment allowed more accurate and faster confirmation than the normal-limit criteria. The GP was less useful but was crucial in 2 rePTX cases; it was not specific for parathyroid tissue. Both techniques have potential pitfalls that could result in surgical failure.
Jaskowiak
Nora T
NT
Department of Surgery, Pritzker School of Medicine, The University of Chicago, Chicago, IL, USA.
Sugg
Sonia L
SL
Helke
James
J
Koka
Mahalashmana Rao
MR
Kaplan
Edwin L
EL
D000236:Adenoma / Q000150:complications / Q000601:surgery*; D000293:Adolescent; D000328:Adult; D000368:Aged; D005260:Female; D006801:Humans; D006961:Hyperparathyroidism / Q000209:etiology / Q000601:surgery*; D007432:Intraoperative Period; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic; D010281:Parathyroid Hormone / Q000097:blood*; D010282:Parathyroid Neoplasms / Q000150:complications / Q000601:surgery*; D016105:Parathyroidectomy / Q000379:methods*; D019275:Radiopharmaceuticals; D012086:Reoperation; D017256:Technetium Tc 99m Sestamibi; D013997:Time Factors
D010281:Parathyroid Hormone; D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi