title: Primary hyperparathyroidism with normal baseline intraoperative parathyroid hormone: A challenging population.
abstract: Patients with primary hyperparathyroidism and baseline intraoperative parathyroid hormone levels in the normal range are challenging. This study compares the predictive value of a commonly used intraoperative parathyroid hormone algorithm, a software model for cure prediction, and surgeon judgment in this population.
  
  
  
  This was a retrospective review of consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism at a single institution from March 2013 to October 2014.
  
  
  
  Of 541 operative patients, 114 (21.1%) had a mean normal baseline intraoperative parathyroid hormone of ≤69 pg/mL (median 59.0 ± 10.3; range 26-69). Of the 114 patients, 93 (81.6%) were women, median age was 61 years (range 18-88). Overall, 107/108 (99.1%) patients were cured; 47 (41.2%) patients had single adenomas, 16 (14%) had double adenomas, and 51 (44.7%) had multigland hyperplasia. Using the 50% decline algorithm, a correct prediction was made in 86 (75.4%) patients. Using the computer software, a correct prediction was made in 88 (77.2%) patients. Surgeon judgment, however, was 99.1% accurate.
  
  
  
  Patients with normal baseline intraoperative parathyroid hormone have a high incidence of multigland disease (58.8%), greater than reported previously. Current software modeling and the 50% decline algorithm are insufficient to predict cure in this population; intraoperative parathyroid hormone interpretation combined with operative findings and surgical judgment yield optimal outcomes.
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Mahsa
authors.initials: M
authors.lastname: Javid
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Glenda
authors.initials: G
authors.lastname: Callender
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Courtney
authors.initials: C
authors.lastname: Quinn
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Tobias
authors.initials: T
authors.lastname: Carling
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT.
authors.forename: Patricia
authors.initials: P
authors.lastname: Donovan
authors.affiliation: Department of Surgery, Section of Endocrine Surgery, Yale University School of Medicine, New Haven, CT. Electronic address: robert.udelsman@yale.edu.
authors.forename: Robert
authors.initials: R
authors.lastname: Udelsman
mesh_terms: D000046:Academic Medical Centers; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D049950:Hyperparathyroidism, Primary / Q000097:blood* / Q000503:physiopathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000379:methods; D010281:Parathyroid Hormone / Q000097:blood*; D016105:Parathyroidectomy / Q000379:methods*; D011237:Predictive Value of Tests; D012016:Reference Values; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012737:Sex Factors; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D010281:Parathyroid Hormone