Advertisement

Springer Nature is making SARS-CoV-2 and COVID-19 research free. View research | View latest news | Sign up for updates

Intraoperative Parathormonmessung bei Hyperparathyreoidismus

Intraoperative measurement of parathyroid hormone in hyperparathyroidism

  • 44 Accesses

Zusammenfassung

Die intraoperative Parathormonbestimmung (IOPTH) beruht auf der kurzen Halbwertszeit des Parathormons (PTH) und der schnellen Analysetechnologien. Ihre funktionelle Aussage über die Korrektur des Überfunktionszustandes beim Hyperparathyreoidismus (HPT) ist der makroskopischen Einschätzung der Nebenschilddrüse (NSD), aber auch jeder (Schnellschnitt‑)Histologie überlegen (sog. biochemischer Schnellschnitt). Im Folgenden wird die Relevanz und Bewertung der IOPTH für die wichtigsten HPT-Formen, den primären HPT, den renalen sekundären und tertiären HPT, die multiple endokrine Neoplasie (MEN1) sowie das Nebenschilddrüsenkarzinom, und klinische Szenarien anhand der aktuellen Datenlage eingeordnet. Es wird deutlich, dass der Zusatznutzen der IOPTH von diversen Voraussetzungen der HPT-Form, der Diagnostik sowie auch patientenindividueller und resektionsstrategischer Überlegungen abhängt. Dabei sind die Kosten der IOPTH vergleichsweise gering und erscheinen im Hinblick auf den Qualitätsgewinn gerechtfertigt. In der Hand des spezialisierten endokrinen Chirurgen ist die IOPTH ein unverzichtbares Instrument der intraoperativen Entscheidungsfindung und Qualitätssicherung.

Abstract

Intraoperative parathyroid hormone (IOPTH) determination is based on the short half-life of parathyroid hormone (PTH) and the rapid analytical technology. The IOPTH provides functional information regarding correction of the overproductive state in hyperparathyroidism (HPT) and is superior to macroscopic evaluation of the parathyroid gland (PG) as well as any (intraoperative frozen section) form of histology (so-called biochemical frozen section). In this article the relevance and evaluation of IOPTH is defined for the most important forms of HPT, for primary HPT, renal secondary and tertiary HPT, multiple endocrine neoplasia type 1 (MEN1) and parathyroid carcinoma and clinical scenarios based on the currently available data. It becomes apparent that the additional benefits of IOPTH depend on diverse prerequisites of the specific type of HPT, the diagnostics as well as individual patient factors and strategic considerations for resection. Overall, the costs for IOPTH are comparably low and seem to be justified with respect to the gain in quality. In the hands of specialized endocrine surgeons IOPTH is an essential tool for intraoperative decision-making and quality assurance.

This is a preview of subscription content, log in to check access.

Literatur

  1. 1.

    Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA (1988) Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. Surgery 104:1121–1127

  2. 2.

    Irvin GL, Dembrow VD, Prudhomme DL (1991) Operative monitoring of parathyroid gland hyperfunction. Am J Surg 162:299–302

  3. 3.

    D’Amour P, Brossard JH, Rousseau L, Nguyen-Yamamoto L, Nassif E, Lazure C, Gauthier D, Lavigne JR, Zahradnik RJ (2005) Structure of non-(1-84) PTH fragments secreted by parathyroid glands in primary and secondary hyperparathyroidism. Kidney Int 68:998–1007

  4. 4.

    Lorenz K, Dralle H (2003) Surgical treatment of hyperparathyroidism. Chirurg 74:593–615

  5. 5.

    Lorenz K, Dralle H (2010) Intraoperative parathyroid hormone determination for primary hyperparathyroidism. Chirurg 81(636):638–642

  6. 6.

    Sartori PV, Saibene AM, Leopaldi E, Boniardi M, Beretta E, Colombo S, Morenghi E, Pauna J, De Pasquale L (2019) Intraoperative parathyroid hormone testing in primary hyperparathyroidism surgery: time for giving up? Eur Arch Otorhinolaryngol 276:267–272

  7. 7.

    Khokar AM, Kuchta KM, Moo-Young TA, Winchester DJ, Prinz RA (2019) Increasing trend of bilateral neck exploration in primary hyperparathyroid. Am J Surg. https://doi.org/10.1016/j.amjsurg.2019.09.039

  8. 8.

    Kiernan CM, Wang T, Perrier ND, Grubbs EG, Solórzano CC (2019) Bilateral neck exploration for sporadic primary hyperparathyroidism: use patterns in 5,597 patients undergoing parathyroidectomy in the collaborative endocrine surgery quality improvement program. J Am Coll Surg 228:652–659

  9. 9.

    Sturgeon CM, Sprague S, Almond A, Cavalier E, Fraser WD, Algeciras-Schimnich A, Singh R, Souberbielle JC, Vesper HW (2017) Perspective and priorities for improvement of parathyroid hormone (PTH) measurement—a view from the IFCC working group for PTH. IFCC working group for PTH. Clin Chim Acta 467:42–47

  10. 10.

    Sturgeon CM, Sprague SM, Metcalfe W (2011) Variation in parathyroid hormone immunoassay results—a critical governance issue in the management of chronic kidney disease. Nephrol Dial Transplant 26:3440–3445

  11. 11.

    Shawky MS (2016) Quick parathyroid hormone assays: a comprehensive review of their utility in clinical practice. Hormones 15:355–367

  12. 12.

    Smit MA, van Kinschot CMJ, van der Linden J, van Noord C, Kos S (2019) Clinical guidelines and PTH measurement: does assay generation matter? Endocr Rev 40:1468–1480

  13. 13.

    Bieglmayer C, Prager G, Niederle B (2002) Kinetic analyses of parathyroid hormone clearance as measured by three rapid immunoassays during parathyroidectomy. Clin Chem 48:1731–1738

  14. 14.

    Johnson LR, Doherty G, Lairmore T, Moley JF, Brunt LM, Koenig J, Scott MG (2001) Evaluation of the performance and clinical impact of a rapid Intraoperative parathyroid hormone assay in conjunction with preoperative imaging and concise parathyroidectomy. Clin Chem 47:919–925

  15. 15.

    Hanon EA, Sturgeon CM, Lamb EJ (2013) Sampling and storage conditions influencing the measurement of parathyroid hormone in blood samples: a systematic review. Clin Chem Lab Med 51:1925–1941

  16. 16.

    Roche Diagnostics Deutschland GmbH (2019) ElecsysT PTH (1 – 84). https://www.roche.de/res/content/9933/_pth_factsheet.pdf. Zugegriffen: 24.11.2019

  17. 17.

    bioMérieux SA (2019) VIDAS® PTH (1-84). https://www.biomerieux.de/klinische-diagnostik/vidasr-pth-1-84. Zugegriffen: 24.11.2019

  18. 18.

    Verband der privaten Krankenversicherung (PKV) (2008) Gebührenordnung für Ärzte (GOÄ) mit verkürzten Leistungsbezeichnungen. https://www.pkv.de/service/rechtsquellen/gesetze-und-verordnungen/gebuehrenordnung-fuer-aerzte-goae.pdf. Zugegriffen: 24.11.2019

  19. 19.

    Carneiro-Pla D (2011) Contemporary and practical uses of intraoperative parathyroid hormone monitoring. Endocr Pract 17:44–53

  20. 20.

    Ito F, Sippel R, Lederman J, Chen H (2007) The utility of intraoperative bilateral internal jugular venous sampling with rapid parathyroid hormone testing. Ann Surg 245:959–963

  21. 21.

    Barczynski M, Konturek A, Cichon S, Hubalewska-Dydejczyk A, Golkowski F, Huszno B (2007) Intraoperative parathyroid hormone assay improves outcomes of minimally invasive parathyroidectomy mainly in patients with a presumed solitary parathyroid adenoma and missing concordance of preoperative imaging. Clin Endocrinol 66:878–885

  22. 22.

    Perrier ND, Ituarte P, Kikuchi S, Siperstein AE, Duh QY, Clark OH, Gielow R, Hamill T (2000) Intraoperative parathyroid aspiration and parathyroid hormone assay as an alternative to frozen section for tissue identification. World J Surg 24:1319–1322

  23. 23.

    Coan KE, Yen TWF, Carr AA, Evans DB, Wang TS (2020) Confirmation of parathyroid tissue: are surgeons aware of new and novel techniques? J Surg Res 246:139–144

  24. 24.

    Egan RJ, Iliff H, Stechman MJ, Scott-Coombes DM (2018) Intraoperative parathyroid hormone assay remains predictive of cure in renal impairment in patients with single parathyroid adenomas. World J Surg 42:2835–2839

  25. 25.

    Sohn JA, Oltmann SC, Schneider DF, Sippel RS, Chen H, Elfenbein DM (2015) Is intraoperative parathyroid hormone testing in patients with renal insufficiency undergoing parathyroidectomy for primary hyperparathyroidism accurate? Am J Surg 209:483–487

  26. 26.

    Graves CE, McManus CM, Chabot JA, Lee JA, Kuo JH (2020) Biochemical profile affects IOPTH kinetics and cure rate in primary hyperparathyroidism. World J Surg 44(2):488–495. https://doi.org/10.1007/s00268-019-05157-x

  27. 27.

    Trinh G, Rettig E, Noureldine SI, Russell JO, Agrawal N, Mathur A, Prescott JD, Zeiger MA, Tufano RP (2018) Surgical management of normocalcemic primary hyperparathyroidism and the impact of intraoperative parathyroid hormone testing on outcome. Otolaryngol Head Neck Surg 159:630–637

  28. 28.

    Medas F, Erdas E, Loi G, Podda F, Barca L, Pisano G, Calò PG (2019) Intraoperative parathyroid hormone (PTH) testing in patients with primary hyperparathyroidism and PTH levels in the normal range. BMC Surg 18:124

  29. 29.

    Libutti SK, Alexander HR, Bartlett DL, Sampson ML, Ruddel ME, Skarulis M, Marx SJ, Spiegel AM, Simmonds W, Remaley AT (1999) Kinetic analysis of the rapid intraoperative parathyroid hormone assay in patients during operation for hyperparathyroidism. Surgery 126:1145–1150

  30. 30.

    Richards ML, Thompson GB, Farley DR, Grant CS (2008) Reoperative parathyroidectomy in 228 patients during the era of minimal-access surgery and intraoperative parathyroid hormone monitoring. Am J Surg 196:937–942

  31. 31.

    Sohn JA, Oltmann SC, Schneider DF, Sippel RS, Chen H, Elfenbein DM (2015) Is intraoperative parathyroid hormone testing in patients with renal insufficiency undergoing parathyroidectomy for primary hyperparathyroidism accurate? Am J Surg 209:483–487

  32. 32.

    Liu SN, Yusufali AH, Mao ML, Khan ZF, Farrá JC, Lew JI (2018) Stricter ioPTH criterion for successful parathyroidectomy in stage III CKD patients with primary hyperparathyroidism. Surgery 164:1306–1310

  33. 33.

    Khan ZF, Picado O, Marcadis AR, Farrá JC, Lew JI (2019) Additional 20-minute intraoperative parathormone measurement can minimize unnecessary bilateral neck exploration. J Surg Res 235:264–269

  34. 34.

    Claflin J, Dhir A, Espinosa NM, Antunez AG, Cohen MS, Gauger PG, Miller BS, Hughes DT (2019) Intraoperative parathyroid hormone levels ≤40 pg/mL are associated with the lowest persistence rates after parathyroidectomy for primary hyperparathyroidism. Surgery 166:50–54

  35. 35.

    Riss P, Geroldinger A, Selberherr A, Brammen L, Heidtmann J, Scheuba C (2018) Applicability of a shortened interpretation model for intraoperative parathyroid hormone monitoring in patients with primary hyperparathyroidism in an endemic goiter region. Eur Surg 50:228–231

  36. 36.

    Heller KS, Blumberg SN (2009) Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy. Arch Otolaryngol Head Neck Surg 135:1103–1107

  37. 37.

    Carneiro-Pla D, Solorzano CC (2012) A summary of the new phenomenon of normocalcemic hyperparathyroidism and appropriate management. Curr Opin Oncol 24:42–45

  38. 38.

    Norlén O, Glover A, Zaidi N, Aniss A, Sywak M, Sidhu S, Delbridge L (2015) The weight of the resected gland predicts rate of success after image-guided focused parathyroidectomy. World J Surg 39:1922–1927

  39. 39.

    Li J, Vasilyeva E, Hiebert J, Britton H, Walker B, Wiseman SM (2019) Limited clinical utility of intraoperative frozen section during parathyroidectomy for treatment of primary hyperparathyroidism. Am J Surg 217:893–898

  40. 40.

    Udelsman R, Donovan P, Shaw C (2014) Cure predictability during parathyroidectomy. World J Surg 38:525–533

  41. 41.

    Schneider DF, Mazeh H, Sippel RS, Chen H (2012) Is minimally invasive parathyroidectomy associated with greater recurrence compared to bilateral exploration? Analysis of more than 1,000 cases. Surgery 152:1008–1015

  42. 42.

    Wharry LI, Yip L, Armstrong MJ, Virji MA, Stang MT, Carty SE, McCoy KL (2014) The final intraoperative parathyroid hormone level: how low should it go? World J Surg 38:558–563

  43. 43.

    Wachtel H, Cerullo I, Bartlett EK, Kelz RR, Karakousis GC, Fraker DL (2015) What can we learn from intraoperative parathyroid hormone levels that do not drop appropriately? Ann Surg Oncol 22:1781–1788

  44. 44.

    Morris LF, Zanocco K, Ituarte PH, Ro K, Duh QY, Sturgeon C, Yeh MW (2010) The value of intraoperative parathyroid hormone monitoring in localized primary hyperparathyroidism: a cost analysis. Ann Surg Oncol 17:679–685

  45. 45.

    Lorenz K, Dralle H (2005) Will intra-operative measurement of parathyroid hormone alter the surgical concept of renal hyperparathyroidism? Langenbecks Arch Surg 390:277–279

  46. 46.

    Lorenz K, Bartsch DK, Sancho JJ, Guigard S, Triponez F (2015) Surgical management of secondary hyperparathyroidism in chronic kidney disease—a consensus report of the European society of endocrine surgeons. Langenbecks Arch Surg 400:907–927

  47. 47.

    El-Husseini A, Wang K, Edon A, Saxon D, Lima F, Sloan D, Sawaya BP (2018) Value of intraoperative parathyroid hormone assay during parathyroidectomy in dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism. Nephron 138:119–128

  48. 48.

    Golingan H, Samuels SK, Camacho P, Dadhania DM, Pedraza-Taborda FE, Randolph G, Parangi S, Bimston DN, Harrell RM (2019) Management of hyperparathyroidism in kidney transplanation candiates: a need for consensus. Endocr Pract. https://doi.org/10.4158/EP-2019-0392

  49. 49.

    Casarim AL, Arcadipane FAMC, Santos Martins A, Del Negro A, Rodrigues AA, Tincani AJ, Marchi E (2019) Pattern of intraoperative parathyroid hormone and calcium in the treatment of tertiary hyperparathyroidism. Otolaryngol Head Neck Surg 161:954–959

  50. 50.

    Triponez F, Kebebew E, Dosseh D, Duh QY, Hazzan M, Noel C, Chertow GM, Wambergue F, Fleury D, Lemaitre V, Proye CA, Clark OH (2006) Less-than-subtotal parathyroidectomy increases the risk of persistent/recurrent hyperparathyroidism after parathyroidectomy in tertiary hyperparathyroidism after renal transplantation. Surgery 140:990–997

  51. 51.

    Nilubol N, Weisbrod AB, Weinstein LS, Simonds WF, Jensen RT, Phan GQ, Hughes MS, Libutti SK, Marx S, Kebebew E (2013) Utility of intraoperative parathyroid hormone monitoring in patients with multiple endocrine neoplasia type 1‑associated primary hyperparathyroidism undergoing initial parathyroidectomy. World J Surg 37:1966–1972

  52. 52.

    Dobrinja C, Santandrea G, Giacca M, Stenner E, Ruscio M, de Manzini N (2017) Effectiveness of intraoperative parathyroid monitoring (ioPTH) in predicting a multiglandular or malignant parathyroid disease. Int J Surg 1:S26–S33

  53. 53.

    Machens A, Lorenz K, Dralle H (2017) Parathyroid hormone levels predict long-term outcome after operative management of parathyroid cancer. Horm Metab Res 49:485–492

  54. 54.

    Teo R, Farrá JC, Khan ZF, Marcadis AR, Lew JI (2018) Intraoperative parathormone spikes during parathyroidectomy may be associated with multiglandular disease. Surgery 163:393–396

  55. 55.

    Maurer E, Wächter S, Holzer K, Bartsch DK (2018) Do we have to wait for the result of the intraoperative quick parathormone test in preoperative localised sporadic parathyroid adenoma? Zentralbl Chir 143:367–372

  56. 56.

    Wilhelm SM, Wang TS, Ruan DT, Lee JA, Asa SL, Duh QY, Doherty GM, Herrera MF, Pasieka JL, Perrier ND, Silverberg SJ, Solórzano CC, Sturgeon C, Tublin ME, Udelsman R, Carty SE (2016) The American association of endocrine surgeons guidelines for definitive management of primary hyperparathyroidism. JAMA Surg 151:959–968

  57. 57.

    BAES (2006) Guidelines on training and management of endocrine disease

  58. 58.

    Udelsman R, Åkerström G, Biagini C, Duh Q‑Y, Miccoli P, Niederle B, Tonelli F (2014) The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the fourth international workshop. J Clin Endocrinol Metab 99:3595–3606

  59. 59.

    Bergenfelz AO, Hellman P, Harrison B, Sitges-Serra A, Dralle H (2009) European society of endocrine surgeons positional statement of the European society of endocrine surgeons (ESES) on modern techniques in pHPT surgery. Langenbecks Arch Surg 394:761–764

  60. 60.

    Barczyński M, Bränström R, Dionigi G, Mihai R (2015) Sporadic multiple parathyroid gland disease—a consensus report of the European society of endocrine surgeons (ESES). Langenbecks Arch Surg 400:887–905

  61. 61.

    Stack BC Jr, Tolley NS, Bartel TB, Bilezikian JP, Bodenner D, Camacho P, Cox JPDT, Dralle H, Jackson JE, Morris JC 3rd, Orloff LA, Palazzo F, Ridge JA, Scott-Coombes D, Steward DL, Terris DJ, Thompson G, Randolph GW (2018) AHNS series: do you know your guidelines? Optimizing outcomes in reoperative parathyroid surgery: definitive multidisciplinary joint consensus guidelines of the American head and neck society and the British association of endocrine and thyroid surgeons. Head Neck 40:1617–1629

  62. 62.

    Iacobone M, Carnaille B, Palazzo FF, Vriens M (2015) Hereditary hyperparathyroidism—a consensus report of the European society of endocrine surgeons (ESES). Langenbecks Arch Surg 400:867–886

  63. 63.

    Vidal Fortuny J, Sadowski SM, Belfontali V, Guigard S, Poncet A, Ris F, Karenovics W, Triponez F (2018) Randomized clinical trial of intraoperative parathyroid gland angiography with indocyanine green fluorescence predicting parathyroid function after thyroid surgery. Br J Surg 105:350–357

  64. 64.

    DiMarco A, Chotalia R, Bloxham R, McIntyre C, Tolley N, Palazzo FF (2019) Autofluorescence in parathyroidectomy: signal intensity correlates with serum calcium and parathyroid hormone but routine clinical use is not justified. World J Surg 43:1532–1537

Download references

Author information

Correspondence to Univ.-Prof. Dr. med. habil. K. Lorenz.

Ethics declarations

Interessenkonflikt

K. Lorenz, R. Schneider und M. Elwerr geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lorenz, K., Schneider, R. & Elwerr, M. Intraoperative Parathormonmessung bei Hyperparathyreoidismus. Chirurg (2020). https://doi.org/10.1007/s00104-020-01123-9

Download citation

Schlüsselwörter

  • Erfolgskriterium
  • Biochemischer Schnellschnitt
  • Nebenschilddrüsenkarzinom
  • MEN1
  • Operationsstrategie

Keywords

  • Success criteria
  • Biochemical frozen section
  • Parathyroid carcinoma
  • MEN1
  • Surgical strategy