Hyperparathyroidism other diagnostic studies: Difference between revisions
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==Overview== | ==Overview== | ||
Other diagnostic study useful for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]] include super selective venous sampling. Another diagnostic study include measurement of [[intraoperative parathyroid hormone]] (IOPTH) by using a modified sensitive assay (immunoradiometric assay). IOPTH is beneficial for predicting long term surgical outcomes. | Other diagnostic study useful for preoperative localization of hyper-functioning [[Parathyroid gland|parathyroid glands]] include super selective venous sampling. Another diagnostic study include measurement of [[intraoperative parathyroid hormone]] ([[IOPTH]]) by using a modified sensitive assay (immunoradiometric assay). [[IOPTH]] is beneficial for predicting long term [[surgical]] outcomes. | ||
==Other Diagnostic Studies== | ==Other Diagnostic Studies== | ||
===Super Selective Venous Sampling=== | ===Super Selective Venous Sampling=== | ||
*Real-time super selective venous sampling (sSVS) is the most common invasive modality for preoperative localization of hyper-functioning parathyroid glands.<ref name="pmid25868412">{{cite journal| author=Lebastchi AH, Aruny JE, Donovan PI, Quinn CE, Callender GG, Carling T et al.| title=Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery. | journal=J Am Coll Surg | year= 2015 | volume= 220 | issue= 6 | pages= 994-1000 | pmid=25868412 | doi=10.1016/j.jamcollsurg.2015.01.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25868412 }} </ref> | *Real-time super selective venous sampling (sSVS) is the most common [[Invasive (medical)|invasive]] modality for preoperative localization of hyper-functioning [[parathyroid glands]].<ref name="pmid25868412">{{cite journal| author=Lebastchi AH, Aruny JE, Donovan PI, Quinn CE, Callender GG, Carling T et al.| title=Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery. | journal=J Am Coll Surg | year= 2015 | volume= 220 | issue= 6 | pages= 994-1000 | pmid=25868412 | doi=10.1016/j.jamcollsurg.2015.01.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25868412 }} </ref> | ||
*Real-time sSVS is a highly sensitive and specific technique used when traditional | *Real-time sSVS is a highly sensitive and specific technique used when traditional non-invasive imaging studies fail to localize hyper-functioning [[parathyroid glands]] preoperatively in patients with persistent or recurrent primary hyperparathyroidism.<ref name="pmid8256203">{{cite journal| author=Sugg SL, Fraker DL, Alexander R, Doppman JL, Miller DL, Chang R et al.| title=Prospective evaluation of selective venous sampling for parathyroid hormone concentration in patients undergoing reoperations for primary hyperparathyroidism. | journal=Surgery | year= 1993 | volume= 114 | issue= 6 | pages= 1004-9; discussion 1009-10 | pmid=8256203 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8256203 }} </ref> | ||
*Patients with a 2-fold gradient or more in | *Patients with a 2-fold gradient or more in cervical vein drainage locations (inferior, middle, and superior [[thyroid veins]]; [[Thymic veins|thymic]] and [[vertebral veins]]) compared to the baseline value in the [[iliac vein]] are considered for exploration.<ref name="pmid19958942">{{cite journal| author=Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF et al.| title=Reoperation for parathyroid adenoma: a contemporary experience. | journal=Surgery | year= 2009 | volume= 146 | issue= 6 | pages= 1144-55 | pmid=19958942 | doi=10.1016/j.surg.2009.09.015 | pmc=3467310 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19958942 }} </ref> | ||
===Intraoperative parathyroid hormone (IOPTH)=== | ===Intraoperative parathyroid hormone (IOPTH)=== | ||
*Measurement of intraoperative parathyroid hormone (IOPTH) by using a modified sensitive assay (immunoradiometric assay) is beneficial for predicting long term surgical outcomes.Post-surgical success is defined as postoperative normocalcemia. | *Measurement of [[intraoperative parathyroid hormone]] ([[IOPTH]]) by using a modified sensitive assay (immunoradiometric assay) is beneficial for predicting long term surgical outcomes. Post-surgical success is defined as postoperative normocalcemia. | ||
*Patients with hyperparathyroidism due to lesion in a single gland shows a rapid decline of intact parathyroid hormone. The levels of intact parathyroid hormone | *Patients with hyperparathyroidism due to lesion in a single [[gland]] shows a rapid decline of intact [[parathyroid hormone]] after [[resection]]. The levels of intact [[parathyroid hormone]] becomes undetectable within hours of [[resection]].<ref name="pmid3194839">{{cite journal| author=Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA| title=Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism. | journal=Surgery | year= 1988 | volume= 104 | issue= 6 | pages= 1121-7 | pmid=3194839 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3194839 }} </ref> | ||
*After resection of parathyroid adenoma, intact parathyroid hormone levels decrease by 85% | *After [[resection]] of [[parathyroid adenoma]], intact [[parathyroid hormone]] levels decrease by 85% in first 15 minutes. This fall in [[parathyroid hormone]] levels is due to its short [[half-life]].<ref name="pmid8145618">{{cite journal| author=Bergenfelz A, Isaksson A, Ahrén B| title=Intraoperative monitoring of intact PTH during surgery for primary hyperparathyroidism. | journal=Langenbecks Arch Chir | year= 1994 | volume= 379 | issue= 1 | pages= 50-3 | pmid=8145618 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8145618 }} </ref> | ||
*The fall in parathyroid hormone level is significantly more after resection of parathyroid adenoma than after resection of parathyroid hyperplasia. | *The fall in [[parathyroid hormone]] level is significantly more after [[resection]] of [[parathyroid adenoma]] than after [[resection]] of [[Parathyroid gland|parathyroid]] [[hyperplasia]]. | ||
*A fall in level of parathyroid hormone 15 minutes after resection of hyper-functioning parathyroid glands may help differentiating | *A fall in level of [[parathyroid hormone]] 15 minutes after resection of hyper-functioning [[Parathyroid gland|parathyroid glands]] may help differentiating single gland disease from multiple gland disease.<ref>{{cite journal |last1=Irvin III |first1=George L. |last2=Dembrow |first2=Victor D. |last3=Prudhomme |first3=David L. |date= December 1993 |title=Clinical usefulness of an intraoperative “quick parathyroid hormone” assay |url=http://www.surgjournal.com/article/0039-6060(93)90317-7/abstract |journal=Surgery |volume=114 |issue=6 |pages=1019 - 1023 |doi= |access-date= }}</ref><ref name="pmid9718013">{{cite journal| author=Bergenfelz A, Isaksson A, Lindblom P, Westerdahl J, Tibblin S| title=Measurement of parathyroid hormone in patients with primary hyperparathyroidism undergoing first and reoperative surgery. | journal=Br J Surg | year= 1998 | volume= 85 | issue= 8 | pages= 1129-32 | pmid=9718013 | doi=10.1046/j.1365-2168.1998.00824.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9718013 }} </ref> | ||
*IOPTH monitoring has a predictive accuracy of 97%. <ref name="pmid8957480">{{cite journal| author=Boggs JE, Irvin GL, Molinari AS, Deriso GT| title=Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy. | journal=Surgery | year= 1996 | volume= 120 | issue= 6 | pages= 954-8 | pmid=8957480 | doi=10.1016/S0039-6060(96)80040-7 | pmc= | url=http://ac.els-cdn.com/S0039606096800407/1-s2.0-S0039606096800407-main.pdf?_tid=99caa004-930c-11e7-92b8-00000aab0f01&acdnat=1504706978_12ba7c16e03bb28c66dc1c17a05074c4}} </ref> | *[[IOPTH]] monitoring has a predictive accuracy of 97%. <ref name="pmid8957480">{{cite journal| author=Boggs JE, Irvin GL, Molinari AS, Deriso GT| title=Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy. | journal=Surgery | year= 1996 | volume= 120 | issue= 6 | pages= 954-8 | pmid=8957480 | doi=10.1016/S0039-6060(96)80040-7 | pmc= | url=http://ac.els-cdn.com/S0039606096800407/1-s2.0-S0039606096800407-main.pdf?_tid=99caa004-930c-11e7-92b8-00000aab0f01&acdnat=1504706978_12ba7c16e03bb28c66dc1c17a05074c4}} </ref> | ||
====Technique for intraoperative parathyroid hormone (IOPTH) monitoring==== | ====Technique for intraoperative parathyroid hormone (IOPTH) monitoring==== | ||
*When the enlarged parathyroid gland is first visualized intraoperatively, | *When the enlarged [[parathyroid gland]] is first visualized intraoperatively, a baseline sample should be obtained.<ref name="pmid11822958">{{cite journal| author=Westerdahl J, Lindblom P, Bergenfelz A| title=Measurement of intraoperative parathyroid hormone predicts long-term operative success. | journal=Arch Surg | year= 2002 | volume= 137 | issue= 2 | pages= 186-90 | pmid=11822958 | doi=10.1001/archsurg.137.2.186 | pmc= | url=http://jamanetwork.com/journals/jamasurgery/fullarticle/212128 }} </ref> | ||
*The baseline | *The baseline sample should never be obtained before induction of [[anesthesia]]. It is due to the fact that an increase in [[parathyroid hormone]] level may be observed after [[General anaesthesia|general anesthesia]]. | ||
*After excision of enlarged gland, 2nd and 3rd samples are collected at 5 and 10 minutes respectively. | *After [[excision]] of enlarged gland, 2nd and 3rd samples are collected at 5 and 10 minutes respectively. | ||
*Several criteria are used for predicting post-operative normocalcemia including: | *Several criteria are used for predicting post-operative normocalcemia including: | ||
**A decline in parathyroid hormone levels of ≥60% from baseline value at 15 minutes. | **A decline in [[parathyroid hormone]] levels of ≥60% from baseline value at 15 minutes. | ||
**A decline in parathyroid hormone levels of ≥50% from baseline value at 10 minutes. | **A decline in [[parathyroid hormone]] levels of ≥50% from baseline value at 10 minutes. | ||
==References== | ==References== | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]
Overview
Other diagnostic study useful for preoperative localization of hyper-functioning parathyroid glands include super selective venous sampling. Another diagnostic study include measurement of intraoperative parathyroid hormone (IOPTH) by using a modified sensitive assay (immunoradiometric assay). IOPTH is beneficial for predicting long term surgical outcomes.
Other Diagnostic Studies
Super Selective Venous Sampling
- Real-time super selective venous sampling (sSVS) is the most common invasive modality for preoperative localization of hyper-functioning parathyroid glands.[1]
- Real-time sSVS is a highly sensitive and specific technique used when traditional non-invasive imaging studies fail to localize hyper-functioning parathyroid glands preoperatively in patients with persistent or recurrent primary hyperparathyroidism.[2]
- Patients with a 2-fold gradient or more in cervical vein drainage locations (inferior, middle, and superior thyroid veins; thymic and vertebral veins) compared to the baseline value in the iliac vein are considered for exploration.[3]
Intraoperative parathyroid hormone (IOPTH)
- Measurement of intraoperative parathyroid hormone (IOPTH) by using a modified sensitive assay (immunoradiometric assay) is beneficial for predicting long term surgical outcomes. Post-surgical success is defined as postoperative normocalcemia.
- Patients with hyperparathyroidism due to lesion in a single gland shows a rapid decline of intact parathyroid hormone after resection. The levels of intact parathyroid hormone becomes undetectable within hours of resection.[4]
- After resection of parathyroid adenoma, intact parathyroid hormone levels decrease by 85% in first 15 minutes. This fall in parathyroid hormone levels is due to its short half-life.[5]
- The fall in parathyroid hormone level is significantly more after resection of parathyroid adenoma than after resection of parathyroid hyperplasia.
- A fall in level of parathyroid hormone 15 minutes after resection of hyper-functioning parathyroid glands may help differentiating single gland disease from multiple gland disease.[6][7]
- IOPTH monitoring has a predictive accuracy of 97%. [8]
Technique for intraoperative parathyroid hormone (IOPTH) monitoring
- When the enlarged parathyroid gland is first visualized intraoperatively, a baseline sample should be obtained.[9]
- The baseline sample should never be obtained before induction of anesthesia. It is due to the fact that an increase in parathyroid hormone level may be observed after general anesthesia.
- After excision of enlarged gland, 2nd and 3rd samples are collected at 5 and 10 minutes respectively.
- Several criteria are used for predicting post-operative normocalcemia including:
- A decline in parathyroid hormone levels of ≥60% from baseline value at 15 minutes.
- A decline in parathyroid hormone levels of ≥50% from baseline value at 10 minutes.
References
- ↑ Lebastchi AH, Aruny JE, Donovan PI, Quinn CE, Callender GG, Carling T; et al. (2015). "Real-Time Super Selective Venous Sampling in Remedial Parathyroid Surgery". J Am Coll Surg. 220 (6): 994–1000. doi:10.1016/j.jamcollsurg.2015.01.004. PMID 25868412.
- ↑ Sugg SL, Fraker DL, Alexander R, Doppman JL, Miller DL, Chang R; et al. (1993). "Prospective evaluation of selective venous sampling for parathyroid hormone concentration in patients undergoing reoperations for primary hyperparathyroidism". Surgery. 114 (6): 1004–9, discussion 1009-10. PMID 8256203.
- ↑ Powell AC, Alexander HR, Chang R, Marx SJ, Skarulis M, Pingpank JF; et al. (2009). "Reoperation for parathyroid adenoma: a contemporary experience". Surgery. 146 (6): 1144–55. doi:10.1016/j.surg.2009.09.015. PMC 3467310. PMID 19958942.
- ↑ Nussbaum SR, Thompson AR, Hutcheson KA, Gaz RD, Wang CA (1988). "Intraoperative measurement of parathyroid hormone in the surgical management of hyperparathyroidism". Surgery. 104 (6): 1121–7. PMID 3194839.
- ↑ Bergenfelz A, Isaksson A, Ahrén B (1994). "Intraoperative monitoring of intact PTH during surgery for primary hyperparathyroidism". Langenbecks Arch Chir. 379 (1): 50–3. PMID 8145618.
- ↑ Irvin III, George L.; Dembrow, Victor D.; Prudhomme, David L. (December 1993). "Clinical usefulness of an intraoperative "quick parathyroid hormone" assay". Surgery. 114 (6): 1019–1023.
- ↑ Bergenfelz A, Isaksson A, Lindblom P, Westerdahl J, Tibblin S (1998). "Measurement of parathyroid hormone in patients with primary hyperparathyroidism undergoing first and reoperative surgery". Br J Surg. 85 (8): 1129–32. doi:10.1046/j.1365-2168.1998.00824.x. PMID 9718013.
- ↑ Boggs JE, Irvin GL, Molinari AS, Deriso GT (1996). "Intraoperative parathyroid hormone monitoring as an adjunct to parathyroidectomy" (PDF). Surgery. 120 (6): 954–8. doi:10.1016/S0039-6060(96)80040-7. PMID 8957480.
- ↑ Westerdahl J, Lindblom P, Bergenfelz A (2002). "Measurement of intraoperative parathyroid hormone predicts long-term operative success". Arch Surg. 137 (2): 186–90. doi:10.1001/archsurg.137.2.186. PMID 11822958.