A >50% Intraoperative Parathyroid Hormone Level Decrease Into Normal Reference Range Predicts Complete Excision of Malignancy in Patients With Parathyroid Carcinoma

• Published in: The Journal of surgical research Vol. 300; pp. 567 - 573
• Main Authors: Armstrong, Valerie L., Vaghaiwalla, Tanaz M., Saghira, Cima, Chen, Cheng-Bang, Wang, Yujie, Anantharaj, Johan, Ackin, Mehmet, Lew, John I.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01-08-2024
• Subjects: Intraoperative PTH monitoring; ioPTH monitoring; Parathyroid cancer; Parathyroid carcinoma; Parathyroid malignancy; Primary hyperparathyroidism; Parathyroid malignancy; Intraoperative PTH monitoring; Primary hyperparathyroidism; Parathyroid cancer; ioPTH monitoring; Parathyroid carcinoma
• ISSN: 0022-4804; 1095-8673; 1095-8673
• DOI: 10.1016/j.jss.2023.11.074

The mainstay of successful treatment for parathyroid carcinoma remains complete surgical excision. Although intraoperative parathyroid hormone (ioPTH) monitoring is a useful adjunct during parathyroidectomy for benign primary hyperparathyroidism, its utility for parathyroid carcinoma remains unclear.
A retrospective review of 796 patients who underwent parathyroidectomy with ioPTH monitoring for primary hyperparathyroidism revealed 13 patients with parathyroid carcinoma on final pathology from two academic institutions. A systematic review yielded 5 additional parathyroid carcinoma patients. Complete excision of malignancy, or operative success (eucalcemia ≥6 mo. after parathyroidectomy); operative failure (persistent hypercalcemia <6 mo. after parathyroidectomy); and perioperative complications were evaluated. Comparison of the >50% ioPTH decrease alone to >50% ioPTH decrease into normal reference range was analyzed using Chi-squared, Kolmogorov–Smirnov, Kruskal–Wallis tests.
All 18 parathyroid carcinoma patients achieved a >50% ioPTH decrease, and 14 patients also had a final ioPTH level decrease into normal reference range. 93% of patients who met normal parathyroid hormone reference range had operative success, whereas only two of the four (50%) patients with parathyroid carcinoma with a >50% ioPTH decrease alone demonstrated operative success.
Parathyroidectomy guided by a >50% ioPTH decrease into normal reference range may better predict complete excision of malignant tissue in patients with parathyroid carcinoma compared to >50% ioPTH decrease alone. IoPTH monitoring should be used in conjunction with clinical judgment and complete en bloc resection for optimal treatment and success.
•There are minimal intraoperative adjuncts to guide resection of parathyroid cancer.•>50% intraoperative parathyroid hormone decrease into normal reference predicts complete surgical excision.•Intraoperative parathyroid hormone monitoring with complete en bloc excision should be completed.