Centre for Endocrine Surgery, University College London Hospital & London Clinic, London, UK.
Department of General Surgery, Alexandria University, Alexandria, Egypt.
Clin Endocrinol (Oxf). 2019 Feb;90(2):277-284. doi: 10.1111/cen.13882. Epub 2018 Nov 19.
BACKGROUND/OBJECTIVE: Intraoperative parathyroid hormone (IOPTH) monitoring during surgery for primary hyperparathyroidism (PHPT) could improve cure rate and simplify current care pathways. This study assesses the performance of US, MIBI and IOPTH monitoring and their impact on outcomes and perioperative strategy.
This is a retrospective study of a prospectively maintained database of patients who underwent parathyroidectomy guided by preoperative US, MIBI and IOPTH monitoring. Test performance (sensitivity, specificity, PPV, NPV, accuracy) and IOPTH added value (percentage of patients in whom test contributed to achieving cure) were calculated.
A total of 617 patients (median age 59 years, 75% females), 603 (97.7%) of them cured, were included in analysis. Sensitivity of US was higher than MIBI (78.2% vs 70%, P < 0.05), but both were inferior to IOPTH (98.6%, P < 0.05). US and MIBI were more sensitive at detecting single gland disease (SGD) than multigland disease (MGD) (85% vs 55% and 77.5% vs 45.5%, respectively, P < 0.05), while IOPTH performed well in both situations (98.8% vs 96.7%, P > 0.05). In 41 patients with incorrect US predictions, MIBI gave correct result only in 12 (29.3%) cases, while IOPTH gave correct predictions in all but one patient (97.6%). Minimally invasive parathyroidectomy (MIP) was completed in 409 patients, with a similar completion rate regardless whether both or one scan was positive. IOPTH added value was significant in whole cohort (14%) and in subgroups of patients with concordant vs discordant scans, minimally invasive vs conventional surgery, and initial vs reoperative surgery.
Intraoperative parathyroid hormone monitoring is more accurate at predicting cure than US and MIBI are at identifying abnormal glands in patients undergoing parathyroidectomy for PHPT and significantly contributes to cure rate in range of clinical scenarios. This implies that its routine use could facilitate successful surgery in patients with single positive imaging and increase number of MIPs while maintaining high cure rate.
背景/目的：原发性甲状旁腺功能亢进症（PHPT）手术中进行术中甲状旁腺激素（IOPTH）监测可以提高治愈率并简化当前的护理途径。本研究评估了超声、MIBI 和 IOPTH 监测的性能及其对结果和围手术期策略的影响。
这是一项对接受术前超声、MIBI 和 IOPTH 监测指导的甲状旁腺切除术患者的前瞻性维护数据库进行的回顾性研究。计算了测试性能（敏感性、特异性、PPV、NPV、准确性）和 IOPTH 的附加值（测试有助于实现治愈的患者比例）。
共纳入 617 例患者（中位年龄 59 岁，75%为女性），603 例（97.7%）患者治愈。与 MIBI 相比，超声的敏感性更高（78.2%比 70%，P<0.05），但两者均低于 IOPTH（98.6%，P<0.05）。与 MGD 相比，US 和 MIBI 检测单腺疾病（SGD）的敏感性更高（85%比 55%和 77.5%比 45.5%，P<0.05），而 IOPTH 在两种情况下均表现良好（98.8%比 96.7%，P>0.05）。在 41 例超声预测错误的患者中，MIBI 仅在 12 例（29.3%）患者中给出正确结果，而 IOPTH 在除 1 例患者外的所有患者中给出正确预测（97.6%）。在 409 例接受微创甲状旁腺切除术（MIP）的患者中，无论两次扫描均为阳性还是仅一次扫描为阳性，MIP 的完成率相似。IOPTH 的附加值在整个队列中均有显著意义（14%），在具有一致扫描与不一致扫描、微创与传统手术以及初次手术与再次手术的患者亚组中也有显著意义。
在接受 PHPT 甲状旁腺切除术的患者中，与 US 和 MIBI 相比，术中甲状旁腺激素监测在预测治愈率方面更准确，并且在一系列临床情况下显著有助于提高治愈率。这意味着其常规使用可以促进单阳性影像学患者的成功手术，增加 MIP 的数量，同时保持高治愈率。
