Normocalcemia with elevated parathyroid hormone levels after surgical treatment of primary hyperparathyroidism

doi:10.1016/S0002-9610(01)00664-X

The American Journal of Surgery

Volume 182, Issue 1, July 2001, Pages 15-19

https://doi.org/10.1016/S0002-9610(01)00664-X Get rights and content

Abstract

Background: Thirty percent of patients who undergo successful parathyroidectomy for primary hyperparathyroidism show unexplained elevated postoperative serum parathyroid hormone (PTH) levels despite normocalcemia.

Methods: PTH levels were measured monthly in 97 patients for 6 months after parathyroidectomy. Renal function, 25-OH-vitamin D levels, serum alkaline phosphatase levels, osteocalcin, and bone densitometry were evaluated before and 6 months after surgery. PTH reactivity to calcium loading was tested at the sixth month.

Results: Thirty patients had elevated PTH levels despite normocalcemia after parathyroidectomy. Before surgery, these 30 patients had higher PTH and creatinine levels, lower vitamin D levels, and more extensive bone involvement than those with normal postoperative PTH levels. In patients with normal renal function and normal vitamin D levels, postoperative PTH values correlated with preoperative PTH levels but not with bone disease.

Conclusion: In most cases, elevated PTH levels after surgery is an adaptive reaction to renal dysfunction or vitamin D deficiency. If no adaptive cause can be found, persistent hyperparathyroidism must be suspected.

Section snippets

Study population

Of 120 patients who underwent surgery for suspected pHPT between July 20, 1993, and December 31, 1994, 97 were included in this study. The remaining 23 patients were excluded for the following reasons: misdiagnosis (hypocalciuria-hypercalcemia) in 1 case, association of pHPT with another cause of hypercalcemia in 1 case, loss from follow-up in 12 cases, preoperative PTH level lower than 40 pg/mL in 4 cases, and PTH level higher than 40 pg/mL the day after the procedure in 5 cases. Patients with

Outcome of surgery

The outcome of surgery is summarized in Table 1. Hypercalcemia was normalized within a few days after surgery in all 97 patients. Hypocalcemia requiring treatment was observed in 3 patients, including 1 in whom it persisted until the sixth month. Improvement in bone status at 6 months after surgery was documented by normalization of osteocalcin and alkaline phosphatase, increase in bone density, and decrease in z score. Urinary calcium levels significantly decreased. Renal function and

Comments

As in previous reports [1], [2], [3], [4], our series documents elevated serum PTH levels after surgery for pHPT in 30% of patients. We demonstrate that PTH maximum (ie, highest PTH value observed after surgery for each patient) correlates with three preoperative variables: highest PTH maximum values were observed in patients with high preoperative creatinine levels, low preoperative vitamin D levels, and high preoperative PTH levels.

Several conditions may account for an increased PTH

Conclusion

In the postoperative follow-up of patients undergoing parathyroidectomy for pHPT, serum PTH levels and calcemia must both be measured. Normal PTH and calcium levels in the first month after surgery is a reliable indicator that surgery was successful and that further surveillance is unnecessary at least for patients who had an isolated adenoma. In patients with elevated serum PTH but normal calcium levels, one should determine creatinine and 25-OH-vitamin D levels. In most cases elevated PTH

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Preventing cervical reoperations is important—especially after parathyroidectomy. We sought to examine early predictors of recurrence of primary hyperparathyroidism after surgical cure.
Adult patients with sporadic primary hyperparathyroidism treated with parathyroidectomy between September 1, 1997, and September 1, 2019, with confirmed eucalcemia at 6 months postoperatively were identified. Recurrence was defined as hypercalcemia (>10.2 mg/dL) with an elevated or nonsuppressed parathyroid hormone level on subsequent follow-up.
Parathyroidectomy was performed in 522 patients (median age, 62.1 years, 77% female) with the majority undergoing planned minimally invasive parathyroidectomy (85.4%, n = 446). After a median follow-up of 30.9 months, 13 patients (2.5%) recurred (median time to recurrence 50.2 months, interquartile range 27.9–66.5), all of whom underwent planned minimally invasive parathyroidectomy (n = 13/446, 2.9%). Recurrence was more common in those with higher (but still normal) 6-month calcium (10.1 vs 9.3 mg/dL, P < .001) or parathyroid hormone values (64 vs 46 pg/mL, P < .01). Multivariate analysis revealed that age >66.5 years, calcium ≥9.8mg/dL and parathyroid hormone ≥80 pg/mL at 6 months were associated with increased risk of recurrence. In addition, the presence of at least 1 preoperative imaging study that conflicted with intraoperative findings among minimally invasive parathyroidectomy patients (n = 446) was associated with increased risk of recurrence (hazard ratio 4.93, 95% confidence interval 1.25–16.53, P = .016).
Recurrence of sporadic primary hyperparathyroidism after initial surgical cure in the era of minimally invasive parathyroidectomy is 2.5%. Identification of those at risk for recurrence using 6-month serum calcium ≥9.8 mg/dL, parathyroid hormone ≥80 pg/mL, and/or potentially conflicting localization studies may inform surveillance strategies.
Key Elements of the Biochemical Diagnosis of HPT
2021, Surgery of the Thyroid and Parathyroid Glands
In this chapter, we discuss the current approach to preoperative workup for primary hyperparathyroidism, determine appropriate surgical candidacy, review parathyroid surgical anatomy, and detail a comprehensive search algorithm for surgical exploration. We discuss common pitfalls in workup, diagnosis, and parathyroid exploration to optimize successful outcomes. Current guidelines for surgery, modern localization techniques, use of intraoperative parathyroid hormone monitoring, and surgical techniques are also detailed. Readers will gain sophisticated insights into the biology of primary hyperparathyroidism and current surgical approach to the disease.
Normocalcemic hyperparathyroidism: Preoperatively a disease, postoperatively cured?
2014, American Journal of Surgery
Up to 44% of primary hyperparathyroidism patients have elevated parathyroid hormone (ePTH) with normal calcium postparathyroidectomy (PTx). The question is whether the surgical approach affects the incidence of this phenomenon.
Patients with hyperparathyroidism and presumed single-gland disease on preoperative imaging who underwent PTx between 1994 and 2008 were identified and contacted for long-term follow-up. PTx was either a focused approach (minimally invasive approach [MIP]) or a bilateral neck exploration (BNE).
In total, 171 patients had PTH measured postoperatively (95 MIP and 76 BNE); 30 of 171 (17%) had ePTH with normal calcium (MIP 21 [22%] and BNE 9 [12%], P = .08). This occurred within 2 years in 48% and 67% and after 2 years in 52% and 33%, MIP vs BNE, respectively. Four patients recurred, 2 MIP and 2 BNE.
There is a trend toward a higher incidence of ePTH in patients having undergone an MIP. The etiology of ePTH is multifactorial but may represent an early recurrence.
Discussion
2014, American Journal of Surgery
Up to 44% of primary hyperparathyroidism patients have elevated parathyroid hormone (ePTH) with normal calcium postparathyroidectomy (PTx). The question is whether the surgical approach affects the incidence of this phenomenon.
Patients with hyperparathyroidism and presumed single-gland disease on preoperative imaging who underwent PTx between 1994 and 2008 were identified and contacted for long-term follow-up. PTx was either a focused approach (minimally invasive approach [MIP]) or a bilateral neck exploration (BNE).
In total, 171 patients had PTH measured postoperatively (95 MIP and 76 BNE); 30 of 171 (17%) had ePTH with normal calcium (MIP 21 [22%] and BNE 9 [12%], P = .08). This occurred within 2 years in 48% and 67% and after 2 years in 52% and 33%, MIP vs BNE, respectively. Four patients recurred, 2 MIP and 2 BNE.
There is a trend toward a higher incidence of ePTH in patients having undergone an MIP. The etiology of ePTH is multifactorial but may represent an early recurrence.
Postoperative parathyroid hormone elevation after parathyroidectomy for primary hyperparathyroidism
2013, Revista Portuguesa de Endocrinologia, Diabetes e Metabolismo
A elevação isolada da paratormona (PTH) associada a normocalcemia tem surgido em alguns doentes com hiperparatiroidismo primário (HPTP) submetidos a paratiroidectomia com intenção curativa. Vários fatores têm sido associados a essa elevação, nomeadamente o défice de vitamina D, a hipomagnesemia e a insuficiência renal crónica, situações em que a elevação da PTH é encarada num quadro de hiperparatiroidismo secundário. No entanto, a possibilidade da elevação isolada da PTH ser um primeiro sinal de persistência ou recorrência do hiperparatiroidismo primário, inserida em situações de HPTP normocalcémico, também deve ser ponderada. Os autores discutem os fatores etiológicos passíveis de estarem implicados nesta entidade clínica e o seu tratamento, bem como as situações de persistência de elevação de PTH apesar de revertidos os fatores de risco tratáveis e ainda as situações de hiperparatiroidismo primário normocalcémico.
Postoperative elevation of parathyroid hormone (PTH) after parathyroidectomy for primary hyperparathyroidism has been reported in some patients. It may occur just after surgery, being detected in the first postoperative test analysis, or it can appear later on, after a period of time with normal PTH. Several factors have been implicated in the isolated PTH elevation, such as vitamin D or magnesium deficiencies or even chronic renal failure, which represent cases of secondary hyperparathyroidism. However, the possibility of persistent or recurrent primary hyperparathyroidism (including normocalcemic primary hyperparathyroidism) must also be considered. The authors discuss etiological factors which may be associated with elevated PTH and their treatment, as well as cases of persistently elevated PTH despite correction of treatable risk factors. Normocalcemic primary hyperparathyroidism is also discussed.
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The clinical importance of elevated serum parathyroid hormone (PTH) levels in patients with normocalcemia after curative parathyroidectomy (PTX) for primary hyperparathyroidism (pHPT) is unclear. This study sought to determine whether these patients, when compared with those with normal PTH levels, differ in preoperative and pathologic factors and are at increased risk of recurrent pHPT.
A chart review was performed of sporadic pHPT patients who underwent PTX between December 1999 and July 2011.
Of 1,037 patients who underwent PTX, 310 had 6-month serum calcium, vitamin D, and PTH levels evaluated. PTX was curative (normocalcemia at ≥6 months) in 97%. At 6 months, 62 (21%) had elevated serum PTH levels. Compared with patients with normal postoperative PTH levels, patients with elevated PTH levels had greater BMI (P < .0001), greater PTH levels (P < .0001), and lesser vitamin D levels (P = .014) preoperatively and lesser vitamin D levels at 6 months (P = .05). At ≥1 year follow-up, 38 (61%) patients had calcium levels checked; all remained normocalcemic. PTH levels were available for 32 patients; 17 had persistently increased PTH levels.
Patients with elevated PTH levels after curative PTX do not have greater rates of recurrence than patients with normal PTH levels. The greater PTH levels and lesser vitamin D levels support postoperative vitamin D supplementation in these patients.

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Scientific paperNormocalcemia with elevated parathyroid hormone levels after surgical treatment of primary hyperparathyroidism

Abstract

Section snippets

Study population

Outcome of surgery

Comments

Conclusion

Surgery

Persistent serum elevated levels of intact parathyroid hormone after operation for sporadic adenomaevidence of detrimental effect of severe parathyroid disease

Surgery

Long-term effects of parathyroid operation on serum calcium and parathyroid hormone values in sporadic primary hyperparathyroidism

Surgery

Normocalcemia with persistent increase of parathyroid hormonea prospective study

Calcif Tissue Int

Transient rise in intact parathyroid hormone concentration after surgery for primary hyperparathyroidism

Br J Surg

Hyperparathormonémie et normocalcémie après traitement chirurgical d’une hyperparathyroïdie primaire

Presse Med

Dosage per opératoire de parathormone. Interêt dans la chirurgie de l’hyperparathyroïdisme primaire

J Chir (Paris)

Role of the oral calcium-loading test with measurement of intact parathyroid hormone in the diagnoses of symptomatic subtle primary hyperparathyroidism

Surgery

Scientific paper
Normocalcemia with elevated parathyroid hormone levels after surgical treatment of primary hyperparathyroidism