ABSTRACT
Background
Following parathyroidectomy for primary hyperparathyroidism (pHPT), serum calcium levels typically normalize relatively quickly. The purpose of this study was to identify potential factors associated with delayed normalization of calcium levels despite meeting intraoperative parathyroid hormone (IOPTH) criteria and to determine whether this phenomenon is associated with higher rates of persistent pHPT.
Methods
This was a retrospective review of 554 patients who underwent parathyroidectomy for sporadic pHPT from January 2009 to July 2013. Patients who underwent presumed curative parathyroidectomy and had elevated POD0 calcium levels (>10.2 mg/dL) were matched 1:2 for age and gender to control patients with normal POD0 calcium levels.
Results
Of the 554 patients, 52 (9 %) had an elevated POD0 Ca (median 10.7, range 10.3–12.2). Compared with the control group, these patients had higher preoperative calcium (12 vs. 11.1, p < 0.001) and PTH (144 vs. 110 pg/mL, p = 0.004) levels and lower 25OH vitamin D levels (26 vs. 31 pg/mL; p = 0.024). Calcium normalization occurred in 64, 90, and 96 % of patients by postoperative days (POD) 1, 14, and 30, respectively. There was no difference in rates of single-gland disease or cure rates between the groups.
Conclusions
After presumed curative parathyroidectomy, nearly 10 % of patients had transiently persistent hypercalcemia. Most of these patients had normal serum calcium levels within the first 2 weeks and did not have increased rates of persistent pHPT. Immediate postoperative calcium levels do not predict the presence of persistent pHPT, and these patients may not require more stringent follow-up.
Similar content being viewed by others
References
Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marococci C, Potts JT. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the fourth international workshop. J Clin Endocrinol Metab. 2014;99:3561–9.
Callender GG, Udelsman R. Surgery for primary hyperparathyroidism. Cancer. 2014;120(23):3602–16.
Udelsman R, Åkerström G, Biagini C, Duh QY, Miccoli P, Niederle B, Tonelli F. The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99(10):3595–606.
Wang TS, Pasieka JL, Carty SE. Techniques of parathyroid exploration at North American endocrine surgery fellowship programs: what the next generation is being taught. Am J Surg. 2014;207(4):527–32.
Chen H, Mack E, Starling JR. A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable. Ann Surg. 2005;242(3):375–80.
Leiker AJ, Yen TW, Eastwood DC, Doffek KM, Szabo A, Evans DB, Wang TS. Factors that influence parathyroid hormone half-life: determining if new intraoperative criteria are needed. JAMA Surg. 2013;148(7):602–6.
Cisco RM, Kuo JH, Ogawa L, Scholten A, Tsinberg M, Duh QY, Clark OH, Gosnell JE, Shen WT. Impact of race on intraoperative parathyroid hormone kinetics: an analysis of 910 patients undergoing parathyroidectomy for primary hyperparathyroidism. Arch Surg. 2012;147(11);1036–40.
Udelsman R. Approach to the patient with persistent or recurrent primary hyperparathyroidism. J Clin Endocrinol Metab. 2011;96:2950–8.
Carsello CB, Yen TW, Wang TS. Persistent elevation in serum parathyroid hormone levels in normocalcemic patients after parathyroidectomy: does it matter? Surgery. 2012;152(4):575–81.
Chen H, Wang TS, Yen TW, Doffek K, Krywda E, Schaefer S, Sippel RS, Wilson SD. Operative failures after parathyroidectomy for hyperparathyroidism: the influence of surgical volume. Ann Surg. 2010;252(4):691–5.
Heller KS, Blumberg SN. Relation of final intraoperative parathyroid hormone level and outcome following parathyroidectomy. Arch Otolaryngol Head Neck Surg. 2009;135(110):1103–7.
Rajaei MH, Bentz AM, Schneider DF, Sippel RS, Chen H, Oltmann SC. Justified follow-up: a final ioPTH over 40 pg/mL is associated with an increased risk of persistence and recurrence in primary hyperparathyroidism. Ann Surg Oncol. 2015;22(2):454–9.
Schneider DF, Mazeh H, Chen H, Sippel RS. Predictors of recurrence in primary hyperparathyroidism: an analysis of 1386 cases. Ann Surg. 2014;259(3):563–8.
Wharry LI, Yip L, Armstrong MJ, Virji MA, Stang MT, Carty SE, McCoy KL. The final intraoperative parathyroid hormone level: how low should it go? World J Surg. 2014;38:558–63.
Yeh MW, Wiseman JE, Chu SD, Ituarte PH, Liu IL, Young KL, Kang SJ, Harari A, Haigh PI. Population-level predictors of persistent hyperparathyroidism. Surgery. 2011;150(6):1113–9.
Goldfarb M, Gondek S, Irvin GL, Lew JI. Normocalcemic parathormone elevation after successful parathyroidectomy: long-term analysis of parathormone variations over 10 years. Surgery. 2011;150:1076–84.
Ning L, Sippel R, Schaefer S, Chen H. What is the clinical significance of an elevated parathyroid hormone level after curative surgery for primary hyperparathyroidism? Ann Surg. 2009;249(3):469–72.
Wang TS, Ostrower ST, Heller KS. Persistently elevated parathyroid hormone levels after parathyroid surgery. Surgery. 2005;138(6):1130–5.
Yen TW, Wang TS, Doffek KM, Kryzwda EA, Wilson SD. Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach. Surgery. 2008;144:611–9.
Malberti F, Farina M, Imbasciatti E. The PTH-calcium curve and the set point of calcium in primary and secondary hyperparathyroidism. Nephrol Dial Transplant. 1999;14:2398–2406.
Debruyne F, Delaere P, Ostyn F, Van Den Bruel A, Bouillon R. Daily follow-up of serum parathyroid hormone and calcium after surgery for primary hyperparathyroidism. J Otolaryngol. 1999;28(6):305–8.
Vasher M, Goodman A, Politz D, Norman J. Postoperative calcium requirements in 6000 patients undergoing outpatient parathyroidectomy: easily avoiding symptomatic hypocalcemia. J Am Coll Surg. 2010;211:49–54.
Graf W, Rastad J, Akerstrom G, Wide L, Ljunghall S. Dynamics of parathyroid hormone release and serum calcium regulation after surgery for primary hyperparathyroidism. World J Surg. 1992;16:625–31.
Wong WK, Wong NACS, Farndon JR. Early postoperative plasma calcium concentration as a predictor of the need for calcium supplement after parathyroidectomy. Br J Surg. 1996;83:532–4.
Carty SE, Roberts MM, Virji MA, Haywood L, Yim JH. Elevated serum parathormone level after “concise parathyroidectomy” for primary sporadic hyperparathyroidism. Surgery. 2002;132:1086–93.
Beyer TD, Solorzano CC, Prinz RA, Babu A, Nilubol N, Patel S. Oral vitamin D supplementation reduces the incidence of eucalcemic PTH elevation after surgery for primary hyperparathyroidism. Surgery. 2007;141:777–83.
Yen TWF, Wilson SD, Kryzwda EA, Sugg SL. The role of parathyroid hormone measurements after surgery for primary hyperparathyroidism. Surgery. 2006;140:665–74.
Alabdulkarim Y, Nassif E. Delayed serum calcium biochemical response to successful parathyroidectomy in primary hyperparathyroidism. J Lab Phys. 2010;2(1):10–3.
Disclosure
The authors have no disclosures.
Author information
Authors and Affiliations
Corresponding author
Additional information
This manuscript was presented as a poster presentation at the 68th Society of Surgical Oncology Annual Cancer Symposium in Houston, TX, March 2015.
Rights and permissions
About this article
Cite this article
Lai, V., Yen, T.W.F., Doffek, K. et al. Delayed Calcium Normalization After Presumed Curative Parathyroidectomy is Not Associated with the Development of Persistent or Recurrent Primary Hyperparathyroidism. Ann Surg Oncol 23, 2310–2314 (2016). https://doi.org/10.1245/s10434-016-5190-7
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1245/s10434-016-5190-7