Primer hiperparatiroidizm sebebiyle cerrahi tedavi uygulanan hastalarda ameliyat sonrası normokalsemik yüksek parathormon sıklığı: Tek merkez deneyimi

Öz

Amaç: Primer hiperparatiroidi nedeniyle paratiroidektomi yapılan bazı hastalarda, serum kalsiyum düzeyleri normale dönmesine rağmen parathormon (PTH) düzeyleri yüksek kalabilir. Bu durum “postoperatif normokalsemik yüksek PTH” olarak tanımlanır. Bu çalışmada, primer hiperparatiroidi nedeniyle ameliyat edilen hastalarda postoperatif normokalsemik yüksek PTH sıklığı araştırılmıştır. Gereç ve Yöntemler: Çalışmada 127 hastanın ameliyat öncesi, ameliyat esnasındaki, erken postoperatif (ameliyattan sonraki gün ile taburculuk dahil ilk 7 gün) ve geç postoperatif (1., 3., 6. ve 12. aylar) laboratuvar değerleri geriye dönük olarak incelendi. Düzeltilmiş kalsiyum, serum albüminine göre hesaplandı. Bulgular: Postoperatif normokalsemik yüksek PTH ile uyumlu laboratuvar bulguları: 1. ayda %56, 3. ayda %44, 6. ayda %42.3, 12. ayda %31.9 olarak bulundu. Ortalama 44.0±27.2 ay (ortanca 36, min 15 – maks 144) takip edilen 91 hastanın tümünde serum kalsiyum düzeyleri normaldi. Son kontrolde hem serum kalsiyum hem PTH değeri bulunan hastalarda postoperatif normokalsemik yüksek PTH sıklığı %34.4 olarak saptandı. Sonuç: Postoperatif normokalsemik yüksek PTH sıklığı, kullanılan kriterlere ve hasta serilerine göre değişebilir. Altta yatan sekonder hiperparatiroidinin katkısı araştırılmalı ve yönetilmelidir. Ayrıca bu bulgunun primer hiperparatiroidi nüksünü gösterebileceği unutulmamalıdır. Hastaların düzenli takibi gereklidir.

Anahtar Kelimeler

• Parathormon
• paratiroidektomi
• postoperatif normokalsemik yüksek PTH
• primer hiperparatiroidi

Proje Numarası

None

Postoperative frequency of normocalcemic elevated parathormone in patients surgically treated for primary hyperparathyroidism: A single-center experience

Öz

Aim: After parathyroidectomy, parathormone levels may remain elevated despite normalization of serum calcium levels in some patients, which is known as “postoperative normocalcemic elevated parathormone”. In this study, we aimed to determine postoperative normocalcemic elevated parathormone frequency in patients undergoing parathyroidectomy due to primary hyperparathyroidism through a retrospective review. Material and Methods: Preoperative, intraoperative, early postoperative (maximum 7-days, starting from the next day of surgery until discharge) and late postoperative (months 1, 3, 6 and 12) laboratory tests of the 127 patients were reviewed retrospectively. Corrected calcium levels were obtained using serum albumin levels. Results: Laboratory values consistent with postoperative normocalcemic elevated parathormone were identified in 56%, 44%, 42.3% and 31.9% of the patients at 1, 3, 6 and 12 months postoperatively. There are missing data in the 127 patients who underwent surgery because some patients did not attend their follow-up visits or were followed up in other centers. Serum calcium values were available and within normal range for all 91 patients followed for a mean duration of 44.0±27.2 months (median= 36, min= 15, max=144). The frequency of postoperative normocalcemic elevated parathormone was 34.4% among patients with serum calcium and PTH measurements available from the last visit. Conclusion: The prevalence of postoperative normocalcemic elevated parathormone varies among different patient series depending on the criteria used. Whether the underlying secondary hyperparathyroidism contributes to postoperative normocalcemic elevated parathormone should be investigated and managed appropriately. Considering that postoperative normocalcemic elevated parathormone may also represent primary hyperparathyroidism recurrence, regular follow-up is required for patients.

Anahtar Kelimeler

• Parathormone
• parathyroidectomy
• postoperative normocalcemic elevated parathyroid hormone
• primary hyperparathyroidism

Proje Numarası

None

Kaynakça

1. Wermers RA, Griebeler ML, Thapa P, Hathcock MA, Kearns AE. Survival in primary hyperparathyroidism over five decades (1965-2010): a population-based retrospective study. Bone. 2021;152:116099. https://doi.org/10.1016/j.bone.2021.116099
2. Walker MD, Silverberg SJ. Primary hyperparathyroidism. Nat Rev Endocrinol. 2018;14(2):115-125. https://doi.org/10.1038/nrendo.2017.104
3. Kearns AE, Thompson GB. Medical and surgical management of hyperparathyroidism. Mayo Clin Proc. 2002;77(1):87-91. https://doi.org/10.4065/77.1.87
4. Ahmed FW, Majeed MS, Kirresh O. Multiple endocrine neoplasias type 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022.
5. Bilezikian JP, Brandi ML, Eastell R, Silverberg SJ, Udelsman R, Marcocci C, et al. Guidelines for the management of asymptomatic primary hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol Metab. 2014;99:3561-3569. https://doi.org/10.1210/jc.2014-1413
6. Cao S, Hu Y, Zhao Y, Su Z, Xu Z, Gao X, et al. A retrospective study of elevated post-operative parathormone in primary hyperparathyroid patients. Oncotarget. 2017;8(60):101158-101164. https://doi.org/10.18632/oncotarget.20416
7. Carty SE, Roberts MM, Virji MA, Haywood L, Yim JH. Elevated serum parathormone level after “concise parathyroidectomy” for primary sporadic hyperparathyroidism. Surgery. 2002;132(6):1086-1092. https://doi.org/10.1067/msy.2002.128479
8. Brown EM. 4-parameter model of the sigmoidal relationship between parathyroid hormone release and extracellular calcium concentration in normal and abnormal tissue. J Clin Endocrinol Metab. 1983;56(3):572-581. https://doi.org/10.1210/jcem-56-3-572

9. 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;141:777-783. https://doi.org/10.1016/j.surg.2007.01.025
10. de la Plaza Llamas R, Ramia Ángel JM, Arteaga Peralta V, Garcia Amador C, López Marcano AJ, Medina Velasco AA, et al. Elevated parathyroid hormone levels after successful parathyroidectomy for primary hyperparathyroidism: a clinical review. Eur Arch Otorhinolaryngol. 2018;275(3):659-669. https://doi.org/10.1007/s00405-017-4836-9
11. Barczynski M, Konturek A, Hubalewska-Dydejczyk A, Cichon S, Nowak W. Evaluation of Halle, Miami, Rome, and Vienna intraoperative iPTH assay criteria in guiding minimally invasive parathyroidectomy. Langenbecks Arch Surg. 2009;394:843-849. https://doi.org/10.1007/s00423-009-0510-z
12. Hessman O, Westerdahl J, Al-Suliman N, Christiansen P, Hellman P, Bergenfelz A. Randomized clinical trial comparing open with video-assisted minimally invasive parathyroid surgery for primary hyperparathyroidism. Br J Surg. 2010;97:177-184. https://doi.org/10.1002/bjs.6810
13. Roman SA, Sosa JA, Mayes L, Desmond E, Boudourakis L, Lin R, et al. Parathyroidectomy improves neurocognitive deficits in patients with primary hyperparathyroidism. Surgery. 2005;138:1121-1128. https://doi.org/10.1016/j.surg.2005.08.033
14. Kifor O, Moore FD, Wang P, Goldstein M, Vassilev P, Kifor I, et al. Reduced immunostaining for the extracellular Ca2+-sensing receptor in primary and uremic secondary hyperparathyroidism. J Clin Endocrinol Metab. 1996;81:1598-1606. https://doi.org/10.1210/jcem.81.4.8636374
15. Gogusev J, Duchambon P, Hory B, Giovannini M, Goureau Y, Sarfati E, et al. Depressed expression of calcium receptor in parathyroid gland tissue of patients with hyperparathyroidism. Kidney Int. 1997;51:328-336. https://doi.org/10.1038/ki.1997.41
16. Yamashita H, Noguchi S, Moriyama T, Takamatsu Y, Sadanaga K, Uchino S, et al. Reelevation of parathyroid hormone level after parathyroidectomy in patients with primary hyperparathyroidism: importance of decreased renal parathyroid hormone sensitivity. Surgery. 2005;137:419-425. https://doi.org/10.1016/j.surg.2004.12.009
17. Mandal AK, Udelsman R. Secondary hyperparathyroidism is an expected consequence of parathyroidectomy for primary hyperparathyroidism: a prospective study. Surgery. 1998;124:1021-1026. https://doi.org/10.1067/msy.1998.92004
18. Zavatta G, Clarke BL. Normocalcemic hyperparathyroidism: a heterogeneous disorder often misdiagnosed? JBMR Plus. 2020;4(8):e10391. https://doi.org/10.1002/jbm4.10391
19. Mazotas IG, Yen TWF, Doffek K, Shaker JL, Carr AA, Evans DB, et al. Persistent/recurrent primary hyperparathyroidism: does the number of abnormal glands play a role? J Surg Res. 2020;246:335-341. https://doi.org/10.1016/j.jss.2019.08.007
20. Shirali AS, Wu SY, Chiang YJ, Graham PH, Grubbs EG, Lee JE, et al. Recurrence after successful parathyroidectomy: who should we worry about? Surgery. 2022;171(1):40-46. https://doi.org/10.1016/j.surg.2021.06.035
21. Pavlidis ET, Pavlidis TE. Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy. World J Clin Cases. 2023;11(10):2213-2225. https://doi.org/10.12998/wjcc.v11.i10.2213
22. Mallick R, Nicholson KJ, Yip L, Carty SE, McCoy KL. Factors associated with late recurrence after parathyroidectomy for primary hyperparathyroidism. Surgery. 2020;167(1):160-165. https://doi.org/10.1016/j.surg.2019.05.076
23. Lou I, Balentine C, Clarkson S, Schneider DF, Sippel RS, Chen H. How long should we follow patients after apparently curative parathyroidectomy? Surgery. 2017;161(1):54-61. https://doi.org/10.1016/j.surg.2016.05.049
24. Alhefdhi A, Schneider DF, Sippel R, Chen H. Recurrent and persistent primary hyperparathyroidism occurs more frequently in patients with double adenomas. J Surg Res. 2014;190:198-202. https://doi.org/10.1016/j.jss.2014.02.024
25. Nordenström E, Westerdahl J, Bergenfelz A. Long-term follow-up of patients with elevated PTH levels following successful exploration for primary hyperparathyroidism. World J Surg. 2004;28:570-575. https://doi.org/10.1007/s00268-004-7124-y
26. Oltmann SC, Maalouf NM, Holt S. Significance of elevated parathyroid hormone after parathyroidectomy for primary hyperparathyroidism. Endocr Pract. 2011;17:57-62. https://doi.org/10.4158/EP10324.RA
27. Goldfarb M, Gondek S, Irvin GL 3rd, Lew JI. Normocalcemic parathormone elevation after successful parathyroidectomy: long-term analysis of parathormone variations over 10 years. Surgery. 2011;150:1076-1084. https://doi.org/10.1016/j.surg.2011.09.017