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Background: Minimally invasive parathyroidectomy has become increasingly popular for the treatment of primary hyperparathyroidism, but is not a feasible option for multiglandular disease. It has been suggested that preoperative intact parathyroid hormone (iPTH) levels may predict multiglandular disease. We examined this hypothesis in patients who underwent surgical intervention for primary hyperparathyroidism at Johns Hopkins Medical Institutions., Methods: We retrospectively reviewed 502 consecutive patients with primary hyperparathyroidism who underwent parathyroidectomy. Multivariable logistic regression analysis assessed preoperative iPTH levels as a predictor of multiglandular disease and a positive sestamibi scan, after adjustment for age, sex, and race., Results: Preoperative iPTH levels were not significantly associated with a greater likelihood of multiglandular disease. However, sestamibi scan positivity was significantly more likely in patients with higher preoperative iPTH levels., Conclusion: Preoperative iPTH levels are not helpful in predicting multiglandular disease and should not be used to exclude a minimally invasive parathyroidecotomy for patients with primary hyperparathyroidism. © 2010 Wiley Periodicals, Inc. Head Neck, 2011., (Copyright © 2010 Wiley Periodicals, Inc.)

Objective: To determine the impact of intact parathyroid hormone (iPTH) baseline levels on severity of primary hyperparathyroidism (PHPT) and outcomes following parathyroidectomy for PHPT., Design: Single institution retrospective review., Setting: Academic tertiary care center., Patients: A total of 447 consecutive patients undergoing parathyroid surgery for PHPT., Main Outcome Measures: Comparison of patients with high (> or =150 pg/mL) and low (<150 pg/mL) baseline iPTH values; preoperative serum calcium, alkaline phosphatase, and 25-hydroxyvitamin D levels; and 6-month postoperative serum calcium and iPTH levels., Results: A total of 304 patients had baseline iPTH values of at least 150 pg/mL (high baseline group), and 143 patients had baseline iPTH values lower than 150 pg/mL (low baseline group). Patients in the high baseline group had significantly higher levels of preoperative serum calcium, serum alkaline phosphatase, and adenoma weights (P < .001 for all comparisons). Serum 25-hydroxyvitamin D levels were significantly lower in patients in the high baseline group (P < .001). Sestamibi scans were more likely to localize an adenoma in the high baseline group (83.7%) than in the low baseline group (68.9%) (P < .01). There were no differences in the serum calcium and iPTH levels between the 2 groups 6 months after surgery., Conclusions: Patients in the high baseline group undergoing surgery for PHPT had higher baseline levels of serum calcium, serum alkaline phosphatase, and parathyroid adenoma weights and lower serum 25-hydroxyvitamin D levels compared with the lower baseline group. Sestamibi scans were more likely to localize an adenoma in the high baseline group (83.7%) than in the low baseline group (68.9%) (P < .01). Despite an apparently lower rate of positive preoperative sestamibi scans for the low baseline group, patients were able to achieve a similar rate of disease cure as other patients with higher baseline iPTH levels. It seems that baseline iPTH level should not be used as a criterion to perform surgery or not perform surgery for patients with PHPT.

Objective: To determine the utility of parathyroid hormone (PTH) monitoring for double adenomas (DAs)., Design: Retrospective chart review., Setting: Tertiary referral center., Patients: The study included 47 patients with primary hyperparathyroidism who had DAs identified during first-time parathyroid exploration., Main Outcome Measures: Intraoperative PTH levels were measured in every case, and the intraoperative PTH assay and its influence on surgical outcome were examined., Results: A total of 47 of 552 consecutive patients (8.5%) with primary hyperparathyroidism were found to have DAs; 457 patients (82.7%) had single adenomas; and 48 patients (8.6%) had disease in more than 2 glands. The mean (SD) age of the patients with DAs was 58 (14) years, and 26 patients (55%) were female. The mean (SD) preoperative intact PTH level was 129 (57) pg/mL (to convert to nanograms per liter, multiply by 1), and the preoperative serum calcium level was 11.0 (0.6) mg/dL (to convert to millimoles per liter, multiply by 0.25). In all patients, the intraoperative PTH levels decreased by 79.7% (11.4%) from baseline after removal of both abnormal parathyroid glands. When the location could be confirmed, the second adenoma was ipsilateral in 17 patients (36%) and contralateral in 27 patients (64%). The mean (SD) postoperative intact PTH level was 46 (26) pg/mL at 6 months, and the cure rate was 98%., Conclusions: Intraoperative PTH monitoring and maintenance of normocalcemia after surgery confirm previous reports that DAs do exist and are not simply missed cases of 4-gland hyperplasia. Intraoperative PTH monitoring accurately predicted the success of parathyroidectomy in 98% of patients with DAs.

The article presents a case study of a 24-year old woman with familial isolated primary hyperparathyroidism. Routine screening of the patient showed elevated total calcium level of 11.6 milligram per deciliter and neck exploration confirmed a presence of enlarged left inferior parathyroid gland. She was treated with resection of double adenoma with intraoperative parathyroid hormone (PTH) monitoring. It suggests that one should consider double adenoma during diagnosis.