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Endocr Pract. 2019 Aug 15. doi: 10.4158/EP-2019-0191. [Epub ahead of print]

RECEIVER OPERATING CHARACTERISTIC ANALYSIS OF INTRAOPERATIVE PARATHYROID HORMONE MONITORING TO DETERMINE OPTIMUM SENSITIVITY AND SPECIFICITY: ANALYSIS OF 896 CASES.

Author information

1
From: 1Department of Endocrine Surgery, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, Ohio.
2
Department of General Surgery, St Vincent's Hospital Melbourne, Fitzroy, Victoria, Australia.
3
Department of Endocrine Surgery, Endocrinology and Metabolism Institute, Banner University Medical Centre, Phoenix Arizona, USA.

Abstract

Importance: While intraoperative parathyroid hormone (IOPTH) monitoring with a ≥50% drop commonly guides extent of exploration for primary hyperparathyroidism (pHPT), receiver operating characteristic (ROC) analysis has not been performed to determine whether other criteria yield better sensitivity and specificity. The aim of this study was to identify the optimum percent change of IOPTH following removal of the abnormal parathyroid pathology, in order to predict biochemical cure. Secondary aims were to identify patient subgroups with increased area under the ROC curve (AUC) and need for moderated criteria. Methods: A retrospective review was performed on patients undergoing primary parathyroid surgery for sporadic pHPT between 1999 and 2010 at a tertiary centre for endocrine surgery. 896 patients with primary hyperparathyroidism were included. Multigland disease (MGD) was defined as the intraoperative detection of more than one enlarged hypercellular gland or persistent disease after single gland excision. ROC analysis was used to determine the value with the best performance at predicting MGD, following bilateral exploration (BE). Results: MGD was diagnosed in 174 (19.4%). ROC analysis demonstrated an AUC of 0.69. An IOPTH drop of 72% was the point of optimal discrimination with a sensitivity of 55% and specificity of 76% for predicting MGD. Subgroup analysis by pre-operative calcium, pre-operative PTH, localization studies, pre- and post-excision IOPTH did not identify any factors associated with an improved AUC. Conclusion: To our knowledge, this is the first study to use ROC analysis in a large patient cohort. An IOPTH drop of 72% was found to have optimal discriminating ability. We failed to identify a subset of patients for whom there was substantial improvement in the AUC, sensitivity or specificity. Abbreviations: pHPT = Primary Hyperparathyroidism, IOPTH = Intraoperative Parathyroid Hormone, MGD = Multigland disease, SGD = Single gland disease, iPTH = Intact Parathyroid Hormone, ROC = Receiver Operating Characteristic, AUC = Area under the ROC curve, IRB = Institutional Review Board, US = Surgeon-performed neck Ultrasound, MIBI = Tc99m-sestamibi I-123 subtraction SPECT/CT, FE = Focal Parathyroid Exploration, BE = Bilateral Neck Exploration.

KEYWORDS:

IOPTH; Intraoperative Parathyroid Hormone Monitoring; PTH; Parathyroid Hormone; Primary Hyperparathyroidism

PMID:
31414903
DOI:
10.4158/EP-2019-0191

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