Uspješnost kirurškog liječenja primarnog hiperparatireoidizma uz intraoperativno mjerenje PTH – iskustvo jednog centra

Marija Pastorčić Grgić , Pavao Perše, Boris Stubljar, Ljiljana Mayer, Vesna Ramljak, Mihaela Gaće, Zvjezdana Špacir Prskalo, Sanja Langer

Uvod: Primarni hiperparatireoidizam liječi se kirurški. Opseg i uspješnost operacije ovise o točnosti prepoznavanja lokalizacije patološki promijenjene žlijezde dijagnostičkim pretragama prije operacije te o intraoperativnoj potvrdi uklanjanja izvora povišene koncentracije PTH. Materijali i metode: Učinjena je retrospektivna analiza bolesnika s dijagnozom primarnog hiperparatireoidizma liječenih u Klinici za tumore u periodu od 2012. do 2019. Godine. Uključena su 54 bolesnika s dijagnozom primarnog hiperparatireoidizma, jedna bolesnica operirana je dva puta. Raspon normalnih koncentracija intaktnog PTH je 15 – 65 pg/mL, a ukupnog kalcija 2,14 – 2,53 mmol/L. Preoperativna koncentracija PTH mjerena je nakon uvoda u opću anesteziju. Intraoperativna koncentracija PTH mjerena je 15 minuta nakon vađenja žlijezde koju smo smatrali zahvaćenom. Kriterij uspješno učinjene operacije bio je pad koncentracije PTH veći od 50% u odnosu na početnu vrijednost. U slučaju izostanka pada koncentracije PTH, prema odluci kirurga, a ovisno o intraoperativnoj situaciji, operacija je produljena traženjem zahvaćene žlijezde, te ponavljanim mjerenjem. Rezultati: Prosječna koncentracija PTH prije operacije bila je 117,4 (39,6 – 305,4) pg/mL, a ukupnog kalcija 2,75 (2,45 – 3,15) mmol/L. Prosječna koncentracija intraoperativnog PTH bila je 35,6 (8,1 – 198,6) pg/mL. Intraoperativne vrijednosti bile su 67,6% manje u odnosu na preoperativne. Kod 44 bolesnika bilo je dovoljno jedno intraoperativno mjerenje koncentracije PTH, dok je kod 11 bolesnika bilo potrebno više mjerenja. Prosječna koncentracija ukupnog kalcija šest mjeseci nakon operacije bila je 2,39 (1,96 – 2,7) mmol/L. Primjenom intraoperativnog određivanja PTH postignuta je uspješnost operacije kod 53 bolesnika (98,14%). Određivanje intraoperativnog pada koncentracije PTH ima visoku osjetljivost 88,7% i pozitivnu prediktivnu vrijednost 97,9%. Zaključak: Intraoperativna potvrda pada koncentracije PTH povećava uspjeh kirurškog liječenja primarnog hiperparatireoidizma, posebno u skupini bolesnika s multiglandularnom bolesti. Zaključak je temeljen na skupini bolesnika kod kojih je bilo potrebno više od jednog određivanja intraoperativnog PTH.

Introduction: Primary hyperparathyreoidism is treated surgically. The extent and efficacy of surgery depend on the precision of preoperative diagnostic localization and intraoperative confirmation of high PTH source removal. Materials and methods: Retrospective analysis was performed. We included patients treated in the University Hospital for Tumors between 2012 and 2019. Fifty-four patients with primary hyperparathyroidism were included, of whom one patient had two surgeries. Normal range for intact PTH is 15–65 pg/mL, and for calcium 2.14–2.53 mmol/L. Preoperative PTH was measured after general anesthesia induction. Intraoperative PTH was measured 15 minutes after the suspected gland removal. PTH decrease more than 50% of the initial value was
considered a proof of sufficient surgery. In cases of persistent PTH levels, according to surgeons’ decision, based on the intraoperative finding, surgery was extended to find the altered gland and to repeat intact PTH level measuring. Results: Average preoperative PTH value was 117.4 (39.6–305.4) pg/mL and calcium 2.75 (2.45–3.15) mmol/L. Average intraoperative PTH value was 35.6 (8.1–198.6) pg/mL. Intraoperative value was 67.6% lower than preoperative. In 44 patients one intraoperative PTH measurement was sufficient, and in 11 patients more than one measurement was needed. Average calcium value six months after surgery was 2.39 (1.96–2.7) mmol/L. Surgery with intraoperative PTH monitoring was successful in 53 patients (98.14%). Intraoperative PTH decrease has high sensitivity (88.7%) and positive predictive value (97.9%). Conclusion: Intraoperative PTH monitoring increases the efficacy
of surgical treatment of primary hyperparathyreoidism, especially in the group of patients with multiglandular disease. The conclusion is based on the group of patients with more than one intraoperative PTH measurement.