Factors Predicting Hypocalcemia after Total Thyroidectomy with Central Lymph Node Dissection in Papillary Thyroid Cancer

Ok Joo Lee; Hyung Chul Kim; Cheol Wan Lim; Eung Jin Shin; Gyou Suk Cho; Jun Chul Jung; Gui Ae Jung; Zisun Kim; Jae Hong Jeong; Kyusung Choi; Sun Wook Han; Sung Mo Hur

doi:10.16956/kjes.2015.15.3.60

Journal List > Korean J Endocr Surg > v.15(3) > 1060148

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Lee, Kim, Lim, Shin, Cho, Jung, Jung, Kim, Jeong, Choi, Han, and Hur: Factors Predicting Hypocalcemia after Total Thyroidectomy with Central Lymph Node Dissection in Papillary Thyroid Cancer

Original Article

Korean Journal of Endocrine Surgery 2015; 15(3): 60-66.

Published online: 24 September 2015

DOI: https://doi.org/10.16956/kjes.2015.15.3.60

Factors Predicting Hypocalcemia after Total Thyroidectomy with Central Lymph Node Dissection in Papillary Thyroid Cancer

Ok Joo Lee, Hyung Chul Kim, Cheol Wan Lim, Eung Jin Shin, Gyou Suk Cho, Jun Chul Jung, Gui Ae Jung, Zisun Kim, Jae Hong Jeong, Kyusung Choi, Sun Wook Han¹, Sung Mo Hur

Department of Surgery, Bucheon Hospital, School of Medicine, Soonchunhyang University, Bucheon, Korea.

¹Department of Surgery, Cheonan Hospital, School of Medicine, Soonchunhyang University, Cheonan, Korea.

Correspondence: Sung Mo Hur. Department of Surgery, Bucheon Hospital, School of Medicine, Soonchunhyang University, 170 Jomaru-ro, Wonmi-gu, Bucheon 14584, Korea. Tel: +82-32-621-5247, Fax: +82-32-621-6950, smkine@gmail.com

Received 18 June 2015 Revised 21 August 2015 Accepted 3 September 2015

(open-access):

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

Total thyroidectomy with central lymph node dissection (CLND) is a treatment modality of choice for thyroid cancer. Hypocalcemia is the most common complication after total thyroidectomy. The aim of the current study was to determine the association between surgery-related clinical factors and postoperative hypocalcemia.

Methods

A prospective analysis was performed for 101 patients who underwent total thyroidectomy with CLND for papillary cancer from June 2013 to June 2014. Correlation between clinicopathologic factors and postoperative hypocalcemia was analyzed.

Results

Based on the postoperative day-2 calcium, 56 patients (55%) developed hypocalcemia and 45 patients (45%) were normal. No significant differences in histopathologic (tumor size, tumor focality, histologic type, number of retrieved lymph nodes, metastatic lymph node, thyroiditis, retrieved parathyroid gland) findings were observed between the hypocalcemia group and normal calcium group. Mean value of the postoperative day-0 parathyroid hormone (PTH) was significantly lower in the hypocalcemia group (hypoca1cemia group: 14.3±9.4 pg/mL; normal group: 25.0±16.4 pg/mL; P<0.001). In logistic regression analysis, postoperative PTH was a factor significantly affecting postoperative hypocalcemia (OR 0.93; CI: 0.90-0.97; P<0.001). In ROC analysis, the cut-off value of PTH was 19.965 (sensitivity 79%, specificity 58%), and area under the curve (AUC) was 0.709 (95% CI: 0.607-0.811).

Conclusion

Postoperative PTH was a factor predicting hypocalcemia after total thyroidectomy with CLND. Use of postoperative PTH as a screening tool for prediction of postoperative hypocalcemia would be useful in management of patients with hypocalcemia.

Keywords: Thyroid cancer, Total thyroidectomy, Hypocalcemia, Parathyroid hormone

Figures and Tables

Fig. 1

Area under curve (AUC) of postoperative parathyroid hormone for postoperative hypocalcemia.

Fig. 2

Change of parathyroid hormone between hypocalcemia and normal group.

Table 1

Comparison of characteristics between hypocalcemic and normocalcemic patients

SD = standard deviation; ETE = extra-thyroidal extension; LN = lymph node; Ca = calcium; PTH = parathyroid hormone.

Table 2

Logistic regression analysis for hypocalcemia

ETE = extra-thyroidal extension; LN = lymph node; Ca = calcium; OR = odds ratio; CI = confidence interval; NA = not available; H-L = Hosmer-Lemeshow; DF = degree of freedom.

Table 3

Receiver Operating Characteristic (ROC) analysis of postoperative parathyroid hormone for hypocalcemia

PTH = parathyroid hormone; SEN = sensitivity; SPE = specificity; ACC = accuracy; PPV = positive predictive value; NPV = negative predictive value; AUC = area under the curve; CI = confidence interval. ^*The thresholds were computed by Youden's index.

References

1. Khan MI, Waguespack SG, Hu MI. Medical management of postsurgical hypoparathyroidism. Endocr Pract. 2011; 17:Suppl 1. 18–25.

2. Pattou F, Combemale F, Fabre S, Carnaille B, Decoulx M, Wemeau JL, et al. Hypocalcemia following thyroid surgery: incidence and prediction of outcome. World J Surg. 1998; 22:718–724.

3. Shindo ML, Sinha UK, Rice DH. Safety of thyroidectomy in residency: a review of 186 consecutive cases. Laryngoscope. 1995; 105:1173–1175.

4. Reeve T, Thompson NW. Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg. 2000; 24:971–975.

5. Nawrot I, Pragacz A, Pragacz K, Grzesiuk W, Barczyński M. Total thyroidectomy is associated with increased prevalence of permanent hypoparathyroidism. Med Sci Monit. 2014; 20:1675–1681.

6. Toniato A, Boschin IM, Piotto A, Pelizzo MR, Guolo A, Foletto M, et al. Complications in thyroid surgery for carcinoma: one institution's surgical experience. World J Surg. 2008; 32:572–575.

7. Chisholm EJ, Kulinskaya E, Tolley NS. Systematic review and meta-analysis of the adverse effects of thyroidectomy combined with central neck dissection as compared with thyroidectomy alone. Laryngoscope. 2009; 119:1135–1139.

8. Ardito G, Rulli F, Revelli L, Moschella F, Galatà G, Giustozzi E, et al. A less invasive, selective, functional neck dissection for papillary thyroid carcinoma. Langenbecks Arch Surg. 2005; 390:381–384.

9. Ywata de Carvalho A, Chulam TC, Kowalski LP. Long-term Results of Observation vs Prophylactic Selective Level VI Neck Dissection for Papillary Thyroid Carcinoma at a Cancer Center. JAMA Otolaryngol Head Neck Surg. 2015; 141:599–606.

10. Fahad Al-Dhahri S, Al-Ghonaim YA, Sulieman Terkawi A. Accuracy of postthyroidectomy parathyroid hormone and corrected calcium levels as early predictors of clinical hypocalcemia. J Otolaryngol Head Neck Surg. 2010; 39:342–348.

11. Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: a multivariate analysis of 5846 consecutive patients. Surgery. 2003; 133:180–185.

12. Park JH, Park HY, Jung JH, Hwang SO, Lee J, Kwon TJ, et al. Can parathyroid score expect hypocalcemia after total thyroidectomy? Korean J Endocr Surg. 2015; 15:34–40.

13. Gauger PG. Parathyroid gland. In : Townsend CM, editor. Sabiston Textbook of Surgery. 17th ed. Philadelphia: Elsevier Saunders;2004. p. 985–987.

14. Lombardi CP, Raffaelli M, Princi P, Santini S, Boscherini M, De Crea C, et al. Early prediction of postthyroidectomy hypocalcemia by one single iPTH measurement. Surgery. 2004; 136:1236–1241.

15. Chow TL, Choi CY, Chiu AN. Postoperative PTH monitoring of hypocalcemia expedites discharge after thyroidectomy. Am J Otolaryngol. 2014; 35:736–740.

16. Khafif A, Pivoarov A, Medina JE, Avergel A, Gil Z, Fliss DM. Parathyroid hormone: a sensitive predictor of hypocalcemia following total thyroidectomy. Otolaryngol Head Neck Surg. 2006; 134:907–910.

17. Puzziello A, Gervasi R, Orlando G, Innaro N, Vitale M, Sacco R. Hypocalcaemia after total thyroidectomy: could intact parathyroid hormone be a predictive factor for transient postoperative hypocalcemia? Surgery. 2015; 157:344–348.

18. Del Rio P, Sommaruga L, Bezer L, Arcuri MF, Cataldo S, Ceresini G, et al. Preoperative PTH as a marker of risk for post-thyroidectomy hypocalcemia. Minerva Endocrinol. 2010; 35:47–52.

19. Sitges-Serra A, Ruiz S, Girvent M, Manjón H, Dueñas JP, Sancho JJ. Outcome of protracted hypoparathyroidism after total thyroidectomy. Br J Surg. 2010; 97:1687–1695.

20. Youngwirth L, Benavidez J, Sippel R, Chen H. Parathyroid hormone deficiency after total thyroidectomy: incidence and time. J Surg Res. 2010; 163:69–71.

21. Chow TL, Chu W, Lim BH, Kwok SP. Outcomes and complications of thyroid surgery: retrospective study. Hong Kong Med J. 2001; 7:261–265.

22. Rosato L, Avenia N, Bernante P, De Palma M, Gulino G, Nasi PG, et al. Complications of thyroid surgery: analysis of a multicentric study on 14,934 patients operated on in Italy over 5 years. World J Surg. 2004; 28:271–276.

23. Barczyński M, Konturek A, Hubalewska-Dydejczyk A, Goł kowski F, Cichoń S, Nowak W. Five-year follow-up of a randomized clinical trial of total thyroidectomy versus Dunhill operation versus bilateral subtotal thyroidectomy for multinodular nontoxic goiter. World J Surg. 2010; 34:1203–1213.

24. Amir A, Sands NB, Tamilia M, Hier MP, Black MJ, Payne RJ. Preoperative serum calcium levels as an indicator of postthyroidectomy hypocalcemia. J Otolaryngol Head Neck Surg. 2010; 39:654–658.

25. Lips P. Worldwide status of vitamin D nutrition. J Steroid Biochem Mol Biol. 2010; 121:297–300.

26. Kirkby-Bott J, Markogiannakis H, Skandarajah A, Cowan M, Fleming B, Palazzo F. Preoperative vitamin D deficiency predicts postoperative hypocalcemia after total thyroidectomy. World J Surg. 2011; 35:324–330.

27. Falcone TE, Stein DJ, Jumaily JS, Pearce EN, Holick MF, McAneny DB, et al. Correlating pre-operative vitamin d status with post-thyroidectomy hypocalcemia. Endocr Pract. 2015; 21:348–354.

28. Salinger EM, Moore JT. Perioperative indicators of hypocalcemia in total thyroidectomy: the role of vitamin D and parathyroid hormone. Am J Surg. 2013; 206:876–881. discussion 881-2.

29. Lee GH, Ku YH, Kim HI, Lee MC, Kim MJ. Vitamin D level is not a predictor of hypocalcemia after total thyroidectomy. Langenbecks Arch Surg. 2015; 400:617–622.

30. Alhefdhi A, Mazeh H, Chen H. Role of postoperative vitamin D and/or calcium routine supplementation in preventing hypocalcemia after thyroidectomy: a systematic review and meta-analysis. Oncologist. 2013; 18:533–542.

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