Adenoma, Endocrine Gland Neoplasms, Hypercalcemia, Hyperparathyroidism, Hyperparathyroidism, Primary, Neoplasms, Glandular and Epithelial, Parathyroid Adenoma, Parathyroid Diseases, Parathyroid Dysfunction, Parathyroid Neoplasms
Conditions
Keywords
Near Infrared Autofluorescence, Parathyroidectomy, Intraoperative Parathyroid Identification, Persistent Hyperparathyroidism, Persistent Hypercalcemia, Failed Parathyroidectomy, Repeat Parathyroidectomy
Brief summary
The goal of this study is to assess whether using PTeye (AiBiomed, Santa Barbara, CA) - a NIRAF detection modality - can improve patient outcomes and reduce healthcare associated costs after parathyroid surgeries. By being able to quickly and definitively locate parathyroid glands while in the operating room, the duration of surgical procedure could be further reduced. In addition, the number of frozen section biopsy and associated costs can be minimized. Furthermore, repeat surgeries as a result of missing a diseased parathyroid gland at the time of the initial parathyroidectomy for hyperparathyroidism could potentially be avoided.
Detailed description
This is a prospective, single-blinded, randomized study comparing the use of PTeye during parathyroidectomy to usual standard practice. PRIMARY OBJECTIVES: I. Assess the impact of PTeye on intra-operative identification of parathyroid tissues. II. Assess the impact of PTeye on improving efficiency of parathyroid surgeries. III. Assess the impact of PTeye on minimizing risk of post-surgical complications. Participants will be randomized to either the experimental or control arm. The surgeon will first take 5 baseline NIRAF measurements on the thyroid gland (or neck muscles, if thyroid is absent) using the disposable sterile fiber probe that is connected to the PTeye console, as per device functionality requirements. The subsequent step would involve touching the target tissue in the neck with the fiber optic probe, following which the PTeye will indicate to the surgeon if the tissue is likely parathyroid or not. For patients assigned to the control arm, the surgeon will not use the PTeye and will proceed with the parathyroid surgery as usual, while relying solely on her/his surgical experience in identifying the parathyroid glands during the operations. Participants will be follow-ed up for up to 6 months after surgery.
Interventions
Intraoperative Tool
Sponsors
Study design
Masking description
Only participants will be masked to the intervention
Eligibility
Inclusion criteria
* All adults \>=18 years old) patients with primary hyperparathyroidism who will be undergoing parathyroid surgery * All adult (\>=18 years old) patients with persistent primary hyperparathyroidism after having undergone a failed prior parathyroid surgery who will be undergoing repeat parathyroid surgery
Exclusion criteria
* Children and minors * Pregnant women * Patients with concurrent parathyroid and thyroid disease that require total thyroidectomy * Patients with secondary or tertiary hyperparathyroidism
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Median Number of Frozen Sections (or Parathyroid Aspirate) Sent for Analysis | At the end of the parathyroidectomy, up to 5 hours | Median number of frozen sections (or aspirate) sent for analysis during the parathyroidectomy (PTx) procedure to confirm potential parathyroid tissue |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Number of Participants With Persistent Hyperparathyroidism or Hypercalcemia (Transient) | 5-14 days after PTx procedure | Elevated blood calcium levels (total blood calcium level \> 10.5 mg/dL or 2.6 mmol/L) with/without elevated parathyroid hormone (PTH) (serum intact PTH \> 65 pg/ml or 6.9 pmol/L) at first postoperative visit. Participants will be categorized as having persistent hyperparathyroidism or hypercalcemia (transient) Yes or No. |
| Number of Participants Persistent Hyperparathyroidism or Hypercalcemia (Failed Parathyroidectomy) | Up to 6 months after PTx procedure | If blood calcium with/without parathyroid hormone (PTH) has not normalized at 1st post-operative visit, calcium and/or PTH is subsequently measured as necessary. Patient is defined to have a failed parathyroidectomy if hypercalcemia/hyperparathyroidism (defined as total blood calcium level \> 10.5 mg/dL or 2.6 mmol/L, with/without elevated serum intact PTH \> 65 pg/ml or 6.9 pmol/L) persists at or after the 6th postoperative month. Participants will be categorized has having persistent hyperparathyroidism or hypercalcemia (failed parathyroidectomy), Yes or No. |
| Number of Parathyroid Glands (PG) Identified | At the end of the parathyroidectomy, up to 5 hours | Overall number of parathyroid glands identified (Combined both the experimental Group (Glands identified with naked eye + NIRAF) and Control Group (Glands identified with naked eye) |
| Median Number of Parathyroid Glands Identified With NIRAF (PTeye Group Only) | At the end of the parathyroidectomy, up to 5 hours | Median number of parathyroid glands identified with NIRAF, which was not seen with surgeon's naked eye during bilateral neck explorations (where the surgeon is looking for more than 1 parathyroid gland) |
| Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands | At the end of the parathyroidectomy, up to 5 hours | Median number of diseased parathyroid glands identified intra-operatively versus glands localized preoperatively using sestamibi, Computerized tomography (CT) or ultrasound |
| Median Number of Intra-operative Parathyroid Hormone (PTH) Assays Sent | At the end of the parathyroidectomy, up to 5 hours | The median number of intra-operative parathyroid hormone assays (per person) sent during the procedure to the lab |
| Median Duration Taken to Identify First Parathyroid Gland | During parathyroidectomy, up to 5 hours | Median duration in minutes taken to identify 1st parathyroid gland in PTx procedure - timed from skin incision to finding PG |
| Number of Participants With Persistent Hyperparathyroidism (Immediate) | 5-14 days after PTx procedure | Failure of intra-operative parathyroid hormone (PTH) to normalize (defined as failure of PTH to drop \> 50% of its baseline value at final intra-operative PTH assay and/or failure of PTH to drop \< 65 pg/ml or 6.9 pmol/L). Participants will be categorized as having persistent hyperparathyroidism (Immediate) Yes or No. |
| Median Duration of Parathyroidectomy (PTx) Procedure | Up to 5 hours | Median duration of PTx procedure - timed from skin incision until the surgeon notifies the anesthesia team to awaken the patient in minutes |
| Median Duration for Intraoperative Parathyroid Hormone (PTH) to Normalize | At the end of the parathyroidectomy, up to 5 hours | Median time in minutes taken for PTH to attain cure criteria or normalize - timed from skin incision until the PTH levels drops \> 50% of its baseline value and/or PTH drops \< 65 pg/ml or 6.9 pmol/L |
| Median Number of Nights in the Hospital After Parathyroidectomy | 0-72 hours after PTx procedure | Median number of nights spent in the hospital post-surgery is defined as having spent \<= 23 hours (0 nights) or \> 23 hours (1 night) at the hospital for postoperative recovery after the surgical procedure. Participants who had surgery scheduled for later in the day will be counted as spending one night in the hospital due to the minimum required observation period post-surgery and followed institutional standards for discharge; discharged the next day. Participants who had surgery scheduled for earlier in the day were discharged on the same day of surgery. |
| Median Number of 'False Positive' Tissue Samples Excised by Surgeon | Up to 10 days after PTx procedure | The median number of tissues per person that were excised by surgeon assumed to be parathyroid tissue, but is later validated as non-parathyroid tissue (false positive) by histology |
| Number of Participants With Reported Doctor Visits/Emergency Department Visits or Hospital Admissions | Up to 6 months after PTx procedure | Number of participants who required a doctor visit/emergency department visit and/or hospital admission due to persistent hypercalcemia and/or associated symptoms after the parathyroidectomy procedure will be categorized as binary (yes or no) if any follow-up visits or admissions occurred. |
| Number of Participants Who Have Had Repeat Parathyroidectomy (PTx) Procedure | From 6 - 12 months after PTx procedure | Number of participants with an indication that repeat PTx procedure may need to be performed after the current procedure will be categorized as binary (yes or no) |
| Median Duration Taken to Identify Last Parathyroid Gland | At the end of the parathyroidectomy, up to 5 hours | Median duration taken to identify last parathyroid gland in PTx procedure - timed from skin incision to finding the last PG |
Countries
United States
Participant flow
Participants by arm
| Arm | Count |
|---|---|
| Parathyroid Eye (PTeye) For participants assigned to the study arm, the surgeon will use the PTeye as an intraoperative tool to identify if a suspect tissue is a parathyroid or not, during the parathyroid surgery. | 38 |
| Usual Standard of Care The surgeon will proceed with the parathyroid surgery as usual, while relying solely on her/his surgical experience in identifying the parathyroid glands during the operations. | 41 |
| Total | 79 |
Baseline characteristics
| Characteristic | Parathyroid Eye (PTeye) | Total | Usual Standard of Care |
|---|---|---|---|
| Age, Continuous | 68 years | 67 years | 64 years |
| Ethnicity (NIH/OMB) Hispanic or Latino | 1 Participants | 5 Participants | 4 Participants |
| Ethnicity (NIH/OMB) Not Hispanic or Latino | 37 Participants | 73 Participants | 36 Participants |
| Ethnicity (NIH/OMB) Unknown or Not Reported | 0 Participants | 1 Participants | 1 Participants |
| Race (NIH/OMB) American Indian or Alaska Native | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Asian | 4 Participants | 7 Participants | 3 Participants |
| Race (NIH/OMB) Black or African American | 2 Participants | 4 Participants | 2 Participants |
| Race (NIH/OMB) More than one race | 0 Participants | 0 Participants | 0 Participants |
| Race (NIH/OMB) Native Hawaiian or Other Pacific Islander | 1 Participants | 2 Participants | 1 Participants |
| Race (NIH/OMB) Unknown or Not Reported | 4 Participants | 12 Participants | 8 Participants |
| Race (NIH/OMB) White | 27 Participants | 54 Participants | 27 Participants |
| Region of Enrollment United States | 38 participants | 79 participants | 41 participants |
| Sex: Female, Male Female | 27 Participants | 57 Participants | 30 Participants |
| Sex: Female, Male Male | 11 Participants | 22 Participants | 11 Participants |
Adverse events
| Event type | EG000 affected / at risk | EG001 affected / at risk |
|---|---|---|
| deaths Total, all-cause mortality | 0 / 38 | 0 / 41 |
| other Total, other adverse events | 0 / 38 | 0 / 41 |
| serious Total, serious adverse events | 2 / 38 | 5 / 41 |
Outcome results
Median Number of Frozen Sections (or Parathyroid Aspirate) Sent for Analysis
Median number of frozen sections (or aspirate) sent for analysis during the parathyroidectomy (PTx) procedure to confirm potential parathyroid tissue
Time frame: At the end of the parathyroidectomy, up to 5 hours
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of Frozen Sections (or Parathyroid Aspirate) Sent for Analysis | 0 frozen aspirate samples |
| Usual Standard of Care | Median Number of Frozen Sections (or Parathyroid Aspirate) Sent for Analysis | 0 frozen aspirate samples |
Median Duration for Intraoperative Parathyroid Hormone (PTH) to Normalize
Median time in minutes taken for PTH to attain cure criteria or normalize - timed from skin incision until the PTH levels drops \> 50% of its baseline value and/or PTH drops \< 65 pg/ml or 6.9 pmol/L
Time frame: At the end of the parathyroidectomy, up to 5 hours
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Duration for Intraoperative Parathyroid Hormone (PTH) to Normalize | 76 minutes |
| Usual Standard of Care | Median Duration for Intraoperative Parathyroid Hormone (PTH) to Normalize | 66 minutes |
Median Duration of Parathyroidectomy (PTx) Procedure
Median duration of PTx procedure - timed from skin incision until the surgeon notifies the anesthesia team to awaken the patient in minutes
Time frame: Up to 5 hours
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Duration of Parathyroidectomy (PTx) Procedure | 87 minutes |
| Usual Standard of Care | Median Duration of Parathyroidectomy (PTx) Procedure | 82 minutes |
Median Duration Taken to Identify First Parathyroid Gland
Median duration in minutes taken to identify 1st parathyroid gland in PTx procedure - timed from skin incision to finding PG
Time frame: During parathyroidectomy, up to 5 hours
Population: Data was not collected for one participant from each group
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Duration Taken to Identify First Parathyroid Gland | 38 minutes |
| Usual Standard of Care | Median Duration Taken to Identify First Parathyroid Gland | 31 minutes |
Median Duration Taken to Identify Last Parathyroid Gland
Median duration taken to identify last parathyroid gland in PTx procedure - timed from skin incision to finding the last PG
Time frame: At the end of the parathyroidectomy, up to 5 hours
Population: Data was not collected for one participant from each group
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Duration Taken to Identify Last Parathyroid Gland | 48 minutes |
| Usual Standard of Care | Median Duration Taken to Identify Last Parathyroid Gland | 35 minutes |
Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands
Median number of diseased parathyroid glands identified intra-operatively versus glands localized preoperatively using sestamibi, Computerized tomography (CT) or ultrasound
Time frame: At the end of the parathyroidectomy, up to 5 hours
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands | Intra-operatively | 1 parathyroid glands |
| Parathyroid Eye (PTeye) | Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands | Localized pre-operatively | 1 parathyroid glands |
| Usual Standard of Care | Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands | Intra-operatively | 1 parathyroid glands |
| Usual Standard of Care | Median Number of Diseased Parathyroid Glands Identified Versus Preoperatively Localized Glands | Localized pre-operatively | 1 parathyroid glands |
Median Number of 'False Positive' Tissue Samples Excised by Surgeon
The median number of tissues per person that were excised by surgeon assumed to be parathyroid tissue, but is later validated as non-parathyroid tissue (false positive) by histology
Time frame: Up to 10 days after PTx procedure
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of 'False Positive' Tissue Samples Excised by Surgeon | 0 tissue samples |
| Usual Standard of Care | Median Number of 'False Positive' Tissue Samples Excised by Surgeon | 0 tissue samples |
Median Number of Intra-operative Parathyroid Hormone (PTH) Assays Sent
The median number of intra-operative parathyroid hormone assays (per person) sent during the procedure to the lab
Time frame: At the end of the parathyroidectomy, up to 5 hours
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of Intra-operative Parathyroid Hormone (PTH) Assays Sent | 5 assays |
| Usual Standard of Care | Median Number of Intra-operative Parathyroid Hormone (PTH) Assays Sent | 5 assays |
Median Number of Nights in the Hospital After Parathyroidectomy
Median number of nights spent in the hospital post-surgery is defined as having spent \<= 23 hours (0 nights) or \> 23 hours (1 night) at the hospital for postoperative recovery after the surgical procedure. Participants who had surgery scheduled for later in the day will be counted as spending one night in the hospital due to the minimum required observation period post-surgery and followed institutional standards for discharge; discharged the next day. Participants who had surgery scheduled for earlier in the day were discharged on the same day of surgery.
Time frame: 0-72 hours after PTx procedure
| Arm | Measure | Group | Value (MEDIAN) |
|---|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of Nights in the Hospital After Parathyroidectomy | <= 23 hours | 0 number of nights |
| Parathyroid Eye (PTeye) | Median Number of Nights in the Hospital After Parathyroidectomy | > 23 hours | 1 number of nights |
| Usual Standard of Care | Median Number of Nights in the Hospital After Parathyroidectomy | <= 23 hours | 0 number of nights |
| Usual Standard of Care | Median Number of Nights in the Hospital After Parathyroidectomy | > 23 hours | 1 number of nights |
Median Number of Parathyroid Glands Identified With NIRAF (PTeye Group Only)
Median number of parathyroid glands identified with NIRAF, which was not seen with surgeon's naked eye during bilateral neck explorations (where the surgeon is looking for more than 1 parathyroid gland)
Time frame: At the end of the parathyroidectomy, up to 5 hours
Population: Only 4 participants had glands identified with NIRAF, which was not seen with surgeon's naked eye
| Arm | Measure | Value (MEDIAN) |
|---|---|---|
| Parathyroid Eye (PTeye) | Median Number of Parathyroid Glands Identified With NIRAF (PTeye Group Only) | 1 parathyroid glands |
Number of Parathyroid Glands (PG) Identified
Overall number of parathyroid glands identified (Combined both the experimental Group (Glands identified with naked eye + NIRAF) and Control Group (Glands identified with naked eye)
Time frame: At the end of the parathyroidectomy, up to 5 hours
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Parathyroid Glands (PG) Identified | 45 parathyroid glands |
| Usual Standard of Care | Number of Parathyroid Glands (PG) Identified | 45 parathyroid glands |
Number of Participants Persistent Hyperparathyroidism or Hypercalcemia (Failed Parathyroidectomy)
If blood calcium with/without parathyroid hormone (PTH) has not normalized at 1st post-operative visit, calcium and/or PTH is subsequently measured as necessary. Patient is defined to have a failed parathyroidectomy if hypercalcemia/hyperparathyroidism (defined as total blood calcium level \> 10.5 mg/dL or 2.6 mmol/L, with/without elevated serum intact PTH \> 65 pg/ml or 6.9 pmol/L) persists at or after the 6th postoperative month. Participants will be categorized has having persistent hyperparathyroidism or hypercalcemia (failed parathyroidectomy), Yes or No.
Time frame: Up to 6 months after PTx procedure
Population: Participants from both groups were missing labs. Not all PTEye participants returned to the clinic for blood draws within 5-14 days to obtain lab values required to calculate this endpoint and standard clinical care does not necessitate participants returning for labs routinely at each follow-up time points.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Participants Persistent Hyperparathyroidism or Hypercalcemia (Failed Parathyroidectomy) | 0 Participants |
| Usual Standard of Care | Number of Participants Persistent Hyperparathyroidism or Hypercalcemia (Failed Parathyroidectomy) | 1 Participants |
Number of Participants Who Have Had Repeat Parathyroidectomy (PTx) Procedure
Number of participants with an indication that repeat PTx procedure may need to be performed after the current procedure will be categorized as binary (yes or no)
Time frame: From 6 - 12 months after PTx procedure
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Participants Who Have Had Repeat Parathyroidectomy (PTx) Procedure | 0 Participants |
| Usual Standard of Care | Number of Participants Who Have Had Repeat Parathyroidectomy (PTx) Procedure | 1 Participants |
Number of Participants With Persistent Hyperparathyroidism (Immediate)
Failure of intra-operative parathyroid hormone (PTH) to normalize (defined as failure of PTH to drop \> 50% of its baseline value at final intra-operative PTH assay and/or failure of PTH to drop \< 65 pg/ml or 6.9 pmol/L). Participants will be categorized as having persistent hyperparathyroidism (Immediate) Yes or No.
Time frame: 5-14 days after PTx procedure
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Participants With Persistent Hyperparathyroidism (Immediate) | 0 Participants |
| Usual Standard of Care | Number of Participants With Persistent Hyperparathyroidism (Immediate) | 1 Participants |
Number of Participants With Persistent Hyperparathyroidism or Hypercalcemia (Transient)
Elevated blood calcium levels (total blood calcium level \> 10.5 mg/dL or 2.6 mmol/L) with/without elevated parathyroid hormone (PTH) (serum intact PTH \> 65 pg/ml or 6.9 pmol/L) at first postoperative visit. Participants will be categorized as having persistent hyperparathyroidism or hypercalcemia (transient) Yes or No.
Time frame: 5-14 days after PTx procedure
Population: Participants from both groups were missing labs. Not all PTEye participants returned to the clinic for blood draws within 5-14 days to obtain lab values required to calculate this endpoint and standard clinical care does not necessitate participants returning for labs routinely at each follow-up time points.
| Arm | Measure | Value (COUNT_OF_PARTICIPANTS) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Participants With Persistent Hyperparathyroidism or Hypercalcemia (Transient) | 0 Participants |
| Usual Standard of Care | Number of Participants With Persistent Hyperparathyroidism or Hypercalcemia (Transient) | 0 Participants |
Number of Participants With Reported Doctor Visits/Emergency Department Visits or Hospital Admissions
Number of participants who required a doctor visit/emergency department visit and/or hospital admission due to persistent hypercalcemia and/or associated symptoms after the parathyroidectomy procedure will be categorized as binary (yes or no) if any follow-up visits or admissions occurred.
Time frame: Up to 6 months after PTx procedure
| Arm | Measure | Value (NUMBER) |
|---|---|---|
| Parathyroid Eye (PTeye) | Number of Participants With Reported Doctor Visits/Emergency Department Visits or Hospital Admissions | 5 participants |
| Usual Standard of Care | Number of Participants With Reported Doctor Visits/Emergency Department Visits or Hospital Admissions | 8 participants |