Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Minimally Symptomatic Hyperparathyroidism An NIH consensus conference was convened in 1991 to define recommended criteria for parathyroidectomy. They stated that there was an asymptomatic group of patients with mild hyperparathyroidism which may not require surgery. Since then, there have been multiple reports that these "asymptomatic" patients actually do have symptoms, and that these are relieved by surgery. This grand rounds reviews the current literature. The NIH conference defined these two groups of patients with hyperparathyroidism:
Multiple studies show a high prevalence of subtle symptoms in "asymptomatic" patients. These include fatigue, weakness, depression, memory loss, personality change, exercise fatigue, back pain, polydipsia, polyuria, constipation, etc. In a case-control study of 152 patients (Chan et al, 1995), it was shown that the prevalence of these symptoms were statistically higher than in normal controls, and that parathyroidectomy relieved many of these subtle symptoms. Another study (Solomon et al., 1994), evaluated the prevalence of psychological symptoms in patients with "asymptomatic" hyperparathyroidism, with similar findings. The effects of minimally symptomatic hyperparathyroidism on bone density has been recently reported. Silverberg et al (1995) followed 66 patients with hyperparathyroidism who did not meet NIH criteria for surgery for 6 years. They also followed 24 patients who did meet surgical criteria, but refused surgery. Although all patients had reduced bone mass compared to normal controls, there was no progression of their disease (i.e. no change in bone density, serum calcium, or PTH level, and no onset of any new symptoms). Additionally, they followed 34 patients who did meet NIH criteria for surgery, and did have surgery. They noted significant (4-13%) increase in bone density. McDermott et al. (1994) gave patients with asymptomatic hyperparathyroidism estrogen, and noted an increase in bone density, nearly to normal levels. Summary of pros and cons for early surgery in patients with minimally symptomatic hyperparathyroidism: Against early surgery:
For early surgery:
Case Presentation A 52-year-old man presented to the Endocrine service after having his first attack of pancreatitis. During that episode, routine chemistries revealed an elevated serum calcium of 11.6 mg/dL (nml 8.5-10.6), while serum albumin and protein levels were normal. A parathyroid hormone assay demonstrated an elevated PTH level of 72 pg/ml (nml 10-65). Two months later, after his pancreatitis had fully resolved, follow-up studies revealed a serum calcium of 11.3 mg/dL and a PTH level of 54. Twenty-four hour urine calcium excretion was 351 mg/24 hours (nml 50-300). Five months after this, his serum calcium was 12.0 and his PTH level was 73. Ultrasound of the neck demonstrated a 2.6 by 2.7 cm mass at the inferior pole of the left thyroid gland. He was then referred to the Otolaryngology - Head and Neck Surgery service for parathyroidectomy. The patient denied recurrence of pancreatitis. He never had a fracture, kidney stone, peptic ulcer disease, hypertension, or gout. He denied any symptoms of renal colic, bone pain, abdominal pain, or depression. In fact, he stated that he felt perfectly well, and did not want surgery. After much discussion of the risks and benefits of surgery, the patient continued to refuse surgery, and is currently being followed in endocrine and otolaryngology clinics. Bibliography Akerstrom G, Rastad J, Juhlin C, Ljunghall S. Primary hyperparathyroidism. Aspects on pathophysiology, symptoms, and treatment. Surg Ann 1991;23:133-155. Akerstrom G, Rastad J, Ljunghall S, Ridefelt P, Juhlin C, Gylfe E. Cellular physiology and pathophysiology of the parathyroid glands. World J Surg 1991;15:672-680. Anonymous. Proceedings of the NIH Consensus Development Conference on diagnosis and management of asymptomatic primary hyperparathyroidism. Bethesda, Maryland, October 29-31, 1990:S1-166. Arnold A. Molecular mechanisms of parathyroid neoplasia. Endocrinol Metabol Clin North Am 1994;23:93-107. Attie JN. Primary hyperparathyroidism. Curr Therapy Endocrinol Metabol 1994;5:515-522. Bailey B, Johnson J, Kohut R, Pillsbury H, Tardy M. Head and Neck Surgery - Otolaryngology. Philadelphia: J. B. Lippincott Company, 1993. Bartsch D, Nies C, Hasse C, Willuhn J, Rothmund M. Clinical and surgical aspects of double adenoma in patients with primary hyperparathyroidism. British Journal of Surgery 1995;82:926-929. Chan AK, Duh QY, Katz MH, Siperstein AE, Clark OH. Clinical manifestations of primary hyperparathyroidism before and after parathyroidectomy. A case-control study. Ann Surg 1995; 222:402-12; discussion 412-4. Chigot JP, Menegaux F, Achrafi H. Should primary hyperparathyroidism be treated surgically in elderly patients older than 75 years? Surg 1995;4:397-401. Chou FF, Sheen-Chen SM, Leong CP. Neuromuscular recovery after parathyroidectomy in primary hyperparathyroidism. Surg 1994;117:18-25. Clark OH. "Asymptomatic" primary hyperparathyroidism: is parathyroidectomy indicated?. Surg 1994;116:947-953. Clark OH. Surgical treatment of primary hyperparathyroidism. Adv Endocrinol Metabol 1995; 6:1-16. Deftos LJ, Parthemore JG, Stabile BE. Management of primary hyperparathyroidism. Ann Rev Med 1993;44:19-26. Doppman J, Miller D. Localization of parathyroid tumors in patients with asymptomatic hyperparathyroidism and no previous surgery. J Bone Miner 1986;6(Suppl 2):s153-s158. Duh QY, Uden P, Clark OH. Unilateral neck exploration for primary hyperparathyroidism: analysis of a controversy using a mathematical model. 1992;16:654-61; discussion 661-2. Garton M, Martin J, Stewart A, Krukowski Z, Matheson N, Robins S, Loveridge N, Reid D. Changes in bone mass and metabolism after surgery for primary hyperparathyroidism. Clin Endocrinol 1995;42:493-500. Halvorson DJ, Burke GJ, Mansberger AR, Wei JP. Use of technetium Tc 99m sestamibi and iodine 123 radionuclide scan for preoperative localization of abnormal parathyroid glands in primary hyperparathyroidism. South Med J 1994;87:336-339. Harrison BJ, Wheeler MH. Asymptomatic primary hyperparathyroidism. World J Surg 1991;15:724-729. Heath H 3d. Primary hyperparathyroidism: recent advances in pathogenesis, diagnosis, and management. Adv Intern Med 1992;37:275-293. Hedback G, Oden A, Tisell LE. Parathyroid adenoma weight and the risk of death after treatment for primary hyperparathyroidism. Surg (1995;117:134-139. Hedback G, Tisell L., Bengtsson B, Hedman I, Oden A. Premature death in patients operated on for primary hyperparathyroidism. World J Surg 1990;14:829-836. Hiatt J, Hiatt N. The Parathyroid Saga: Gland, Hormone, and Adenoma. Cont Surg 1995;47:332-336. Hindie E. Primary hyperparathyroidism: is technetium99 - sestamibi/iodine-123 subtraction scanning the best procedure to locate enlarged glands before surgery? J Clin Endocrinol Metabol 1995;80:302-307. Kaplan EL, Yashiro T, Salti G. Primary hyperparathyroidism in the 1990s. Choice of surgical procedures for this disease. Ann Surg 1992;215:300-317. Khan A, Samtani S, Varma VM, Frost A., Cohen J. Preoperative parathyroid localization: prospective evaluation of technetium 99m sestamibi. Otolaryngol Head Neck Surg 1994;111:467-472. LiVolsi VA., Hamilton R. Intraoperative assessment of parathyroid gland pathology. A common view from the surgeon and the pathologist. Am J Clin Parhol 1994;102:365-373. Lundgren EC, Gillott AR, Wiseman JS, Beck J. The role of preoperative localization in primary hyperparathyroidism. Am Surg 1995;75:393-396. Marx SJ. Etiologies of parathyroid gland dysfunction in primary hyperparathyroidism. J Bone Mineral Res 1991;6(Suppl 2):S19-24; discussion S31-2. McDermott MT, Perloff JJ, Kidd GS. Effects of mild asymptomatic primary hyperparathyroidism on bone mass in women with and without estrogen replacement therapy. J Bone Min Res 1994;9:509-514. Mitchell BK., Kinder BK., Cornelius E, Stewart AF. Primary hyperparathyroidism: preoperative localization using technetium-sestamibi scanning. Clin Endocrinol Metabol 1995;80:7-10. Mitchell BK., Merrell RC, Kinder BK. Localization studies in patients with hyperparathyroidism. Surg Clin North Am 1995;75:483-498. Morrow JS, Miller RH. Diagnosis and management of primary hyperparathyroidism. J Lou State Med Soc 1994;146:77-82. Norton J. Controversies and advances in primary hyperparathyroidism. Ann Surg 1992;215:297-299. Obara T, Fujimoto Y. Diagnosis and treatment of patients with parathyroid carcinoma: an update and review. World J Surg 1991;15:738-744. Oertli D, Richter M, Kraenzlin M, Staub JJ, Oberholzer M, Haas HG, Harder F. Parathyroidectomy in primary hyperparathyroidism: preoperative localization and routine biopsy of unaltered glands are not necessary. Surg 1995;117:392-396. Palmer M, Adami H, Bergstrom R, Jacobsson S, Akerstrom G, Ljunghall S. Survival and renal function in persons with untreated hypercalcemia: A population based cohort study with 14 years of follow up. Lancet 1987;1:59-62. Rodriquez JM, Tezelman S, Siperstein AE, Duh QY, Higgins C, Morita E, Dowd CF, Clark OH. Localization procedures in patients with persistent or recurrent hyperparathyroidism. Arch Surg 1994;129:870-875. Silverberg SJ, Gartenberg F, Jacobs TP, Shane E, Siris E, Staron RB, Bilezikian JP. Longitudinal measurements of bone density and biochemical indices in untreated primary hyperparathyroidism. J Clin Endocrinol Metabol 1995;80:723-728. Solomon BL, Schaaf M, Smallridge RC. Psychologic symptoms before and after parathyroid surgery Am J Med 1994;96:101-106. Strewler GJ. Indications for surgery in patients with minimally symptomatic primary hyperparathyroidism. Surg Clin North Am 1995;75:439-447. Wang C. Parathyroid re-exploration Ann Surg 1977;186:140 Weber CJ, Sewell CW, McGarity WC. Persistent and recurrent sporadic primary hyperparathyroidism: histopathology, complications, and results of reoperation. Surg 1994;116:991-998. Weinberger MS, Robbins KT. Diagnostic localization studies for primary hyperparathyroidism. A suggested algorithm Arch Otolaryngol Head Neck Surg 1994;120:1187-1189. Whitman ED, Norton JA. Endocrine surgical diseases of elderly patients. Surg Clin North Am 1994;74:127-144. Wilson J, Braunwald E, Isselbacher K., Petersdorf R, Martin J, Fauci A., Root R. Harrison's Principles of Internal Medicine, 12th ed. New York: McGraw-Hill, 1991. Grand Rounds Archive | Department Home page BCM Public | BCM Intranet | Privacy Notices | Contact BCM | BCM Site Map | ©2001-2006 Baylor College of Medicine
|