Is surgery necessary for ‘mild’ or ‘asymptomatic’ hyperparathyroidism?

Abstract

A large majority of the currently diagnosed patients with hyperparathyroidism (PHPT) are mild or asymptomatic, mainly women after menopause. Following the debate held at the 16th European Congress of Endocrinology in Wroclaw (Poland) from May 3-7, 2014, arguments are here presented by a surgeon and a medical practitioner considering these situations rather have to profit from surgery, or simply from survey. For the trained endocrine surgeon, it is evident that parathyroidectomy confirms the diagnosis and undoubtedly reduces the discomfort felt by certain patients, prevents all risks of complications, removes patients and medical teams from the monitoring and represents a real individual financial benefit. On the other hand, the medical practitioner considers that mild or asymptomatic PHPT is commonly stable, and very rare are the subjects at risk of complications, particularly of fractures; prevention of vascular and metabolic disorders, nephrolithiasis and bone rarefaction justify regular physical exercise, a safe alimentation, a sufficient calcium and high water intake, the correction of the frequent deficit in vitamin D; finally has also to be considered the impossibility to refer to specialized (endocrine) surgeons, the enormous cohort of subjects more than 50 years with 'mild' or 'asymptomatic' PHPT. The surgeon and the medical practitioner agree to consider that in patients with 'mild' or 'asymptomatic' disease, there is no place for medical treatments, in particular calcimimetics and bisphophonates. Both agree that further studies are needed to clarify the long-term prognosis of operated and non-operated PHPT in term of fractures, cardiovascular risk and mortality. Individual and collective cost/benefit ratios of surgery or survey are also still imperfectly evaluated.

Early neurocognitive improvements following parathyroidectomy for primary hyperparathyroidism

“…Delayed recognition scores trended toward improvement. A comparison of these results (Table ) to the following age‐controlled normative data—ages 50 to 59 years, immediate recall 6.2 (standard deviation [SD] 1.2), delayed recall 9.9 (SD 3.2), and delayed recognition 13.9 (SD 1.4)— reveals that patients in the study had lower than normal immediate memory, delayed recall, and delayed recognition prior to surgery, which improved to above average after surgery.…”

“…However, in the years since serum calcium levels became part of routine laboratory testing, increasing the numbers of patients are being diagnosed incidentally who are presumably asymptomatic. In these cases, the indications for surgical management are not universally agreed upon …”

Preoperative diagnosis and prognosis in 40 Parathyroid Carcinoma Patients

“…A particular problem occurs in asymptomatic cases. A series of long‐term prospective studies have shown that mild and asymptomatic PHPT is usually stable and sometimes very slightly progressive . Many clinicians would avoid surgery for mild and asymptomatic PHPT.…”

“Silent” kidney stones in “asymptomatic” primary hyperparathyroidism—a comparison of multidetector computed tomography and ultrasound

“…In the current guidelines [1], “asymptomatic” patients compose a patients’ group inheriting only a “relative indication” for surgery while in “symptomatic” patients early surgical intervention is recommended [23], so those patient groups need to be discriminated [24]. …”