Presentation, diagnostic assessment and surgical outcomes in primary hyperparathyroidism: a single centre’s experience

Abstract

ObjectivePrimary hyperparathyroidism (PHPT) is a common reason for referral to endocrinology but the evidence base guiding assessment is limited. We evaluated the clinical presentation, assessment and subsequent management in PHPT.DesignRetrospective cohort study.PatientsPHPT assessed between 2006 and 2014 (n = 611) in a university hospital.MeasurementsSymptoms, clinical features, biochemistry, neck radiology and surgical outcomes.ResultsFatigue (23.8%), polyuria (15.6%) and polydipsia (14.9%) were associated with PHPT biochemistry. Bone fracture was present in 16.4% but was not associated with biochemistry. A history of nephrolithiasis (10.0%) was associated only with younger age (P = 0.006) and male gender (P = 0.037). Thiazide diuretic discontinuation was not associated with any subsequent change in calcium (P = 0.514). Urine calcium creatinine clearance ratio (CCCR) was <0.01 in 18.2% of patients with confirmed PHPT. Older age (P < 0.001) and lower PTH (P = 0.043) were associated with failure to locate an adenoma on ultrasound (44.0% of scans). When an adenoma was identified on ultrasound the lateralisation was correct in 94.5%. Non-curative surgery occurred in 8.2% and was greater in those requiring more than one neck imaging modality (OR 2.42, P = 0.035).ConclusionsClinical features associated with PHPT are not strongly related to biochemistry. Thiazide cessation does not appear to attenuate hypercalcaemia. PHPT remains the likeliest diagnosis in the presence of low CCCR. Ultrasound is highly discriminant when an adenoma is identified but surgical failure is more likely when more than one imaging modality is required.

The accuracy of ultrasonography for detection of enlarged parathyroid glands in patients with different forms of hyperparathyroidism

“…In our study we observed much higher number of patients having symptoms and clinical signs of HPT than others did. For example Reid et al 8 showed that a history of nephrolithiasis was present in 10.0% of their patients with pHPT in contrast to 90% in our study. It is interesting that the anamnestic data about bone fracture were very similar (15-16%).…”

“…Measurements were least accurate for adenomas measuring less than 1 cm in diameter. In a recent study of Reid et al 8 performed in 374 patients, neck ultrasound was able to detect adenomas only in 66.0% patients with pHPT. The failure in adenoma detection was associated with older age, lower peak Ca, lower PTH and higher creatinine levels.…”

“…In addition, we also found the predominant localization of pathological changes in the inferior PTG, predominantly in the left lower quadrant. Some authors reported predominant right lower localization 8,33 , or equal right-left lower localization 34 . The exact localization of PTG is of particular importance for planning the adequate surgical procedure 35 .…”

“…The traditional technique has been a bilateral neck exploration under general anaesthesia, involving the evaluation of all four glands. Subsequent removal of pathological PTG by skilled surgeons provides a high rate of cure exceeding 95% 8 . Parathyroid surgery was also indicated for patients with hipercalcemia, high PTH level and/or renal osteodystrophy in sPHP which cannot be successfully medicated.…”

Pre-analytical mysteries: A case of severe hypervitaminosis D and mild hypercalcaemia

“…The 2009 consensus panel on Guidelines in the Management of Asymptomatic PHPT set the CCCR threshold value at less than 0.01 for the diagnosis of FHH, and greater than 0.02 for the diagnosis of PHPT ( 23 ). However there is considerable overlap in CCCR in the two conditions, with up to 20% of individuals with FHH having a CCCR > 0.01, and up to 18.2% of individuals with surgically proven PHPT having preoperative CCCR < 0.01 ( 24 , 25 ). CCCR may be lowered with vitamin D deficiency, renal dysfunction, old age, low dietary calcium intake, and the use of thiazide diuretics and anti-resorptive agents for osteoporosis.…”