Factors associated with late recurrence after parathyroidectomy for primary hyperparathyroidism

Persistent elevated serum parathyroid hormone levels with normocalcaemia after parathyroidectomy: Secondary hyperparathyroidism or pseudo- hyperparathyroidism?

INTRODUCTION

This study aimed to determine the time to normalisation of postoperative parathyroid hormone levels after successful parathyroid surgery and to analyse the pathophysiology of postoperative normocalcaemic hyperparathyroidism.

METHOD

An observational retrospective study was conducted on a cohort of 186 patients who had undergone parathyroidectomy for primary hyperparathyroidism over a 5-year period. Demographic characteristics, surgical and histopathological data, bone densitometry (pre-and postoperative pharmacological treatment), creatinine plasma levels, and pre-and postoperative parathyroid hormone, calcium and vitamin D levels were recorded as predictive variables. The time to normalisation of the postoperative parathyroid hormone levels was recorded as the output variable. A univariate analysis was performed to investigate the factors related to the time to normalisation of parathyroid hormone levels.

RESULTS

The final study sample was comprised of 176 patients, 46 of which (26.1%) had elevated postoperative parathyroid hormone levels and normocalcaemia. The median time to normalisation of the postoperative parathyroid hormone levels was 6 months. The cumulative probability of having normal parathyroid hormone levels 30 months after surgery was 89%. The time to normalisation was associated only with preoperative parathyroid hormone levels (P = .007; HR: 0.998). Vitamin D and creatinine levels were not associated with time to normalisation of parathyroid hormone levels (P = .744).

CONCLUSIONS

Persistently elevated postoperative parathyroid hormone levels with normocalcaemia may occur in one-quarter of patients after parathyroidectomy. Parathyroid hormone levels normalise in up to 90% of cases by 30 months. A high preoperative parathyroid hormone level is predictive of postoperative normocalcaemic hyperparathyroidism, and vitamin D deficiency does not seem to influence the pathogenic mechanism.

Persistent elevation of parathyroid hormone after curative parathyroidectomy: A risk factor for recurrent hyperparathyroidism

BACKGROUND

Up to 45% of patients may have persistently elevated parathyroid hormone (PTH) levels after curative parathyroidectomy for primary hyperparathyroidism (PHPT), although the clinical significance is unclear. We aimed to assess the long-term clinical significance of persistently elevated PTH early after parathyroidectomy.

METHODS

A prospectively collected institutional database was queried for patients who underwent parathyroidectomy for sporadic PHPT between 12/99 and 6/22 and had normal serum calcium levels at 6 months postoperatively. Demographic and clinical data were collected, including diagnoses associated with secondary HPT (gastrointestinal malabsorptive diseases, kidney disease, and vitamin D deficiency). Patients were divided into two groups: normal PTH or elevated PTH at 6 months postoperatively. The rate of persistently elevated PTH, average time to PTH normalization, and time to recurrence were determined.

RESULTS

The final cohort included 1146 patients; 849 (91%) had normal PTH levels and 194 (17%) had early postoperative normocalcemia with elevated PTH at 6 months postoperatively. Among 194 patients (mean follow-up: 50 ± 53 months), 14 (7.2%) developed recurrent pHPT and 86 (44.3%) had normalization of PTH levels (median time to normalization: 12 months) (IQR: 9 and 15). There was no difference in the presence of diagnoses associated with secondary HPT between patients who had recurrent PHPT, normalization of PTH levels, or remained normocalcemic with persistently elevated PTH levels. The median time to recurrence was 22 months (IQR: 11 and 48) for the 7.2% of patients who developed recurrent PHPT compared to 2.4% in the 849 patients with normal calcium and PTH levels at 6 months (p < 0.001).

CONCLUSIONS

Following curative parathyroidectomy, persistent elevation of PTH levels is not uncommon. Although most patients have a durable cure, it may be an early sign of persistent/recurrent PHPT. Long-term surveillance for recurrence is necessary.

Case report: a rare case of primary hyperparathyroidism due to an intrathymic ectopic parathyroid adenoma incidentally diagnosed in a 15-year-old girl

Primary hyperparathyroidism (PHPT) due to ectopic parathyroid adenoma is a rare case of hypercalcemia in the pediatric population. Herein, a rare case of PHPT due to ectopic intrathymic parathyroid adenoma was described in an asymptomatic 15-year-old girl who had incidental diagnosis based on laboratory abnormalities but experienced a 3-month postoperative course of persistently elevated parathyroid hormone (PTH) and hypercalcemia following the initial unsuccessful parathyroidectomy operation carried out in a non-parathyroid expert center. The curative surgical treatment was accomplished only after the patient was reoperated with video-assisted thoracoscopic surgery (VATS) thymectomy by the surgeon experienced in parathyroid surgery with implementation of the combined imaging modalities for accurate localization of ectopic adenoma including 99mTc sestamibi (MIBI) plus neck and thoracic computed tomography (CT) and the appropriate surgical strategies including intraoperative intact PTH monitoring and frozen section diagnosis. Before the reoperation (VATS thymectomy), laboratory findings showed elevated PTH (1,171 ng/L; reference range: 21.80 ng/L-87.5 ng/L) and hypercalcemia (13.4 mg/dL; reference range: 8.4 mg/dL-10.2 mg/dL). The preoperative PTH levels were 94 ng/L at 5 min after thymectomy and 78 ng/L at 10 min. The PTH and calcium levels were 54.3 ng/L and 8.47 mg/dL, respectively, on postoperative day 1 and were 34.2 ng/L and 8.1 mg/dL on postoperative day 2. The patient was discharged on postoperative day 2 without any complications. In conclusion, our findings indicate the likelihood of isolated primary hyperparathyroidism to be incidentally diagnosed based solely on laboratory abnormalities with no specific clinical manifestations in the pediatric age. In addition, using combined imaging modalities (such as MIBI and CT) in accurate localization of ectopic parathyroid adenoma and implementation of surgery by experienced surgeons along with intraoperative intact PTH monitoring and frozen section diagnosis seem crucial to ensure the curative surgical treatment.

Primary Hyperparathyroidism: Part Two: Surgical Management

Primary hyperparathyroidism (PHPT) is caused by the overproduction of parathyroid hormone by 1 or more parathyroid glands resulting in hypercalcemia and its downstream clinical consequences. The definitive management of PHPT is surgery. Approaches to successful surgery include bilateral exploration or focused parathyroidectomy with intraoperative parathyroid hormone monitoring, which in experienced hands are both associated with a low risk of complications.

Complications of microwave ablation in patients with persistent/recurrent hyperparathyroidism after surgical or ablative treatment

OBJECTIVE

To evaluate the complications associated with microwave ablation (MWA) in treating persistent/recurrent hyperparathyroidism (HPT) post-surgical or ablative treatments.

MATERIALS AND METHODS

From January 2015 to December 2022, 87 persistent/recurrent HPT patients (primary HPT [PHPT]: secondary HPT [SHPT] = 13:74) who underwent MWA after surgical or ablative treatment were studied. Grouping was based on ablation order (initial vs. re-MWA), prior treatment (parathyroidectomy [PTX] vs. MWA), and etiology (PHPT vs. SHPT). The study focused on documenting and comparing treatment complications and analyzing major complication risk factors.

RESULT

Among the 87 patients, the overall complication rate was 17.6% (15/87), with major complications at 13.8% (12/87) and minor complications at 3.4% (3/87). Major complications included recurrent laryngeal nerve (RLN) palsy (12.6%) and Horner syndrome (1.1%), while minor complications were limited to hematoma (3.4%). Severe hypocalcemia noted in 21.6% of SHPT patients. No significant differences in major complication rates were observed between initial and re-MWA groups (10.7% vs. 13.8%, p = 0.455), PTX and MWA groups (12.5% vs. 15.4%, p = 0.770), or PHPT and SHPT groups (15.4% vs. 13.5%, p > 0.999). Risk factors for RLN palsy included ablation of superior and large parathyroid glands (>1.7 cm). All patients recovered spontaneously except for one with permanent RLN palsy in the PTX group (2.1%).

CONCLUSION

Complication rates for MWA post-surgical or ablative treatments were comparable to initial MWA rates. Most complications were transient, indicating MWA as a viable and safe treatment option for persistent/recurrent HPT patients.

Long-Term Calcium Monitoring Post Parathyroidectomy for Primary Hyperparathyroidism

BACKGROUND

 Cure rates following parathyroidectomy for primary hyperparathyroidism are excellent, with well-documented low short-term recurrence rates of hypercalcaemia. Rates of long-term recurrence have been investigated to a lesser extent, but recent studies have reported higher than anticipated rates. This study sought to evaluate recurrence rates at more than four years post seemingly corrective surgery and depending on the findings, propose whether recommendations of annual calcium monitoring post-parathyroidectomy are appropriate based on the limited data available at the time of formulating guidelines.

METHODS

Fifty-two sequential parathyroidectomies for primary hyperparathyroidism from 2014-2016 from a single unit were retrospectively followed up with serum calcium levels. A hospital computer system was used to collect data on pre-operative, immediate post-operative and most recent follow-up calcium levels. Patients were excluded if there was no minimum of 48 months between the operation date and most recent calcium. Recurrence was defined as hypercalcaemia more than six months after eucalcaemia post-parathyroidectomy.

RESULTS

Of the 52 cases analysed, two were lost to long-term follow-up, two patients died during the follow-up period while 10 did not meet the inclusion criteria of at least 48 months follow-up. This resulted in a cohort of 38 patients (mean age 66.4 years, 78.9% female). The median follow-up of 73.17 months (range 48.77-95.47 months) demonstrated a hypercalcaemia recurrence of 5.26% (2/38 patients). These cases were due to misdiagnosed parathyroid hyperplasia as opposed to suspected adenoma. Therefore, the long-term cure rate was 94.74% (36/38 patients).

CONCLUSION

These findings support the high cure rates and low recurrence rates of the numerous short-term studies already performed despite a longer follow-up period. This is in contrast to recent series which have documented a higher recurrence in the long-term. This study would, therefore, suggests recommendations of annual calcium monitoring are excessive and that less frequent calcium monitoring is necessary in the first few years post-operation. However, the 5.26% recurrence rate in this study is not insignificant and follow-up is still paramount. Therefore, following the initial post-operative assessment, the authors propose a follow-up at the five-year mark and an annual continuation from this point forward due to the evidenced delayed recurrence of hypercalcaemia.

Long-term Recurrence Rates After Surgery in Primary Hyperparathyroidism

CONTEXT

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia, yet long-term (5- and 10-year) recurrence rates after curative surgery have been unclear.

OBJECTIVE

To perform the first systematic review and meta-analysis investigating the long-term recurrence rates of sporadic PHPT after successful parathyroidectomy.

METHODS

A comprehensive search of multiple databases (including PubMed, EMBASE, Cochrane, EBSCO-CINHAL, EMBASE, Ovid, Scopus, and Google Scholar) was performed from each database's inception to January 18, 2023. Observational studies reporting at least 5 years of follow-up data after surgical resection were included. Two reviewers independently screened articles for relevance. Of 5769 articles initially identified, 242 were examined in full-text review and 34 were deemed eligible for inclusion. Two authors independently performed data extraction and study appraisal, using the National Institutes of Health study quality assessment tools.

RESULTS

Of 30 658 participants, 350 patients (1.1%) experienced recurrence after resection. A meta-analysis of proportions was performed to obtain the pooled recurrence rates. The pooled estimate for overall recurrence rate was 1.56% (95% CI 0.96-2.28%; I2 = 91%). The pooled estimates for 5- and 10-year recurrence rate after resection were 0.23% (0.04-0.53%, 19 studies; I2 = 66%) and 1.03% (0.45-1.80%, 14 studies; I2 = 89%), respectively. Sensitivity analyses did not find a statistically significant difference when adjusting for study size, diagnosis, or surgical approach.

CONCLUSION

Approximately 1.56% of sporadic PHPT patients eventually develop recurrence following parathyroidectomy. The initial diagnosis and procedure type does not influence recurrence rates. Consistent long-term follow-up is warranted to help identify recurrent disease.

Update on the current management of persistent and recurrent primary hyperparathyroidism after parathyroidectomy

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease. The surgical procedure aims for permanent cure, but recurrence has been reported in 4%-10% of pHPT patients. Preoperative localization imaging is highly valuable. It includes ultrasound, computed tomography (CT), single-photon-emission CT, sestamibi scintigraphy and magnetic resonance imaging. The operation has been defined as successful when postoperative continuous eucalcemia exists for more than the first six months. Ongoing hypercalcemia during this period is defined as persistence, and recurrence is defined as hypercalcemia after six months of normocalcemia. Vitamin D is a crucial factor for a good outcome. Intraoperative parathyroid hormone (PTH) monitoring can safely predict the outcomes and should be suggested. PTH ≤ 40 pg/mL or the traditional decrease ≥ 50% from baseline minimizes the likelihood of persistence. Risk factors for persistence are hyperplasia and normal parathyroid tissue on histopathology. Risk factors for recurrence are cardiac history, obesity, endoscopic approach and low-volume center (at least 31 cases/year). Cases with double adenomas or four-gland hyperplasia have a greater likelihood of persistence/ recurrence. A 6-mo calcium > 9.7 mg/dL and eucalcemic parathyroid hormone elevation at 6 mo may be associated with recurrence necessitating long-term follow-up. 18F-fluorocholine positron emission tomography and 4-dimensional CT in persistent and recurrent cases can be valuable before reoperation. With these novel advances in preoperative imaging and localization as well as intraoperative PTH measurement, the recurrence rate has dropped to 2.5%-5%. Six-month serum calcium ≥ 9.8 mg/dL and parathyroid hormone ≥ 80 pg/mL indicate a risk of recurrence. Negative sestamibi scintigraphy, diabetes and elevated osteocalcin levels are predictors of multiglandular disease, which brings an increased risk of persistence and recurrence. Bilateral neck exploration was considered the gold-standard diagnostic method. Minimally invasive parathyroidectomy and neck exploration are both effective surgical techniques. Multidisciplinary diagnostic and surgical management is required to prevent persistence and recurrence. Long-term follow-up, even up to 10 years, is necessary.

Long-term outcome of surgical techniques for sporadic primary hyperparathyroidism in a tertiary referral center in Belgium

PURPOSE

Surgery remains the only permanent treatment option for primary hyperparathyroidism (pHPT). To date, the number of long-term outcome studies of parathyroidectomy is limited. This study aims to compare different surgical approaches and evaluate the importance of preoperative localization imaging in the treatment of pHPT.

METHODS

All 200 consecutive patients with a parathyroidectomy for sporadic pHPT without planned concomitant surgery between 09/2009 and 04/2021 in a Belgian tertiary referral hospital were enrolled. All patients underwent at least two preoperative localization imaging studies (neck ultrasound, CT, SPECT, and/or Sestamibi scintigraphy) of the parathyroid glands. The main outcomes were the (long-term) cured proportion and postoperative morbidity (hypocalcemia, recurrent laryngeal nerve palsy, return to theater for bleeding, and wound morbidity).

RESULTS

Most patients were referred with concordant positive imaging (82%, n = 164). Only nine patients (4.5%) had double negative imaging, not revealing a possible adenoma. The remaining 27 (13.5%) were referred with discordant imaging. Parathyroidectomy was performed via traditional cervicotomy (30%), mini-open approach (39.5%), or endoscopic approach (30.5%). Morbidity was low with no persistent hypocalcemia, one return to theater for bleeding, and no 30-day mortality. In the concordant imaging population, 13 patients (8%) had multiglandular disease. Overall, 97.5% was considered cured. Long-term recurrence was 12% with a minimal follow-up of 5 years.

CONCLUSION

This consecutive, single-surgeon, single-center cohort with extensive data collection and long-term follow-up confirms the safety and excellent cured proportions of minimally invasive parathyroidectomy. Disease recurrence becomes more important long after surgery.

18F-Fluorocholine-PET combined with contrast-enhanced CT for localizing hyperfunctioning parathyroid glands and optimizing surgical treatment in patients with hyperparathyroidism

PURPOSE

Hyperparathyroidism (HPT) is a common disorder. A cure can only be achieved by removing all diseased glands. It is critical to localize the hyperfunctioning glands exactly to prevent extensive surgical exploration. The number of false negative/inconclusive results in standard imaging techniques is high. We aimed to evaluate the diagnostic accuracy of ¹⁸F-Fluorocholine-PET in combination with contrast-enhanced CT (FCH-PET/CT) and its sensitivity in patients with primary, secondary/tertiary, and familial HPT with negative and/or discordant findings in ultrasound and/or ^99mTc-sestamibi scintigraphy/SPECT/CT.

METHODS

A total of 96 patients with HPT and negative/equivocal conventional imaging were referred for FCH-PET/CT. In this retrospective, single institution study, 69 patients, who have undergone surgery and histopathologic workup, were analyzed. Of the 69 patients included, 60 patients suffered from primary HPT, four from secondary or tertiary HPT, and five from familial HPT. Sensitivities, positive predictive values, and accuracies were calculated.

RESULTS

Sensitivity/positive predictive value (PPV) per lesion was 87.5/98.3% for primary HPT, 75/100% for secondary/tertiary HPT and 25/66.7% for familial HPT. Sensitivity/PPV per patient was 91.5/98.2% for primary HPT, 100/100% for secondary/tertiary HPT and 50/100% for familial HPT. All patients showed normalized serum calcium levels in the postoperative period. The follow-up rate was 97%. Of the patients included in the study, 58 of 60 patients with primary HPT, and four of four patients with secondary/tertiary HPT showed normal calcium and parathyroid hormone (PTH) levels after six months and were cured. Of the patients with familial HPT, four of five patients were cured.

CONCLUSION

Diagnostic accuracy of ¹⁸F-Fluorocholine-PET/CT for patients with pHPT is excellent. ¹⁸F-Fluorocholine-PET/CT is a valuable tool for endocrine surgeons to optimize the surgical treatment of patients with hyperparathyroidism.

Changes in Imaging Utilization for Primary Hyperparathyroidism

Introduction

Primary hyperparathyroidism is now largely managed surgically via minimally invasive techniques. This shift was aided by preoperative imaging, which saw drastic increases in utilization in the 1990s. Since then, it is unclear how the role of preoperative imaging has changed with regard to surgical management of primary hyperparathyroidism. This study aims to describe the trend in preoperative localization techniques for surgical management of primary hyperparathyroidism using career data from two endocrine surgeons over the last 20 years.

Methods

Parathyroid case data was obtained from two endocrine surgeons spanning two institutions from 2000-2018. Demographic and clinical data was obtained for each patient at the time of surgery, including record of any preoperative imaging performed. Data was analyzed temporally using four 5-year periods to evaluate changes in imaging utilization over time.

Results

1734 patients were identified who underwent parathyroidectomy for primary hyperparathyroidism. Mean age of the cohort was 60 years (range 10-94) with 78% being female. Overall, we identified a significant decrease in imaging utilization over the time periods (see table, P < .05). Ultrasound and CT use increased, while frequency of sestamibi and thallium-technetium scans decreased. Length of stay was also noted to decrease over time. There was no significant difference in cure rates between the four time periods, though recurrence was found to decrease over time.

Conclusion

The rates of preoperative imaging and length of stay decreased over time for surgical management of primary hyperparathyroidism. Despite the decrease in imaging, cure rates have appeared to remain the same.

Analysis of the cause and management of persistent laboratory abnormalities occurring after the surgical treatment of primary hyperparathyroidism

Purpose

The surgical success rate for primary hyperparathyroidism (PHPT) is currently 95%–98%. However, 3%–24% of patients show persistently elevated (Pe) parathyroid hormone (PTH) levels after parathyroidectomy (PTX). This single-center retrospective study aimed to compare the outcomes of patients with normal PTH and PePTH levels after successful PTX and to identify the factors associated with PePTH.

Methods

The normal group, defined as patients with normal serum calcium and PTH levels immediately after PTX, was compared with the PePTH group (patients with normal or low serum calcium and increased serum PTH levels up to 6 months postoperatively) to determine the causes of disease in the PePTH group.

Results

There were no significant differences in age, sex, or preoperative estimated glomerular filtration rate between the normal PTH group (333 of 364, 91.5%) and the PePTH group (31 of 364, 8.5%). However, there were significant differences in preoperative 25-hydroxyvitamin D (17.9 and 11.8 ng/mL, respectively; P = 0.003) and PTH levels (125.5 and 212.4 pg/mL, respectively; P < 0.001) between the 2 groups. Among the 31 cases of the PePTH group, 18 were attributed to vitamin D deficiency.

Conclusion

Preoperative vitamin D deficiency is a predictive factor for PePTH. Therefore, preoperative administration of vitamin D supplements may reduce the probability of postoperative disease persistence. Patients with temporary laboratory abnormalities within 6 months after successful PTX should be monitored, and appropriate vitamin D and calcium supplementation may reduce the effort and cost of various examinations or reoperations.

Parathyroid Surgery: What Radiologists Need to Know

Surgical intervention remains the mainstay of treatment of hyperparathyroidism and provides the highest chance at cure. After the disease is confirmed by biochemical testing, surgeons must use a combination of patient clinical history and radiographic imaging to determine the most appropriate surgical strategy. Through either minimally invasive parathyroidectomy or bilateral cervical exploration, surgeons provide high rates of cure for hyperparathyroidism with low rates of persistence or recurrence.

Recurrence after successful parathyroidectomy-Who should we worry about?

BACKGROUND

Preventing cervical reoperations is important-especially after parathyroidectomy. We sought to examine early predictors of recurrence of primary hyperparathyroidism after surgical cure.

METHODS

Adult patients with sporadic primary hyperparathyroidism treated with parathyroidectomy between September 1, 1997, and September 1, 2019, with confirmed eucalcemia at 6 months postoperatively were identified. Recurrence was defined as hypercalcemia (>10.2 mg/dL) with an elevated or nonsuppressed parathyroid hormone level on subsequent follow-up.

RESULTS

Parathyroidectomy was performed in 522 patients (median age, 62.1 years, 77% female) with the majority undergoing planned minimally invasive parathyroidectomy (85.4%, n = 446). After a median follow-up of 30.9 months, 13 patients (2.5%) recurred (median time to recurrence 50.2 months, interquartile range 27.9-66.5), all of whom underwent planned minimally invasive parathyroidectomy (n = 13/446, 2.9%). Recurrence was more common in those with higher (but still normal) 6-month calcium (10.1 vs 9.3 mg/dL, P < .001) or parathyroid hormone values (64 vs 46 pg/mL, P < .01). Multivariate analysis revealed that age >66.5 years, calcium ≥9.8mg/dL and parathyroid hormone ≥80 pg/mL at 6 months were associated with increased risk of recurrence. In addition, the presence of at least 1 preoperative imaging study that conflicted with intraoperative findings among minimally invasive parathyroidectomy patients (n = 446) was associated with increased risk of recurrence (hazard ratio 4.93, 95% confidence interval 1.25-16.53, P = .016).

CONCLUSION

Recurrence of sporadic primary hyperparathyroidism after initial surgical cure in the era of minimally invasive parathyroidectomy is 2.5%. Identification of those at risk for recurrence using 6-month serum calcium ≥9.8 mg/dL, parathyroid hormone ≥80 pg/mL, and/or potentially conflicting localization studies may inform surveillance strategies.

Hyperparathyroidism subsequent to radioactive iodine therapy for Graves' disease

BACKGROUND

The development of primary hyperparathyroidism (PHPT) after radioactive iodine (RAI) treatment for thyroid disease is poorly characterized. The current study is the largest reported cohort and assesses the disease characteristics of patients treated for PHPT with a history of RAI exposure.

METHODS

A retrospective analysis comparing patients, with and without a history of RAI treatment, who underwent surgery for PHPT.

RESULTS

Twenty-eight of the 469 patients had a history of RAI treatment, all for Graves' disease. Patients with a history of RAI exposure had similar disease characteristics compared to control; however, patients with a history of RAI treatment had a higher rate of recurrence (7.4% vs 1.2%, p = 0.012).

CONCLUSION

PHPT in patients with a history of RAI treatment can be approached in the same manner as RAI naive PHPT patients; however, the risk of recurrence of PHPT in RAI exposed patients may be higher.

How should we define cure after parathyroidectomy for normocalcemic primary hyperparathyroidism? A retrospective cohort study

Cure after surgery for normocalcemic primary hyperparathyroidism (NHPT) is defined as parathyroid hormone (PTH) normalization. However, an increase of PTH is frequently observed in cured patients with hypercalcemic primary hyperparathyroidism (HHPT). Therefore, this criterion must be redefined. A single-center retrospective study was performed including all patients who underwent surgery for Primary Hyperparathyroidism from 2013 to 2019. Cure rates of different types of hyperparathyroidism were analyzed. PTH reduction was studied as a possible criterion to define cure in patients with NHPT. One-hundred and eighty-six patients were included: 173 with HHPT and 13 with NHPT. After a mean follow-up of 33.4 months, 174 (93.6%) patients were considered cured. Cure was more frequent in the group of patients with HHPT (97.1% vs. 46.2%, p < 0.001). In the multivariate analysis, surgical failure was associated with NHPT and multiglandular disease. Forty-nine (30.1%) cured patients with HHPT had an increased PTH during the follow-up. When decline of PTH levels was studied in patients with HHPT to define cure, the area under curve was 0.92. A cut-off value of 40% in PTH reduction achieved a sensitivity and specificity of 83.4% and 80.0%. If cure was defined as a 40% reduction of PTH, cure rate in the group of patients with NHPT would increase to 69.2%. Patients with NHPT had a lower cure rate than patients with HHPT. A significant number of cured patients with HHPT had an increased PTH during follow-up. A 40% reduction in PTH levels is proposed as an alternative definition for cure in patients with NHPT.

Risk Factors of Redo Surgery After Unilateral Focused Parathyroidectomy: Conclusions From a Comprehensive Nationwide Database of 13,247 Interventions Over 6 Years

BACKGROUND

Surgical removal of hyperfunctional parathyroid gland is the definitive treatment for primary hyperparathyroidism (pHPT). Postoperative follow-up shows variability in persistent/recurrent disease rate throughout different centers.

OBJECTIVE

To evaluate the incidence of redo surgery after targeted parathyroidectomy for pHPT.

METHODS

We performed a nationwide retrospective cohort study on the "Programme de Medicalisation des Systemes d'Information," the French administrative database that collects information on all healthcare facilities' discharges. We extracted data from 2009 to 2018 for all patients who underwent parathyroidectomy for pHPT between January 2011 to December 2016. The primary outcome was the reoperation rate within 2 years since first surgery. Patients who had a first attempt of surgery within the previous 24 months, familial hyperparathyroidism, multiglandular disease, and renal failure were excluded. Results were adjusted according to sex and the Elixhauser Comorbidity Index. Operative volume thresholds to define high-volume centers were achieved by the Chi-Squared Automatic Interaction Detector method.

RESULTS

In the study period, 13,247 patients (median age 63, F/M=3.6) had a focused parathyroidectomy by open (88.7%) or endoscopic approach. Need of remedial surgery was 2.8% at 2 years. In multivariate analysis, factors predicting redo surgery were: cardiac history (P=0.008), obesity (P=0.048), endoscopic approach (P=0.005), and low-volume center (P<0.001). We evaluated that an annual caseload of 31 parathyroidectomies was the best threshold to discriminate high-volume centers and carries the lowest morbidity/failure rate.

CONCLUSION

Although focused parathyroidectomy represents a standardized operation, cure rate is strongly associated with annual hospital caseload, type of procedure (endoscopic), and patients' features (obesity, cardiac history). Patients with risk factors for redo surgery should be considered for an open surgery in a high-volume center.

Histologic hypercellularity in a biopsied normal parathyroid gland does not correlate with hyperfunction in primary hyperparathyroidism

BACKGROUND

About 15% of patients with primary hyperparathyroidism have multiglandular disease, thus during resection of an apparent single adenoma, a visibly normal parathyroid may be identified and biopsied. Using long-term biochemical follow-up, we examined whether normal parathyroid hypercellularity correlates with multiglandular disease or primary hyperparathyroidism recurrence.

METHODS

We reviewed all patients who from 2001 to 2015 had an initial operation for sporadic primary hyperparathyroidism with removal of 1 gland, routine normal parathyroid biopsy, intraoperative parathyroid hormone monitoring, and follow-up of ≥3 years. Recurrence was defined by hypercalcemia after documented cure at 6 months, and hypercellularity by standard histologic criteria.

RESULTS

Of 134 patients with mean follow-up of 9.4 years (range, 3.1-15.9), 132 (98.5%) exhibited cure at 6 months. Two had initial failure, and 8 of 132 (6.1%) developed recurrent hyperparathyroidism (mean 5.8 y, range 4-10.6). The normal parathyroid was hypercellular in 14 of 132 (10.6%) of the cured patients, and this rate did not differ for those with long-term cure (12/124, 9.7%) versus recurrence (2/8, 25%, P = .2). The positive predictive value of normal parathyroid hypercellularity for recurrence was low (14.3%), and the negative predictive value of normal parathyroid normocellularity was high (94.9%).

CONCLUSION

During the initial operation for primary hyperparathyroidism, 10% of normal parathyroids are hypercellular, but this does not signify missed multiglandular disease. In contrast, normal parathyroid normocellularity has high predictive value for durable cure (95%), slightly better than visual identification of a second normal parathyroid (94%).

Early biochemical response to parathyroidectomy for primary hyperparathyroidism and its predictive value for recurrent hypercalcemia and recurrent primary hyperparathyroidism

BACKGROUND

The traditional definition of cure after parathyroidectomy (PTX) for primary hyperparathyroidism is normocalcemia. Our hypothesis was that early postoperative levels of serum calcium and parathyroid hormone after PTX would have predictive value for later recurrence.

METHODS

We performed a retrospective study of 1,146 patients with primary hyperparathyroidism who underwent PTX and had long-term biochemical follow-up. The first postoperative serum level of calcium and parathyroid hormone values were used to categorize patients into the following four early biochemical response groups: (1) complete response (normal calcium and normal parathyroid hormone), (2) partial response with hyperparathormonemia (normal calcium and increased parathyroid hormone), (3) partial response with hypercalcemia (increased calcium and normal parathyroid hormone), and (4) non-response (increases in both calcium and parathyroid hormone). Incidences of recurrent hypercalcemia and recurrent primary hyperparathyroidism >6 months after operation were then analyzed.

RESULTS

The overall rate of any elevated serum levels of calcium and any increase in serum levels of parathyroid hormone during >6-month follow-up was 9.8% (112 of 1146), with 6.6% (57 of 861) for group 1, 27% (35 of 129) for group 2, and 16% (20 of 127) for group 3 (P < .02). Partial biochemical responses with either increased serum calcium or increased parathyroid hormone levels were the strongest predictors of any episode of increased serum levels of calcium after 6 months and was associated with 2.7× to 4.3× the risk of recurrent primary hyperparathyroidism, respectively.

CONCLUSION

This study demonstrates the importance of measuring parathyroid hormone in the early postoperative period to better predict later recurrent primary hyperparathyroidism.

Recent advances in the understanding and management of primary hyperparathyroidism

Primary hyperparathyroidism is a hormonal disorder whose prevalence is approximately 1–2% in the United States of America. The disease has become more recognizable to clinicians in an earlier phase and, at present, patients can be diagnosed with “classic”, “normocalcemic”, “normohormonal”, or “mild, asymptomatic” primary hyperparathyroidism. Surgery, with a focused parathyroidectomy when possible, or a four-gland exploration, is the only way to cure the disease. Cure is determined by use of intra-operative parathyroid hormone monitoring with long-term cure rates ranging from 90–95%. Newer adjuncts to surgery include CT or PET imaging and near-infrared immunofluorescence. This article highlights updates in parathyroid disease and advances in parathyroid surgery; it does not provide a comprehensive summary of the disease process or a review of surgical indications, which can be found in the AAES guidelines or NIH Symposium on primary hyperparathyroidism.

Primary Hyperparathyroidism in Sickle Cell Disease: An Unknown Complication of the Disease in Adulthood

Primary hyperparathyroidism (pHPT) is the third most common endocrine disorder and usually affects patients between 60 and 70 years of age. To our knowledge, this condition has never been studied in young patients with sickle cell disease (SCD). Our objective was to describe the clinical and biological characteristics of pHPT in adult patients with SCD and its management. We conducted a retrospective study that included SCD patients who were diagnosed with pHPT in four SCD referral centers. pHPT was defined by the presence of elevated serum calcium levels with inappropriate normal or increased parathyroid hormone (PTH) serum levels or histopathological evidence of parathyroid adenoma or hyperplasia. Patients with severe renal impairment (GFR <30 mL/min) were excluded. Twenty-eight patients (18 women, 64%; 22 homozygous genotype, 79%) were included. The median age at pHPT diagnosis was 41 years (interquartile range -IQR- 31.5-49.5). The median serum calcium and PTH concentration were, respectively, 2.62 mmol/L (IQR 2.60-2.78) and 105 pg/mL (IQR 69-137). Bone mineral density (BMD) revealed very low BMD (-2.5 SD) in 44% of patients explored (vs. 12.5% among 32 SCD patients matched for SCD genotype, sex, age, and BMI, p = 0.03). Fourteen patients (50%) received surgical treatment, which was successful in all cases, but four of these patients (29%) presented with pHPT recurrence after a median time of 6.5 years. Three of these patients underwent a second cervical surgery that confirmed the presence of a new parathyroid adenoma. These results suggest that SCD is a condition associated with pHPT in young subjects. SCD patients with pHPT have a high risk of very low BMD. A diagnosis of pHPT should be suspected in the presence of mild hypercalcemia or low BMD in SCD patients.

Primary Hyperparathyroidism in Sickle Cell Disease: An Unknown Complication of the Disease in Adulthood

Primary hyperparathyroidism (pHPT) is the third most common endocrine disorder and usually affects patients between 60 and 70 years of age. To our knowledge, this condition has never been studied in young patients with sickle cell disease (SCD). Our objective was to describe the clinical and biological characteristics of pHPT in adult patients with SCD and its management. We conducted a retrospective study that included SCD patients who were diagnosed with pHPT in four SCD referral centers. pHPT was defined by the presence of elevated serum calcium levels with inappropriate normal or increased parathyroid hormone (PTH) serum levels or histopathological evidence of parathyroid adenoma or hyperplasia. Patients with severe renal impairment (GFR <30 mL/min) were excluded. Twenty-eight patients (18 women, 64%; 22 homozygous genotype, 79%) were included. The median age at pHPT diagnosis was 41 years (interquartile range -IQR- 31.5-49.5). The median serum calcium and PTH concentration were, respectively, 2.62 mmol/L (IQR 2.60-2.78) and 105 pg/mL (IQR 69-137). Bone mineral density (BMD) revealed very low BMD (-2.5 SD) in 44% of patients explored (vs. 12.5% among 32 SCD patients matched for SCD genotype, sex, age, and BMI, p = 0.03). Fourteen patients (50%) received surgical treatment, which was successful in all cases, but four of these patients (29%) presented with pHPT recurrence after a median time of 6.5 years. Three of these patients underwent a second cervical surgery that confirmed the presence of a new parathyroid adenoma. These results suggest that SCD is a condition associated with pHPT in young subjects. SCD patients with pHPT have a high risk of very low BMD. A diagnosis of pHPT should be suspected in the presence of mild hypercalcemia or low BMD in SCD patients.