How asymptomatic is asymptomatic primary hyperparathyroidism?

Abstract

We observed several cases of patients who believed they were free of symptoms or signs of primary hyperparathyroidism (pHPT) preoperatively. reported a change of complaints following parathyroidectomy (PTX). We, therefore, decided to examine a larger group of patients to discover if these findings were incidental or of more general significance. The role of PTX in these patients with asymptomatic pHPT remains controversial. In 1991 criteria were defined at a NIH-consensus conference, according to which patients qualify for either operative therapy or long term medical surveillance. Until now, it was generally believed that the majority of asymptomatic patients would never develop symptoms. In a epidemiological cohort-study, the perioperative data of 582 consecutive patients with pHPT, including 116 asymptomatic patients (20.9%), who underwent parathyroidectomy between 1987 and 1998 were evaluated by uni- and multivariate analysis. At a median of 72 months postoperatively, all patients underwent a planned follow-up which included a standardised, validated questionnaire, physical examination and laboratory investigations. Eighty-six patients who were asymptomatic preoperatively were available for follow-up. Only eight (9.3%) were definitely asymptomatic, 4.6% of the entire, representative cohort. Postoperative improvement was reported in 81.4% of the "asymptomatic" patients. Multivariate analysis did not reveal a single or a set of preoperative measurements, that would allow to predict the retrospectively definitely asymptomatic patient. PTX resulted in normocalcaemia in 98.8% of preoperatively asymptomatic patients, with an operative morbidity of 1.2% and no mortality. Many apparently asymptomatic patients with pHPT will only realise that they did in fact have preoperative symptoms in retrospect, following PTX. This study suggests that using an up-to-date definition of asymptomatic pHPT, there are only a small number of truly asymptomatic patients and that these cannot be predicted preoperatively, as their symptoms may become apparent only after PTX. "Asymptomatic" patients with pHPT may share the same objective and subjective benefits from PTX as symptomatic patients. They should be operated as soon as the diagnosis is established.

Inhibition of Growth Hormone Secretion in Mild Primary Hyperparathyroidism

“…On the other hand, the benefit of a surgical parathyroid excision in patients in fairly good clinical condition is debated [7]. Some authors suggest a surgical approach in the case of mild nonspecific symptoms, because the symptomatology usually disappears after operation [10, 11, 12]. Other authors recommend surgery only for patients with PTH values higher than 150 pg/ml [13], or for subjects younger than 50 years with serum calcium concentrations greater than 12 mg/dl, marked hypercalciuria (>400 mg/day) and reduction in bone density [14].…”

EPIDEMIOLOGIChESKIE ASPEKTY PERVIChNOGOGIPERPARATIREOZA V ROSSII

“…нефролитиаз выявляют у 15-34% пациентов, по не-которым данным до 45%; язвы желудка и/или двенадцати-перстной кишки встречаются в 10-15% случаев [6,7,9,13]. анализируя собранные анкеты, нами было получено, что не-фролитиаз встречается у 45% пациентов, язвенная болезнь -у 18% пациентов.…”

“…от 9,4 до 81% пациентов име-ют нарушения в психоэмоциональной сферы (бессонница, вялость, сонливость, раздражительность, тревожность, де-прессивность, снижение памяти) в качестве ведущего про-явления пгпт. так же среди прочих проявлений пгпт ча-сто обсуждаются инсипидарный синдром, желчекаменная болезнь, кальцификация сосудов и клапанов сердца [6,11]. результаты нашего исследования по частоте таких проявле-ний у пациентов с пгпг представлены на рисунке 8. они свидетельствуют о том, что пациент с пгпт может обра-титься к врачам любой специальности (терапевту, ревмато-логу, урологу, нефрологу, неврологу, ортопеду-травматоло-гу, кардиологу и др.)…”

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

“…PHPT is a chronic disease displaying various clinical courses. By definition (2), only very few are 'asymptomatic' (i.e., free of symptoms, no organ manifestations even after careful screening) (3).…”

“…However, multivariate analysis has not identified a single or a set of biochemical parameters that would allow predicting the clinical course of these subjects (3). Careful analysis of patients has revealed that postoperative metabolic complications occur in those with a long history of PHPT.…”