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Long-term cure rates better with bilateral vs. unilateral parathyroidectomy
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PHILADELPHIA — When compared with the unilateral approach, bilateral parathyroidectomy for primary hyperparathyroidism resulted in removal of a greater number of abnormal glands and improved long-term cure rates that persisted for nearly 2 decades, according to data presented at the American Association of Clinical Endocrinologists 21st Annual Scientific and Clinical Congress.
The development of unilateral parathyroidectomy stemmed from the theory that a single adenoma was responsible for at least 75% of all cases of primary hyperparathyroidism and, therefore, evaluation of all four glands would be unnecessary in certain patients.
“After a sobering period of introspection, we figured out that we were wrong,” Douglas Politz, MD, of the Norman Parathyroid Center in Tampa, Fla., said during a presentation. “With high surgical volumes, unilateral surgery did not have the same cure rate. We found ourselves performing more bilateral surgery when every indicator told us to stop at unilateral, and we would find tumors in over 15% of those patients. With a volume of 2,000 patients per year, even a failure rate of 2% would be unmanageable.”
To compare cure rates between unilateral and bilateral surgery, Politz and colleagues conducted an 18-year, single center study involving 15,500 patients undergoing parathyroidectomy for primary hyperparathyroidism. They compared the number of glands removed and recurrence rates for unilateral vs. bilateral operations. Eligible patients had normal calcium and parathyroid hormone levels for at least 2 months after removal of one or more abnormal glands.
Approximately 20% of patients underwent unilateral and 80% underwent bilateral surgery. Twenty-six percent of those in the bilateral group vs. only 3% in the unilateral group had more than one abnormal gland removed (P<.0001). Results also revealed recurrence rates of 0.19% at 1 year, 0.27% at 10 years and 0.31% at 18 years for bilateral parathyroidectomy (P=.96) vs. 3.9% at 1 year, 5.9% at 5 years, 8.1% at 10 years and 10.1% at 18 years, respectively, for unilateral parathyroidectomy (all P<.0001). Additionally, the recurrence rate was about 0.4% per year after 10 years. Unilateral patients had a second or third adenoma without hyperplasia at reoperation. After a second operation, patients remained cured long term, according to the data.
In a subset analysis of 223 patients who had operations at other centers that used intraoperative parathyroid hormone assays and were believed to be cured by that measure, the researchers found that a number of patients still had an adenoma on the contralateral side.
“It looks to us that bilateral operation is the only way to get the most durable cure,” Politz said. “What does this mean? We need to follow-up those who undergo unilateral surgery for life, essentially, because they do not appear to achieve durable cure rates when compared to those who have all four glands evaluated.” – by Melissa Foster
For more information:
- Norman J. Abstract #833. Presented at: the American Association of Clinical Endocrinologists 21st Annual Scientific and Clinical Congress; May 23-27, 2012; Philadelphia.
Perspective
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Jeffrey Garber, MD
Unilateral exploration has been promoted heavily. Although it has a wonderful short-term cure rate, the long-term cure rate isn’t as good as a bilateral exploration because it is not just that all the glands are involved that multiple adenomas, which are sometimes small, eventually crop up later. So, they’re making n argument that looking at both sides still has value even in the world of minimally invasive surgery. One needs to be aware of these findings, but one also needs to contrast them with other factors, such as surgical morbidity and what the definition of ‘cure’ is. In other words, did the researchers characterize a normal calcium as 10.1 mg/dL or as 8 mg/dL? It would be interesting to see the data in a more comprehensive fashion.
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