Parathyroidectomy in the elderly

The current issue of the Journal of Clinical Endocrinology and Metabolism reports that only 14% out of 3,388 patients aged 70 and older diagnosed with primary hyperparathyroidism (PHPT) underwent parathyroidectomy (PTX). Only 45% of those aged between 60 and 69 years who met the consensus criteria for recommending PTX had the surgery; only 24% of patients age 70 and older who met the same criteria had PTX.

Patients with symptomatic PHPT are clearly candidates for surgery no matter their age — always provided that an experienced parathyroid surgeon is available. But many (or most) patients with parathyroid disease do not have symptoms related to hypercalcemia, hypercalciuria, or overt evidence of metabolic bone disease.

The 2002 consensus panel took this into consideration when preparing their recommendations. To my recollection, nowhere in that document does it state that PTX is contraindicated in patients with a confirmed diagnosis of PHPT, but who do not meet the consensus criteria. It has long been my practice to refer all patients with PHPT to an appropriate surgeon and leave it to the surgeon to decide that surgery is appropriate for that patient. Unlike many of my colleagues, I do not order parathyroid gland localizing studies (sestamibi scan or ultrasound) prior to that referral, but leave that up to the surgeon once a recommendation to proceed to surgery has been made.

In the hands of an experienced surgeon, complications from elective PTX are few. What remains poorly documented is what benefits, if any, does the asymptomatic patient with mild PHPT acquire as a result of PTX. During 1987, my colleagues and I reported that neurobehavioral symptoms in mild PHPT were related to hypercalcemia but not improved by PTX. Anecdotally, I can report that several of the patients who had PTX reported that they had felt well and symptom-free before surgery, but felt much better after PTX — the science did not support the anecdotes. The patients all had a formal psychometric evaluation and consultation with a psychiatrist at the time of diagnosis; 6 months later in those who did not have PTX; and 6 months post-operatively in those who had PTX. While serum calcium was restored to normal post-PTX, there were no statistically significant changes in any of the psychometrics. During 2004, similar, but not identical findings in a more sophisticated randomized clinical trial of surgery vs. no surgery were reported by my colleagues at that same institution.

There are still so many unknowns about PHPT and its effects on longevity, quality of life and overall wellness despite a large amount of prospective and cross-sectional data in the peer-reviewed literature. Why the disease is more common in postmenopausal women remains unknown. Diabetes, cardiovascular disease and cerebrovascular disease are all more common in PHPT than in control populations, yet none have been conclusively demonstrated to improve post PTX with the exception of bone mineral density. The literature gives us no clues about appropriate management of normocalcemic PHPT.

Of one thing I am confident: Parathyroidectomy performed by an experienced surgeon is associated with a very low incidence of early or late postoperative complications.

If you have such a surgeon available for your patients I can see no justification for the very low rate of PTX in the elderly as noted in the opening paragraph of this blog.

Wu B. J Clin Endocrinol Metab. 2010;95:4324-4330.

Bilezikian JP. J Clin Endocrinol Metab. 2002;87:5353-5361.

Brown GG. Henry Ford Hosp Med J. 1987;35:211-215.

Rao DS. J Clin Endocrinol Metab. 2004;89:5415-5422.