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Most hyperparathyroidism cases can be considered cured after surgery

 

Key clinical point: The vast majority of cures could be identified during surgery, reducing the need for costly follow-up to monitor calcium levels.

Major finding: Concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.

Data source: A retrospective analysis of 214 patients at a single center.

Disclosures: The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.


 

AT WSA 2017

 

– Patients with hyperparathyroidism and single-gland disease can be considered cured if their intraoperative parathyroid hormone (PTH) level drops by 50% or more, or to normal or near-normal levels (15-65 pg/mL), and don’t require immediate follow-up for lab work, according to a retrospective review of patients who underwent parathyroidectomy at Mayo Clinic, Rochester, Minn.

Dr. Melanie L. Lyden professor of surgery, Mayo Clinic, Rochester, MIN
Dr. Melanie L. Lyden
A primary hyperparathyroidism diagnosis is established by the presence of hypercalcemia with elevated PTH levels and no other evident cause of hypercalcemia. Surgical procedures have improved in recent years, and estimates put the 6-month cure rate at 93%-100%. The current study suggests that, in this patient population, clinicians need not wait that long, according to Dr. Lyden, professor of surgery at Mayo Clinic, Rochester, who was a coauthor of the study. “Because there are reported very late recurrences, we would still recommend getting calcium checked once a year, but they don’t need to be coming back the next day, the next week, and a couple months later,” Dr. Lyden said in an interview.

Her team conducted a retrospective analysis of 214 patients who underwent parathyroidectomy at Mayo Clinic, Rochester, between January 2012 and March 2014. The investigators excluded patients with a history of multiple endocrine neoplasia syndrome, as well as patients with secondary or tertiary hyperparathyroidism. All patients received instructions at discharge for completing calcium testing, as well as a follow-up letter and phone call.

The overall cure rate at 6 months was 94% (202 cured, 12 not cured). In 205 of 214 cases (96%), the patients had an intraoperative drop in PTH level by 50% to normal or near-normal levels, and were therefore considered cured immediately.

The cured and not cured rate groups had no significant differences in age, gland weight, or preoperative PTH levels. Final intraoperative PTH levels were lower in patients who were cured (37 pg/mL vs. 55 pg/mL, P = .008), and the percentage decrease in PTH was greater (69% vs. 43%, P less than .0001).

A subgroup analysis found that concordant sestamibi imaging, single adenoma pathology, and an intraoperative cure combined to correlate with a 6-month cure rate of 97%.

In addition to identifying cures early, the findings suggest that patients whose PTH levels don’t drop adequately during surgery, and those with multiglandular disease should be aggressively targeted for follow-up – an important concern because many patients fail to complete calcium testing. “We were very aggressive in terms of follow-up recommendations, a follow-up letter, and a follow-up phone call, and still close to 30% of them we were not able to get to come in and get their blood checked,” said Dr. Lyden.

The study received no external funding. Dr. Lyden reported having no relevant financial disclosures.
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