Endocrine Abstracts

Although primary hyperparathyroidism (PHPT) can be successfully cured by parathyroidectomy (PTX) and indications for surgery are well defined, a considerable number of patients do not get operated on. By evaluating referrals for PTX in our academic hospital, we might improve our approach to the care of these patients. We retrospectively reviewed patients’ hospital records with newly diagnosed PHPT between 2014 and 2020. Biochemical and clinical parameters along with results of diagnostic tests were collected. Among 123 retrieved patients, 26 were not sent for surgery by a referring clinician (nonsurgical group) and they were compared with 66 patients that underwent PTX. The remaining 31 patients were unwilling to undergo surgery, lost from follow up or their workup and surgery were postponed. The statistical analysis was performed by c² test, parametric tests, and multivariate logistic regression. The comparison between the nonsurgical group and the PTX group found that the age of non-operated patients was higher, but they had no more comorbidities. Non-operated patients had lower serum calcium at first presentation, lower PTH and calciuria, but higher serum phosphate. There were also more normocalcemic PHPT patients in the nonsurgical group. The presence of PHPT complications (osteoporosis, fractures, and urolithiasis) was similar between groups and so was the presence of at least one indication for surgery. The sonographic size of enlarged parathyroid glands did not differ between groups. The nonsurgical group had significantly fewer positive findings on ultrasound, FNA cytology, PTH washout, and sestamibi scan. At least two concordant imaging tests (ultrasound, sestamibi scan, or 4DCT) were significantly less frequent among non-operated patients. In a logistic regression model, the absence of concordant imaging tests was the only independent predictor for the nonsurgical approach (OR 14, 95% CI 3.9–50.2, P < 0.001). Parathyroid disease localization should not be a criterion for surgery, but these results emphasized a tendency to obtain concordant imaging prior to the referral for PTX. This impression also emerged in our multidisciplinary team meetings and similar real-life data were already encountered in different settings. In practice, this means opting for focused minimally invasive surgery and potentially a lower risk of persistent and recurrent disease, especially in rare multigland disease. The asymptomatic nature and the option for pharmacological intervention in the control of the PHPT complications also seem to discourage surgery. Further improvements in imaging methods and genetic testing to exclude multigland hereditary hyperparathyroidism might contribute to overcoming barriers to PTX.