Surgical Intervention in Guideline-Discordant Primary Hyperparathyroidism: Trends and Outcomes

INTRODUCTION: Parathyroidectomy is recommended for primary hyperparathyroidism (PHPT) based on guidelines criteria, but the treatment of guideline-discordant disease is evolving. Our objectives were to characterize institutional trends in (1) preoperative biochemical data; (2) guideline concordance; and (3) cure for PHPT. METHODS: We performed a retrospective cohort study of patients undergoing parathyroidectomy for PHPT at a tertiary hospital (2002 to 2019). Trends were evaluated at 3-year intervals. Concordant patients adhered to the 2016 American Association of Endocrine Surgery guidelines for PHPT. Cure was defined as calcium ≤10.3 mg/dL ≥6 months postoperatively. RESULTS: Among 1,087 patients, those undergoing parathyroidectomy in 2017 to 2019 compared with 2002 to 2004 exhibited lower preoperative parathyroid hormone (PTH) (110.3 vs 169.7 pg/mL, p = 0.0001) and calcium (10.7 vs 10.8 mg/dL, p = 0.0001). Patients were more often symptomatic (57.2% vs 51.1%, p < 0.0001) with lower prevalence of hypercalcemia ≥11.3 mg/dL (11.4% vs 28.7%, p = 0.001), nephrolithiasis (3.4% vs 26.6%, p < 0.0001), and guideline concordance (86.0% vs 92.6%, p = 0.0004, Fig. 1). Guideline-discordant patients (n = 107) were older (64 vs 60 years, p = 0.0002) with lower PTH (115.0 vs 134.4 pg/mL, p = 0.0003) and calcium (10.5 vs 10.7 mg/dL p = 0.0001) and higher glomerular filtration rate (80.0 vs 76.1 mL·min–1·1.73 m–2, p = 0.04) and prevalence of osteopenia (40.4% vs 27.6%, p = 0.008). The cure rate was 90.9%, with no difference over time or between groups.Figure 1CONCLUSION: Parathyroidectomy is increasingly performed outside of guideline criteria. Patients have less pronounced end-organ effects at the time of surgery but maintain excellent cure rates, suggesting a role for broader operative indications for PHPT such as osteopenia.