Abstract
Background
Primary hyperparathyroidism consists of 3 biochemical phenotypes: classic, normocalcemic,
and normohormonal primary hyperparathyroidism. The clinical outcomes of patients with
normocalcemic primary hyperparathyroidism and normohormonal primary hyperparathyroidism
are not well described.
Method
A retrospective review of patients who underwent parathyroidectomy at a single institution
was performed. A logistical regression analysis of postoperative nephrolithiasis and
highest percentage change in dual-energy x-ray absorptiometry scan comparison using
Kruskal-Wallis test and Cox proportional hazard analysis of recurrence-free survival
were performed.
Results
A total of 421 patients were included (340 classic, 39 normocalcemic primary hyperparathyroidism,
42 normohormonal primary hyperparathyroidism). Median follow-up was 8.8 months (range
0–126). Higher rates of multigland disease were seen in normocalcemic primary hyperparathyroidism
(64.1%) and normohormonal primary hyperparathyroidism (56.1%) compared to the classic
(25.8%), P < .001. There were no differences in postoperative complications. The largest percentage
increases in bone mineral density at the first postoperative dual-energy x-ray absorptiometry
scan were higher for classic (mean ± SD, 6.4 ± 9.1) and normocalcemic primary hyperparathyroidism
(4.8 ± 11.9) compared to normohormonal primary hyperparathyroidism, which remained
stable (0.2 ± 14.2). Normocalcemic primary hyperparathyroidism were more likely to
experience nephrolithiasis postoperatively, 6/13 (46.2%) compared to 11/68 (16.2%)
classic, and 2/13 (15.4%) normohormonal primary hyperparathyroidism, P = .0429. Normocalcemic primary hyperparathyroidism was the only univariate predictor
of postoperative nephrolithiasis recurrence (odds ratio [95% confidence interval]
4.44 [1.25–15.77], P = .029). Normocalcemic primary hyperparathyroidism was significantly associated with
persistent disease with 6/32 (18.8%) compared to 1/36 (2.8%) and 3/252 (1.2%) in normohormonal
primary hyperparathyroidism and classic (P < .001).
Conclusion
Three phenotypes of primary hyperparathyroidism are distinct clinical entities. Normocalcemic
primary hyperparathyroidism had higher incidence of persistent disease and postoperative
nephrolithiasis but demonstrated improvements in postoperative bone density. These
data should inform preoperative discussions with patients with normocalcemic primary
hyperparathyroidism and normohormonal primary hyperparathyroidism regarding postoperative
expectations.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Diagnosis of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop.J Clin Endocrinol Metab. 2014; 99: 3570-3579
- The surgical management of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop.J Clin Endocrinol Metab. 2014; 99: 3595-3606
- The American Association of Endocrine Surgeons guidelines for definitive management of primary hyperparathyroidism.JAMA Surg. 2016; 151: 959-968
- The effect of parathyroidectomy on the recurrence of nephrolithiasis.Surgery. 1987; 102: 910-913
- The relationship of parathyroidectomy and bisphosphonates with fracture risk in primary hyperparathyroidism: an observational study.Ann Intern Med. 2016; 164: 715-723
- Population-level predictors of persistent hyperparathyroidism.Surgery. 2011; 150: 1113-1119
- Prevention and management of complications in parathyroid surgery.Otolaryngol Clin North Am. 2004; 37: 897-907, xi
- Normal PTH levels in primary hyperparathyroidism: still the same disease?.Ann Surg Oncol. 2011; 18: 3437-3442
- The phenotype of primary hyperparathyroidism with normal parathyroid hormone levels: how low can parathyroid hormone go?.Surgery. 2011; 150: 1102-1112
- Use of calcium and parathyroid hormone nomogram to distinguish between atypical primary hyperparathyroidism and normal patients.World J Surg. 2017; 41: 122-128
- Classic primary hyperparathyroidism versus normocalcemic and normohormonal variants: do they really differ?.World J Surg. 2018; 42: 992-997
- Normocalcemic hyperparathyroidism and hypoparathyroidism in two community-based nonreferral populations.J Clin Endocrinol Metab. 2013; 98: 2734-2741
- Normocalcemic primary hyperparathyroidism: one-year follow-up in one hundred postmenopausal women.Endocrine. 2012; 42: 764-766
- Population-based screening for primary hyperparathyroidism with serum calcium and parathyroid hormone values in menopausal women.Surgery. 1997; 121: 287-294
- Differences in single gland and multigland disease are seen in low biochemical profile primary hyperparathyroidism.Surgery. 2017; 161: 70-77
- Biochemical and skeletal outcomes of parathyroidectomy for normocalcemic (incipient) primary hyperparathyroidism.Ann Surg Oncol. 2019; 26: 539-546
- Normocalcemic primary hyperparathyroidism: further characterization of a new clinical phenotype.J Clin Endocrinol Metab. 2007; 92: 3001-3005
- Bone mineral density evolution after successful parathyroidectomy in patients with normocalcemic primary hyperparathyroidism.J Clin Endocrinol Metab. 2013; 98: 3213-3220
- Bone mineral density changes after parathyroidectomy are dependent on biochemical profile.Surgery. 2019; 165: 107-113
- The normohormonal primary hyperparathyroidism: a surgical dilemma pre and intra-operatively.Am J Surg. 2022; 223: 589-591
- Normocalcemic primary hyperparathyroidism: evidence for a generalized target-tissue resistance to parathyroid hormone.J Clin Endocrinol Metab. 2003; 88: 4641-4648
- Normocalcemic primary hyperparathyroidism in clinical practice: an indolent condition or a silent threat?.Arq Bras Endocrinol Metabol. 2011; 55: 314-317
- Normocalcemic versus hypercalcemic primary hyperparathyroidism: more stone than bone?.J Osteoporos. 2012; 2012128352
- Characterization of normocalcemic primary hyperparathyroidism.Am J Med. 2004; 117: 861-863
- Normocalcemic and normohormonal primary hyperparathyroidism: laboratory values and end-organ effects.Otolaryngol Head Neck Surg. 2021; 165: 387-397
- Is parathyroidectomy safe and effective in patients with normocalcemic primary hyperparathyroidism?.Langenbecks Arch Surg. 2018; 403: 317-323
Article info
Publication history
Published online: October 13, 2022
Accepted:
May 20,
2022
Identification
Copyright
© 2022 Published by Elsevier Inc.
