Parathyroidectomy in the elderly is beneficial and safe with similar improvements in postoperative bone mineral density

Bilateral exploration in primary hyperparathyroidism: Double adenoma distribution and biochemical patterns over two decades

BACKGROUND

We investigated if anatomic patterns of abnormal parathyroid glands have ch anged for primary hyperparathyroidism (pHPT) as atypical biochemical presentation (normohormonal and normocalcemic) has increased.

METHODS

Retrospective review of patients with pHPT who underwent routine bilateral neck exploration.

RESULTS

2762 patients were included. The "late" cohort (2014-2020) exhibited lower preoperative calcium (10.8 vs 11.1 ​mg/dL; P ​= ​0.001) and PTH levels (101 vs. 146 ​pg/mL; P ​= ​0.001) compared to the "early" cohort (2000-2006). Patients with atypical biochemical profiles increased from 25.5% to 31.3% (P ​< ​0.001). The prevalence of single adenoma (SA) decreased (66.1% vs 58.9%, P ​= ​0.02) while the proportion of double adenoma (DA) increased (17.3% vs. 22.6%, P ​< ​0.01). Upper parathyroid adenoma(s) remained the most common finding for SA and DA in both time points.

CONCLUSIONS

Despite changes in patient characteristics, single upper adenoma and bilateral double upper adenomas remain the most common findings for patients with pHPT.

Parathyroidectomy Improves Bone Density in Women With Primary Hyperparathyroidism and Preoperative Osteopenia

CONTEXT

Osteoporosis and/or bone fractures are indications of parathyroidectomy in primary hyperparathyroidism (PHPT), especially in women. However, the benefit of surgery in patients with osteopenia remains unclear.

OBJECTIVE

To evaluate bone mineral density (BMD) and bone remodeling biomarkers changes 1 year after parathyroidectomy in women with PHPT.

DESIGN

In the prospective, monocentric, observational prospective cohort with primary hyperparathyroidism patients (CoHPT) cohort, women operated for sporadic PHPT since 2016 with ≥1 year follow-up were included. BMD (dual-X ray absorptiometry) and bone remodeling biomarkers [cross-linked C-telopeptide (CTX), procollagen type 1 N-terminal propeptide (P1NP), and bone-specific alkaline phosphatases] were assessed before and 1 year after parathyroidectomy.

SETTING

Referral center.

PATIENTS

A total of 177 women with PHPT (62.5 ± 13.3 years, 83.1% menopausal, 43.9% osteopenic, and 45.1% osteoporotic) were included.

INTERVENTION

Parathyroidectomy.

MAIN OUTCOME MEASURE

BMD change between before and 1 year after parathyroidectomy.

RESULTS

Parathyroidectomy resulted in significant increase in BMD and decrease in serum bone remodeling biomarker concentrations. In the 72 patients with baseline osteopenia, mean BMD significantly increased at the lumbar spine [+0.05 g/cm2 (95% confidence interval [CI], 0.03-0.07)], the femoral neck [+0.02 g/cm2 (95% CI 0.00-0.04)], the total hip [+0.02 g/cm2 (95% CI 0.01-0.02)], and the forearm [+0.01 (95% CI 0.00-0.02)], comparable to osteoporotic patients. Among osteopenic patients, those with individual BMD gain (>0.03 g/cm2) at ≥1 site had higher preoperative serum CTX, P1NP, and urine calcium concentrations than those without improvement.

CONCLUSION

Parathyroidectomy significantly improved BMD and remodeling biomarkers in women with osteopenia, thereby supporting the benefit of parathyroidectomy in these patients. Preoperative serum CTX and P1NP concentrations could be useful to predict expected BMD gain.

Primary Hyperparathyroidism in Older Adults: A Narrative Review of the Most Recent Literature on Epidemiology, Diagnosis and Management

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder among older adults. The aim of this review is to shed light on PHPT, particularly in this age group, in terms of prevalence, clinical manifestations, medical and surgical management, and post-operative complications.

METHODS

Eligible studies were those considering PHPT exclusively in the older population (main databases: PubMed, Medline, Google Scholar and the University Online database). Articles published in the last 10 years (2013-2023) were considered. Eligibility criteria followed the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. The methodological quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tool. A total of 29 studies (mainly observational) matched the inclusion criteria.

RESULTS

The prevalence of PHPT is approximately 1 per 100 in the elderly, and it is more common in females. The clinical presentation varies by age and can include osteoporosis, fractures, and neuropsychiatric symptoms. Conservative management can be an option whenever surgery is not indicated or feasible. However, parathyroidectomy (PTX) remains a safe and effective modality in aging populations with improvement to symptoms, bone mineral density, fracture risk, frailty, quality of life, and metabolic derangements. Complication rates are similar in elderly people compared to younger ones, except for mildly longer length of hospital stay and reoperation for those with higher frailty.

CONCLUSION

PHPT is a common yet overlooked and underdiagnosed condition among the older population. The safety and efficacy of PTX in the older population on different levels is now well demonstrated in the literature.