Management of asymptomatic hyperparathyroidism.

From January 1, 1971, to December 31, 1982, 242 patients with uncomplicated biochemical or asymptomatic hyperparathyroidism underwent operative therapy at the Massachusetts General Hospital. They represent 36.1 percent of the 670 total operative cases during this period. Before 1971, from 1941 to 1970, there were only 33 hyperparathyroid patients with asymptomatic hyperparathyroidism who underwent surgery. The initial surgical procedures included 88 unilateral and 134 bilateral cervical explorations. There were 19 patients who underwent reexploration, including 15 referrals and 4 patients who had their primary operation at the Massachusetts General Hospital. There were no deaths, no recurrent nerve injuries, and only one patient with protracted but temporary postoperative hypocalcemia. Four patients (1.7 percent) had persistent hypercalcemia and therefore, must be considered treatment failures. The procedure resulted in normocalcemia in 238 of the patients (98.3 percent). The mean serum calcium level decreased from a preoperative value of 11.1 to 8.9 mg/100 ml the serum phosphorus level increased from 2.8 to 3.9 mg/100 ml postoperatively. Pathologic examination revealed 201 adenomas (83.1 percent), 39 hyperplasias (16.1 percent), 2 patients with normal glands (0.8 percent), and no carcinomas. The size of the abnormal glands appeared to correlate with the degree of hypercalcemia. Patients with marked hypercalcemia generally had a large gland that was more easily identified than the gland patients who had milder disease in whom it was smaller, harder to locate, and more difficult to distinguish pathologically from a normal gland. In general, patients with milder disease (serum calcium less than 11 mg/100 ml) should be followed expectantly. In some of these patients, there is doubtless progressive exacerbation of hypercalcemia, increases in the parathyroid hormone level, osteopenia, or renal insufficiency which ultimately requires surgical intervention. In others, there is apparently severe biochemical, asymptomatic hyperparathyroidism as manifested by a serum calcium level greater than 11 mg/100 ml, an increased parathyroid hormone level, increased 24 hour urinary calcium excretion greater than 150 mg, progressive loss of bone mass, or deterioration of renal function. These latter patients should be operated on without delay. For patients who risk the long-term complications of hyperparathyroidism and menopausal patients who are potentially threatened by postmenopausal osteoporosis, surgery is likely to be beneficial. For those whose compliance with therapy or follow-up poses a significant logistic problem, surgical therapy is often the best solution.