Natural History of Treated Primary Hyperparathyroidism

Lars-Erik Tisell, MD, PhD

In 1925, Mandl of Austria performed the first operation for primary hyperparathyroidism (PHPT).1 His patient had sustained a spontaneous thigh bone fracture and was immobilized. Three months after a parathyroid adenoma had been excised, the patient could walk with crutches. The effect of the operation was conspicuous. During the next 4 decades, most patients with PHPT continued to have obvious symptoms relieved by surgery.

In the mid-1960s, the number of operations for PHPT started to increase in most centers. This also happened at our hospital, but the number of patients with substantial disease remained remarkably constant.2 In patients with mild hypercalcemia, with few or no symptoms, it is difficult to register any immediate positive effects of surgery. Therefore, controversy exists as to whether surgical therapy should be used in such patients. In one study, one third of the population of asymptomatic patients had silent complications such as premature osteopenia and abnormal renal function.3 Martin and colleagues4 found that the bone loss of mineral content as a result of PHPT is only partially reversible. However, at that time, they and others5 believed that surgery for PHPT should not be undertaken solely to prevent osteoporosis. The results of some studies suggest an improvement of muscle strength and psychiatric symptoms after surgery for mild PHPT.67 Other observations indicate increased morbidity and mortality among patients with mild hypercalcemia who are observed without surgical treatment.8 Some studies suggest that PHPT may cause lasting damage, resulting in increased morbidity and mortality for a long time after the parathyroid surgery.913 If PHPT is indeed a risk factor for increased morbidity and premature death, a positive attitude toward early surgery is indicated for patients with asymptomatic PHPT.

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