K. L. O’Sullivan1, T. W. Yen1, K. Doffek1, S. Wagner1, I. Mazotas1, D. B. Evans1, T. S. Wang1 1Medical College Of Wisconsin,Endocrine Surgery,Milwaukee, WI, USA
Introduction: Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (pHPT) and is associated with low morbidity. An increasing number of elderly patients are undergoing elective surgery and are at greater risk for morbidity and mortality. The aim of this study was to examine the presentation and indications for surgery based on age for pHPT patients at a high-volume institution over 20 years.
Methods: This is a retrospective review of all patients who underwent initial parathyroidectomy for sporadic pHPT from 1/1999-3/2018. Elderly patients were defined as ≥75 years. To study the progression of pHPT over time, the cohort were divided into 3 timeframes: 1999-2007, 2007-2012, and 2013-2018. Demographic and clinical data were collected.
Results: Of the 1900 patients, 1508 (79%) were female. The median age was 59.7 years (range, 18-94); 202 (11%) were ≥75 years. For the entire cohort, preoperative median serum calcium, ionized calcium, parathyroid hormone (PTH), and 24-hour urine calcium levels decreased over time, while 25-OH vitamin D levels and patient body mass index (BMI) increased (Table). There was no difference in 24-hr urine calcium levels (p=0.06). Over the 3 timeframes, the elderly had lower preoperative serum calcium (11 vs 10.7 vs 10.7;p=0.05) and PTH (150.4 vs 111.9 vs 107.9;p<0.001) levels, but higher 25-OH vitamin D (16 vs 28 vs 31;p<0.001) levels. Fewer patients had fragility fractures (27% vs 20% vs 14%;p=0.005) and more reported symptoms of gastroesophageal reflux (24% vs 41% vs 46%;p<0.001). When compared to patients <75 years, the elderly had similar preoperative serum calcium levels (10.8 vs 10.9;p=0.91), higher PTH (102 vs 121;p<0.001) and creatinine (0.8 vs 0.9;p<0.001) levels, lower 24-hr urine calcium (315 vs 196;p<0.001) levels, and lower BMI (29.4 vs. 27.4;p<0.001). The elderly were more likely to be taking vitamin D (52% vs 43%;p=0.01), have osteoporosis (58% vs 21%;p<0.001), and a history of fractures (20% vs 10%;p<0.001); younger patients had higher rates of nephrolithiasis (27% vs 16%;p=0.001). Postoperatively, by age groups, there was no difference in rates of recurrent laryngeal nerve injury (1.5% in both groups) or hypoparathyroidism (1.4% vs. 2.0%).
Conclusion: Over the 3 timeframes, elderly patients who underwent parathyroidectomy for sporadic pHPT had lower serum calcium and PTH levels, although the clinical significance of these findings is unclear. There was no difference in endocrine-specific complications between the age groups, suggesting that parathyroidectomy in the elderly is not associated with higher morbidity and that elderly patients with hypercalcemia should be evaluated for pHPT and considered for surgical referral.
