Surgeons Advocate Early Surgical Treatment for Elderly Patients with Hyperactive Parathyroid Gland

Newswise — Elderly patients with an overactive parathyroid gland (hyperparathyroidism) should receive surgical treatment before they begin to exhibit the advanced objective consequences of the disease, such as osteoporosis (brittle or fragile bones caused by a loss of calcium deposition in underlying bone), according to surgeons from M. D. Anderson Cancer Center in Houston, TX. "Elderly patients with primary hyperparathyroidism were more likely to have advanced bone disease [osteoporosis] at the time of parathyroidectomy--suggesting that the disease had progressed on the continuum from osteopenia to osteoporosis before surgical referral. Parathyroidectomy decreases the risk of fracture in patients with normal, osteopenic, and osteoporotic bones but the largest impact is in patients with osteoporosis. Bone mineral density can be improved by 12 to 14 percent in one year--not an insignificant number, particularly when compared to the single digit effect of bones from oral or intravenous medications," according to Nancy D. Perrier, MD, FACS, associate professor of surgery at M. D. Anderson Cancer Center, the University of Texas Health Sciences Center. Dr. Perrier believes that "if we operate earlier on in the progression of the disease, we may allow elderly patients to perform their daily functions better and remain independent for a longer period of time."

Dr. Perrier is advocating prompt surgical treatment upon diagnosis because of findings from a study that showed elderly patients had more severe hyperparathyroidism than younger patients at the time they underwent parathyroidectomy (surgical removal of the parathyroid gland). The study was presented at the 2008 Clinical Congress of the American College of Surgeons. Patients in the study who were over age 70 had significantly more severe osteoporosis and lower mean bone density scores than younger patients operated upon in the same time interval. Elderly patients also had higher levels of creatinine (which reflects impaired kidney function) and parathyroid hormone. The study included 392 patients who underwent parathyroidectomy between 2005 and 2007 at M. D. Anderson Cancer Center. One hundred four of these patients were over the age of 70.

The researchers found that parathyroidectomy was just as safe in the elderly as in the young. The rate of complications during the operation was similar in older patients (5.1 percent) compared to younger ones (4.8 percent). "There is no higher risk of complications if patients are 80 or if they are 60. The complication risk of the surgical procedure is the same for those considered young or elderly. It is small for both," Dr. Perrier said. Allowing the disease to progress may however result in more complications in the older cohort because they have less reserve and recovery from complications of the disease may be longer. There has been progressive improvement in the surgical management of patients with hyperparathyroidism over the last decade. "Experienced endocrine surgeons do these operations with minimally invasive techniques and with incisions that are one to two centimeters in length. The operations can be performed under attended local anesthesia. The patients are admitted on an outpatient basis, and they are usually discharged from the hospital within four to six hours of the procedure," she explained. Patients return to activities of daily living on the next day.

Consequently, Dr. Perrier believes there is no reason to delay surgical treatment of hyperparathyroidism, even among the elderly population. She advocates that cure, for which parathyroidectomy is the only definitive means, can prevent downstream disability. It can be considered "preventive" in a sense because the disease can be treated at diagnosis, before progression takes place. "I often compare it to car maintenance," Dr. Perrier explained. "Are you going to bring your car in for the 10,000-mile checkup, get the tires checked, and the oil changed to do the preventive maintence? Or, do you drive it for 250,000 miles and then take it in when steam is coming out of the engine and it is burning up?" she asked. "That's the same sort of situation with hyperparathyroidism. Early intervention may prevent or reverse osteoporosis, decrease the risk of cardiac death and cardiovascular disease, and improve quality of life for problems that one may not even attribute to the disease. Such problems include sleep disorder, depression, and difficulty with memory. In addition, any measure that can improve bone mineral density is favorable because the consequences of hip fracture are so profound," Dr. Perrier said. In a population that has ongoing risk of falls and frailty, it makes sense to proceed with a measure that has low risk but high benefit--such as minimally invasive parathyroidectomy.

"We're suggesting early intervention by a trained endocrine surgeon to prevent the onset of more objective symptoms. When performed by a trained endocrine surgeon, it is quick, safe and offers tremendous benefit," Dr. Perrier concluded.

Hyperparathyroidism occurs when the parathyroid glands produce excessive amounts of parathyroid hormone and lose the ability to autoregulate. The result is a high serum calcium level. The parathyroid glands reside in the front of the neck behind the thyroid gland and they secrete parathyroid hormone (PTH), which regulates the amount of calcium to be deposited in bones and blood.

Approximately 100,000 new cases of hyperparathyroidism are diagnosed each year. Hyperparathyroidism is more common in the elderly, and particularly in women. The disease affects nearly 13 percent of women over the age of 65. It can be diagnosed on the basis of results from from routine blood sample. Serum calcium and intact parathyroid hormone tests are not expensive.

In its early stages, hyperparathyroidism causes vague and subtle symptoms, such as fatigue, depression, and decreased ability to concentrate. When severe, the disease may progress to more objective symptoms including osteoporosis, kidney stones, pancreatits or rarely, mental status changes.

Also participating in the study were Susanna H. Shin, MD; Holly Holmes, MD; Ruijun Bao, MD; Camillo Jiminez, MD; Douglas B. Evans, MD, FACS; and Jeffrey E. Lee, MD, FACS.