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THE NON-CLASSICAL PRIMARY HYPERPARATHYROIDISM; A SURGICAL DILEMMA PRE AND INTRA-OPERATIVELY
T Fedorova, A Hawasli
Ascension St. John Hospital and Medical Center

Background
Non-classical primary hyperparathyroidism (NcPHPT), characterized by elevated serum calcium >10.2 mg/dl with normal parathyroid hormone (PTH) 50% results in a successful operation. We decided to look at our experience in the last 10 years to study this subgroup of patients.

Methods
A retrospective chart review was conducted for all adult patients who underwent parathyroidectomy between 2009-2019 by a single surgeon in a community teaching hospital. Data was collected on pre-operative localization, PTH, calcium, creatinine level, intra-operative PTH (ioPTH) and pathology.

Results
A total of 337 patients had undergone parathyroidectomy. In 33 (9.8%) patients the indication was NcPHPT. There were 28 females and 5 males with average age of 64.2+9.9 years. The pre-operative average calcium level was 10.5+0.4 mg/dl and average PTH of 53.9+8.2 pg/ml. Negative pre-operative localization was present in 18 (54.5%) patients. The intra-operative findings were: 27 (81.8%) single adenomas, 3 (9.1%) double adenomas and 3 (9.1%) hyperplasia.
In the single adenomas patients, the ioPTH dropped from 56.7+7.8 to 23.4 +9.8 pg/ml and was below 30 pg/ml in 22 (81.5%). In the remaining 5 patients;1 patient had a repeat parathyroidectomy after 3.5 years for recurrent hypercalcemia and 4 patients their PTH went below 40 pg/ml over one week follow up with normal calcium. The average size of the parathyroid adenomas was 420+360 mg (median of 352 mg).

Conclusion
NcPHPT is an uncommon situation where the disease is diagnosed in its early stages. It poses a surgical dilemma for surgeons where the patients are presented with normal PTH level and often negative pre-operative localization imaging. The glands are often single adenomas and small. It takes experienced surgeons familiar with 4 gland exploration to operate on these patients rather than waiting until the disease progresses to the point that it can be detected with localizations studies. The intra-operative drop in PTH below 30 pg/ml can be utilized as an indicator of a successful operation.


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