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The Changing Landscape Of Primary Hyperparathyroidism: Changes In Anatomic Patterns And Implications For Surgical Management
*Salem Noureldine, *Gustavo Romero-Velez, *Talia Burneikis, *Robert Naples, *Brian Tang, *Judy Jin
Cleveland Clinic, Cleveland, OH

OBJECTIVE(S): With increased screening for primary hyperparathyroidism (pHPT), most patients now present with a milder form of the classic disease. Furthermore, technological improvements have shifted the surgical approach from bilateral exploration to a more focused approach. However, in cases of multigland disease (double adenomas [DA] or 3-4 gland hyperplasia [MGH]), bilateral exploration continues to play an important role. Here, we review our experience in managing patients with pHPT to identify changes in the anatomic patterns of diseased glands and implications for surgical management.
METHODS: All consecutive patients with sporadic pHPT who underwent initial parathyroidectomy at a tertiary care center that practices routine bilateral neck exploration were included for two time points: early (2000-2006) versus recent (2014-2020).
RESULTS: Overall, 2,006 patients were included (Table 1). Patients in the recent group were older (61.5 vs 59.9 years, p=.02), and had lower preoperative calcium (10.8 vs 11.1 mg/dL, p=.001) and PTH levels (101 vs 146 pg/mL, p=.001). The prevalence of multigland disease increased significantly over time (32.9% vs 41.1%, p=.02). This was most pronounced in the increase in DA. An upper parathyroid adenoma remained the most common finding in patients with single adenoma (SA) from both time points (57.6% vs 60%, p=NS). While the proportion of patients with either upper or lower DA both increased significantly, upper DA accounted for 48% of all DA cases in the recent group. With a mean follow up of 352 months, rates of persistent/recurrent disease in the recent group were 2.0%, 3.2, and 3.9% in patients with SA, DA, and MGH (p=NS).
CONCLUSIONS: Despite the significant change in patient profile over time, similar anatomical distribution of adenomas remained unchanged. Abnormal upper glands were more common in patients with either SA or DA. This finding is important for surgical decision making when bilateral exploration becomes necessary, by understanding the diseased gland distribution and each of its probability. With routine bilateral exploration, the cure rate remains similar in patients with SA, DA, and MGH.


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