Primary Hyperparathyroidism Management Audit :
Criteria for Surgical Referral, Imaging and Surgical Outcomes
A Bala, C Archer, S Kaniyur, J Stephens, G Mochloulis, F Kaplan; The Lister Hospital, Stevenage.
Primary hyperparathyroidism (PHPT) is a common clinical condition with a prevalence of 1 in 500. Although patients are generally asymptomatic, further questioning may reveal symptoms such as fatigue and subtle cognitive impairment. The condition is associated with significant morbidity in the forms of osteoporosis and renal calculi. The aim of this audit was to review the overall management of this common condition at our hospital –looking at aspects such as diagnosis, clinical assessment, selection of imaging, imaging concordance and surgical outcomes. Criteria for referrals to surgery were compared to the 2009 National Institute for Health guidelines.
The names of patients with primary hyperparathyroidism from 2006-2008 were obtained from surgical, radiological and endocrine databases – a total of 31 case notes were accessible for analysis. A questionnaire was composed from NIH guidelines and expert opinion. Data collated from medical notes and computerised (pathology and radiology) systems were entered into an excel spreadsheet and analysed.
The majority of patients (71%) were female and presented with average corrected calcium of 2.80mmol/L (NR 2.2-2.65) and an average PTH of 17.4pmol/L (NR 1.6-9.3). The diagnosis of primary hyperparathyroidism was most frequently made by medical specialists within secondary care, although in 2 cases the patients were diagnosed by the urologists after presenting with renal calculi. Following diagnosis, family history was documented in 3% of cases and 6% were screened for MEN. For localisation, a parathyroid ultrasound was employed in 84% and a Sestamibi scan in 90%. The concordance rate was found to be 48%. An adenoma was found in less than half of the non-concordant cases. MRI and CT were rarely requested as additional imaging. Following localisation, a total of 74% of patients were referred for surgery and the majority had over 1 NIH indication. Within our population, 35% of patients had a cCa >2.85mmol/L and 64% of these were referred for surgery; 23% were symptomatic and 23% had evidence of renal stone disease – the majority of these groups (86%, 57% respectively) were referred for surgery. The criterion which most commonly led to referral to surgery was urinary calcium excretion >10mmol/L (100% referred) followed by renal stone disease (86%) and subsequently osteoporosis, and age <50years (each 75%). The average time from diagnosis to parathyroidectomy was 8 months and the procedure was most frequently performed by the ENT surgeons. There were no immediate complications noted and 78% were cured. Histology confirmed a parathyroid adenoma in all but 6 patients. The average length of stay was 2.6 days and 100% of patients remained well at 1 year follow-up. The majority of patients were not followed up beyond 1 year.
Overall, the audit conclusions showed appropriate management. The majority of patients with PHPT in this population were referred to surgery appropriately, often based on more than 1 indication. Surgery was generally successful with no immediate complications and histology confirmed the presence of an adenoma in the vast majority of cases.With the inclusion of more cases, further work in this area may include the examination of imaging concordance in more detail to demonstrate its impact on outcomes. Review of bone mineral density in postoperative patients, and a comparison of morbidity data between conservatively and surgically managed cohorts would also be useful.