Hyperparathyroidism: the limits of surgery in cases of bone or cardiovascular involvement

In primary hyperparathyroidism (PHPT), asymptomatic bone disease can be det ected by bone densitometry, The bone mineral density is about 10% lower tha n normal control values, especially in the cortical radius. Without parathy roidectomy, bone mineral density is frequently stable, but a few patients, mostly postmenopausal women, have a significant decrease. Histology shows m aintenance of trabecular connectivity but with an increase in cortical poro sity, After parathyroidectomy, bone mineral density increases, particularly at the lumbar spine and femoral neck, and the benefit persists after 10 ye ars. The fracture risk is controversial but risk of trabecular bone fractur e may be higher than that for controls. The impact of PHPT on survival is a lso controversial, but highest quartile of serum calcium, osteoporosis, old age, and low lean mass are each associated with a death risk. There is als o a debate about the criteria for distinguishing between asymptomatic and s ymptomatic PHPT and about the bone mineral density threshold that should be used as a basis to recommend surgery. The rate of progression of PHPT is s low but in some cases bone loss progresses, justifying bone mineral density follow-up, The frequency of inadequate follow-up and the cost of nonoperat ive follow-up are in favor of recommending surgery. With broader indication s for surgery, it is mandatory to improve the biochemical diagnosis of PHPT . (C) 2000 Lippincott Williams & Wilkins, Inc.