Research Article
Characteristics of Primary Hyperparathyroidism Patients Based on One Saudi Center Experience
Amal Abdulhaq, Saif Alsobhi and Amal Alhefdhi*
Department of Surgery, King Faisal Specialist Hospital and Research Center, Saudi Arabia
*Corresponding author: Amal Alhefdhi, Department of Surgery, King Faisal Specialist Hospital and Research Center (KFSH&RC), MBC 40, Riyadh, Saudi Arabia
Published: 28 Jun, 2018
Cite this article as: Abdulhaq A, Alsobhi S, Alhefdhi
A. Characteristics of Primary
Hyperparathyroidism Patients Based
on One Saudi Center Experience. Clin
Surg. 2018; 3: 1992.
Abstract
Introduction: The prevalence and presentation of the Primary Hyperparathyroidism (PHPT)
geographically varies. There is a paucity of published literature on PHPT in Saudi Arabia, so this
study aimed to investigate the characteristic features and the surgical outcome of PHPT patients.
Methods: A retrospective review of PHPT patients underwent parathyroidectomy at King Faisal
Specialist Hospital and Research Center, from 2010 to 2016.
Results: There were 88 patients; 72 (81.8%) were female and 16 (18.2%) were male. The mean age
was 46 ± 15 year. The mean preoperative serum level was 2.85 ± 0.33 for calcium and 407 ± 475 for
parathyroid hormone. The majority of the cases presented with bone symptoms 50 patients (56.8%),
followed by no symptoms in 25 patients (28.4%), fatigability 7 (7.9%), renal symptoms 4 (4.6%) and
gastric symptoms 2 (2.3%). Sestamibi scanning localized diseased gland in 71 cases (81.6%). The
causes of PHPT were single adenoma in 75 (85.2%), double adenoma in 6(6.8%) and hyperplasia in
7(8%). The persistent rate was 1.1% and the recurrent rate was 2.2%. Females found to have a lower
preoperative vitamin D level comparing with males 39.7 nmol/L ± 28.6 nmol/L vs. 73.87 nmol/L
± 19.73 nmol/L (p= 0.0001). Moreover, patients with multiple gland disease had a higher rate of
recurrence comparing with patients with single adenoma 0% vs. 15.4% (p=0.020).
Conclusion: While half of PHPT patients in Saudi Arabia still present with bone symptoms, one
fourth of the cases are asymptomatic. Moreover, one third of the cases are younger than 40 years old.
Keywords: Primary hyperparathyroidism; Causes; Parathyroidectomy
Introduction
Primary Hyperparathyroidism (PHPT) is the uncontrollable overproduction of Parathyroid
Hormone (PTH) causing an abnormal calcium homeostasis [1-5]. PHPT is a common endocrine
disorder worldwide [1-5]. The prevalence of PHPT varies from country to country [1-5]. While the
reported literatures estimate the range of PHPT prevalence in the US, Europe and Australia to be 1
to 21 per 1,000 individuals [6], PHPT was as low as 61 cases over a decade in India [7].
In addition, patients’ presentation can vary from asymptomatic to severe systemic manifestations
[1-7]. Although routine calcium test was introduced in Saudi hospital since 2000 [8], the clinical
features, and the overall pattern of PHPT patients in the Kingdom of Saudi Arabia (KSA) is still not
clear. Few studies published in the literature discuss about the clinical features of PHPT patients in
the KSA [8-10].
The aim of this study is to investigate the characteristic feature and the surgical treatment
outcome of patients with primary hyperparathyroidism who were operated in King Faisal Specialist
Hospital and Research Center (KFSH & RC), Riyadh, KSA. Such a study will enrich our literature
and help health providers, endocrinologist and endocrine surgeons to develop an overall view about
patients with PHPT in the KSA.
Methods
This is a descriptive study in which we systematically reviewed all the clinic-pathological features
and the surgical treatment modalities for all adult patients with PHPT who underwent initial
parathyroidectomy at KFSH&RC, Riyadh, KSA, for 6 years (January 2010-June 2016). However,
we exclude patients who were on thiazide diuretics or lithium, pediatric patients, patients who were
operated outside KFSH & RC, and patients with secondary or tertiary hyperparathyroidism. KFSH
& RC is a single tertiary institution. In this study, we defined the persistence of disease as high
postoperative calcium level within 6 months, whereas the recurrent
disease as manifested by high postoperative calcium after the 6
months.
Data was collected from the electronic medical records and
missing information extracted from the patient’s charts. The
parameters include: Patient’s demographics, age, gender, presenting
symptoms, the preoperative radiological image findings, pre- and
post-operative serum levels of calcium and Parathyroid Hormone
(PTH), causes of PHPT which could be adenoma, double adenomas
or hyperplasia, presence of coincidence thyroid gland pathology, type
of surgery, follow up persistence and recurrent rate.
This study was approved by KFSH & RC’s Research Advisory
Council (RAC). Data was analyzed using SPSS version 20. Continuous
data was summarized as means and Standard Deviation (SD), whereas
categorical data was summarized as absolute values and percentages.
Differences between continuous data were analyzed using unpaired
Student’s test: Whereas categorical data was analyzed using the chisquare
test or fisher's exact test, as appropriate. p value of 0.05 or less
was considered statistically significant.
Table 1
Results
In total 88 patients met the inclusion criteria. The mean age
was 46 ± 15 years and 72 (81.8%) were females and 16 (18.2%) were
males. The mean preoperative serum levels were 2.85 mg/dl ± 0.33
mg/dl for calcium and 407 pg/ml ± 475 pg/ml for PTH. Moreover,
50 patients (56.8%) were presented with bone symptoms, 25 patients
(28.4%) were asymptomatic, 7 patients (7.9%) were presented with
fatigability, 4 patients (4.6%) were presented with renal symptoms
(polyuria, nephritis and kidney stone) and 2 patients (2.3%) were
presented with gastric symptoms (nausea, vomiting and abdominal
pain).
Eighty-seven patients (99%) underwent a preoperative
localization images in the form of parathyroid sestamibi scan. One
patient with men I was planned for subtotal parathyroidectomy;
therefore the surgeon did not order a preoperative localization
images. Sestamibi scanning localized the diseased gland in 71 cases
(81.6%). In addition, ultrasound neck was performed on 77 patients
(87.5%) to evaluate the thyroid gland and confirm the localization.
Ultrasound neck localized the diseased gland in 50 cases (64.9%)
and among them, a synchronous thyroid nodule(s) were found in
20 patients (40%). Only 8 patients (16%) underwent thyroid surgery:
6 (12%) underwent total thyroidectomy due to thyroid cancer; and
2 (4%) underwent hemithyroidectomy due to Follicular Lesion of
Undermined Significance (FLUS) which turned to be benign in the
final pathology.
The majority underwent minimally invasive parathyroidectomy:
75 patients (85.2%) and 13 patients (14.8%) underwent bilateral neck
exploration. Single adenoma was the major cause of the PHPT in 75
patients (85.2%), followed by hyperplasia in 7 patients (8%) and then
double adenoma in 6 patients (6.8%). The mean postoperative serum
levels were 2.27 mg/dl ± 0.15 mg/dl for calcium and 79 pg/ml ± 53
pg/ml for PTH. The persistence and recurrence rates were 1.1% and
2.2% respectively.
We compared females vs. males, but there were no statistically
significant differences between them in the form respect of age,
preoperative levels of calcium and PTH, causes of PHPT, persistence,
recurrent rate and presentations. However, we noticed a statistically
significant difference in the level of vitamin D preoperatively between
two groups of patients (39.7 nmol/L ± 28.6 nmol/L vs. 73.87 nmol/L
± 19.73 nmol/L, p=0.0001, Table 1). In addition, the immediate
postpone calcium level was lower and the immediate postoperatively
level of the PTH was higher in females (2.52 mg/dl ± 0.61 mg/dl vs.
2.35 mg/dl ± 0.22 mg/dl, p=0.005 and 88 pg/ml ± 67 pg/ml vs. 98 pg/
ml ± 108 pg/ml, p=0.006, respectively, Table 1).
In addition, we compared the younger patients (<40 years) vs.
older patients (>40 years) but there was no statistical difference in
respect of gender, serum level of calcium and PTH, presentations and
causes, but the younger patients presented with more bone symptoms
22 (68.8%) vs. 28 (50%); however, it was not statistically significant
(p=0.234). Moreover, patients over 40 years old were found to have
more thyroid nodules compared to patients under 40 years old: 2
(6.25%) vs. 17 (30.4%), (p=0.008), which could be explained by the
age (Table 2).
Finally, we compared those patients who had a single adenoma
with those who had a multiple glands disease. There was no statistical
difference in respect of age, gender, preoperative serum level of
calcium and PTH and presentations, but the immediate postoperative
level of calcium was lower among those with SA 2.26 mg/dl ± 0.13 mg/
dl vs. 2.41 mg/dl ± 0.17 mg/dl (p=0.0004). In addition, the recurrence
rate was higher among those with a multiple glands disease 0 (0%)
vs. 2 (15.4%) (p=0.020) younger patient presented with more bone
symptoms (Table 3).
Table 2
Discussion
Percivale et al. [6] and Bilezikian et al. [2] in their recent review
reported the annual worldwide incidence of the PHPT to be 20 cases
per 100,000 people and the prevalence of the PHPT to be 0.5% to 2%
[11,12]. Nevertheless, in the KSA, there is no accurate available data
on the incidence or the prevalence of the disease. In our study, we
identified 88 cases during a period of 6 years. This study cannot reflect
an accurate data of the incidence or the prevalence of the PHPT in the
KSA; however, it reflects an increase in the number of the diagnosed
cases as compared with the available previous national studies [8,9].
Bismar et al. [9] reported 41 cases from 1992 to 2002, and Malabu et
al. [8] reported 46 cases from 2000 to 2006.
In our study, the mean age of the cases was 46 years at the
presentation of PHPT, with a male to female ratio of approximately
1:4.5. While we are in agreement with the literature in respect of the
male to female ratio which was reported to be from 1:3 to 1:5 [8,9,11-
13]. The mean age of our patients was younger than that reported
in the western literature [11-14], but older than the age reported by
the developed countries [7,14,15] and similar to the age of the PHPT
patients in the previous national studies [8,9].
The majority of our patients (57%) presented with bone
symptoms, while 28% were asymptomatic and 5% presented with
renal stone. However, in the El-Bakry et al. [9] study, 73% of the
patients presented with musculoskeletal symptoms, 14.6% patients
presented with renal stones and 5% patients were asymptomatic [9]
and in the Malabu et al. [8], 45.7% complained of bone symptoms,
23.9% were asymptomatic and 15.2%, had renal manifestations [8].
Our findings demonstrate the decline of the renal presentation and
the increase of the number of the patients with asymptomatic disease
which could be due to the introduction of routine calcium test in
Saudi hospitals [8].
In our study, the parathyroid sestamibi scan localized the
diseased gland in 81.6% of the cases and ultrasound neck localized
the diseased gland in only 64.9% of the cases. This goes along with the
previously reported sensitivity of the 99 mTc sestamibi scan and the
neck ultrasound; 70% to 90% and 22% to 80%, respectively [16-18].
Moreover, the incidence of finding a synchronous thyroid nodule was
40% in our study in which 12% found to have a thyroid cancer. Thus,
our results are in agreement with the previous literatures [19].
In regard to the causes of PHPT, our study demonstrates that
single adenoma was the cause in 85.2% of the cases which is in
agreement with the previous national and international literatures
[2,3,8,9,11]. However, 85.2% of our cases underwent minimally
invasive parathyroidectomy comparing with 9.8% in the Bismar
et al. [9] study and 0% in the Malabu et al. [8] study. That can be
explained by the difference in the time of the study. MIP is a relatively
new surgical approach which appears to have become the standard
operation in KSA nowadays. Moreover, our persistence (1.1%) and
recurrence rates (2.2%) are in agreement with previously published
national and international figures [8,9,20,21].
In addition, we found that females had a lower preoperative
vitamin D level and higher immediate postoperatively PTH level
which may indicate a vitamin D deficiency among them. This was
in agreement with the Malabu et al. [8] study. Moreover, younger
than 40 years old patients presented with more bone symptoms and
patients more than 40 years old were found to have more thyroid
nodules. Shah et al. [14] found that bone presentation were common
in young patients, while renal presentations were common in adults.
Finally, the recurrence rate was higher among those with a multiple
glands disease which is in agreement with the previously published
studies [20-22].
The results of this study should be taken with caution since this
study is retrospective study. Detailed information about pre- and
postoperative vitamin D levels were missing. Generalizability is
limited as well, since the study was carried out on a single, highvolume
tertiary hospital and the operations were performed by
experienced endocrine surgeons. Thus, further prospective studies on
a larger population are needed to validate our findings and to clarify
the incidence and the prevalence of PHPT in Saudi Arabia.
Table 3
Conclusion
Our data suggested that PHPT patients in Saudi Arabia affecting females more than males. Although half of the patients still presented mainly with bone symptoms, one fourth of the patients were asymptomatic. Moreover, one third of the cases are younger than 40 years old.
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