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Severity, Clinical Significance, Relationship to Primary Hyperparathyroidism, and Response to Parathyroidectomy

John R. Burgess, MD, FRACP; Ruben David, BSc; Timothy M. Greenaway, PhD, FRACP; V. Parameswaran, PhD; Joseph J. Shepherd, MD, FRACS

Arch Surg. 1999;134:1119-1123.

Background  Sporadic primary hyperparathyroidism (PHPT) occurs most frequently in postmenopausal women. Multiple endocrine neoplasia type 1 (MEN 1) is an autosomal-dominant disease in which mild to moderate PHPT develops in most gene carriers by 20 years of age. Primary hyperparathyroidism associated with MEN 1 is typically recurrent, despite initially successful subtotal parathyroidectomy. Osteoporosis is considered a complication of sporadic PHPT and an indication for parathyroidectomy. In the setting of MEN 1, however, the relationship of bone mass to PHPT, fracture risk, and parathyroidectomy is unknown.

Hypothesis  Parathyroidectomy improves bone mineral density for patients with primary hyperparathyroidism in the setting of MEN 1.

Design  Case series.

Setting  Tertiary referral center.

Patients  Twenty-nine women with MEN 1 belonging to a single family with a history of MEN 1.

Interventions  Parathyroidectomy.

Main Outcome Measures  Bone mineral density (BMD) and history of skeletal fracture.

Results  Osteopenia and osteoporosis were diagnosed in 41% and 45% of patients, respectively. Forty-four percent of patients with uncontrolled PHPT had severe osteopenia (T score, <-2.0) by 35 years of age. Reduction in BMD was greatest at the femoral neck. Reduced BMD was associated with an increased likelihood of skeletal fracture (P=.05). Patients with uncontrolled PHPT had lower femoral neck and lumbar spine BMDs than those in whom PHPT was controlled by parathyroidectomy (P=.005 and .02, respectively). Successful parathyroidectomy improved femoral neck and lumbar spine BMDs by a mean±SEM of 5.2%±2.5% and 3.2%±2.9%, respectively.

Conclusions  Osteoporosis is a frequent and early complication of PHPT in MEN 1. Despite difficulty in achieving a cure of PHPT in MEN 1, parathyroidectomy has an important role in the optimization of BMD for patients with MEN 1.

From the Departments of Diabetes and Endocrine Services (Drs Burgess, Greenaway, and Parameswaran) and Clinical Chemistry (Mr David), Royal Hobart Hospital, and the Department of Surgery, University of Tasmania (Dr Shepherd), Hobart, Australia.

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