Indications for operative intervention in patients with asymptomatic primary hyperparathyroidism: Practice patterns of endocrine surgery

Indications for operative intervention in patients with asymptomatic primary hyperparathyroidism: Practice patterns of endocrine surgery Maria A. Kouvaraki, MD, PhD,a Marilyn Greer, PhD,b Sheena Sharma, MPH,b David Beery, BSASE,b Robert Armand, MS,b Jeffrey E. Lee, MD, FACS,a Douglas B. Evans, MD, FACS,a and Nancy D. Perrier, MD, FACS,a Houston, Texas

Background. Currently, many patients with primary hyperparathyroidism (PHPT) are diagnosed when they are considered to be “asymptomatic.” The need for parathyroidectomy in these patients has been questioned. A consensus statement drafted after the National Institutes of Health (NIH) 2002 Workshop on Asymptomatic PHPT provided guidelines for management of such patients but has been criticized for being too conservative. The purpose of this survey was to determine the impact of these guidelines on practice patterns of endocrine surgeons. Methods. Members of the American Association of Endocrine Surgeons (AAES) were surveyed to determine whether previously published consensus guidelines for management of asymptomatic patients with PHPT are used to base the decision of whether to offer parathyroidectomy and to ascertain what parameters are considered indicators to proceed with operative intervention. AAES members were asked about the management of patients with asymptomatic PHPT, specialty characteristics, and demographics. Results. Of 257 AAES members, 96 (37%) responded to the survey. Although the majority of the respondents were aware of and followed the NIH consensus conference guidelines, the majority of surgeons (80%) would operate on a patient with PHPT who did not meet these criteria but had other nonspecific symptoms. Surgeons favored operative intervention when preoperative localization studies were positive, even if the criteria of the NIH guidelines were not fulfilled. Most of the responders who would operate on all patients with PHPT, regardless of objective parameters, were surgeons with a high-volume practice (⬎30 parathyroidectomies per year). The presence of multiple endocrine neoplasia (MEN) syndromes did not alter the decision to operate on asymptomatic patients. Conclusions. Endocrine surgeons do not base the decision to intervene operatively in patients with PHPT solely on objective criteria. Most high-volume, experienced endocrine surgeons believe that subjective complaints warrant operative intervention. (Surgery 2006;139:527-34.) From the Departments of Surgical Oncologya and Institutional Researchb, The University of Texas M.D. Anderson Cancer Center

Primary hyperparathyroidism (PHPT) is an almost exclusively benign hormonal disorder characterized by a high or high-normal serum calcium concentration and an inappropriately increased parathyroid hormone (PTH) level. Ap-

Accepted for publication September 12, 2005. Reprint requests: Nancy D. Perrier, MD, Department of Surgical Oncology, Unit 444, The University of Texas M.D. Anderson Cancer Center, 1400 Holcombe Blvd., Houston, TX 77030-1402. E-mail: [email protected] 0039-6060/$ - see front matter © 2006 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2005.09.006

proximately 100,000 new patients are diagnosed each year in the United States.1,2 The disease is most common in individuals over 60 years old, in women, and in patients with a family history of multiple endocrine neoplasia (MEN) or other inherited genetic syndromes.1,3 Although nephrolithiasis and osteoporosis is still found in 24% to 38% of patients diagnosed with PHPT, symptomatic nephrolithiasis and actual symptomatic fractures or bone pain from osteoporosis, as well as other classic symptoms of “abdominal groans” from peptic ulcer disease and pancreatitis, and “psychic overtones,” now account for a small minority of patients. Eighty percent of patients with SURGERY 527

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newly diagnosed PHPT present with subtle, subjective symptoms, such as weakness, bone and joint pain, cognitive dysfunction, sleep disorders, depression, decreased ability to complete tasks, and decreased social interaction, and these patients are often considered “asymptomatic.”4 –12 Currently, operative intervention remains the only curative therapy for PHPT. Parathyroidectomy has been shown to reverse some of the deleterious effects of long-standing PTH excess on bone density and may also improve overall survival.11,13,14 However, contemporary medical management, which enables the diagnosis of PHPT to be made early in the disease process, has sparked debate about the timing or need for operative intervention. Early intervention to possibly prevent future disability from osteoporosis and other consequences of PHPT should be weighed against potential benefits of avoiding an invasive operative procedure early in the course of the disease. To address this management question, the National Institutes of Health (NIH) held two consensus conferences, one in 1990 and a second one in 2002, to establish recommendations for parathyroidectomy and conservative medical management of patients with asymptomatic PHPT.2,15–19 Since that time, Eigelberger et al,20 Quiros et al,21 and Pasieka et al 22 have published data suggesting that the criteria for operation are too conservative. In addition, a recent joint statement by the American Association of Clinical Endocrinologists (AACE) and the American Association of Endocrine Surgeons (AAES) also supported operative intervention in PHPT patients with an acceptable life expectancy regardless of whether they meet the NIH criteria.23 Furthermore, we and others,13,20,22,24 have suggested that “asymptomatic PHPT” is a medical misnomer, because accumulated evidence indicates that the majority of so-called asymptomatic patients have vague, nonspecific complaints that are difficult to quantify but that improve after parathyroidectomy.13,20,22,24 In 2003, Mahadevia et al25 surveyed practicing endocrinologists and found that as many as 25% of physicians who saw a high volume of PHPT patients and 50% who treated a low volume were not aware of the 1990 NIH guidelines.25 Because the final decision about operative intervention is often influenced by surgeon bias, we conducted a survey of experienced surgeons who treat PHPT to determine surgical practice patterns for PHPT and whether the NIH consensus guidelines issued in 2002 have had any effect on their practice patterns.

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MATERIAL AND METHODS Study design and participants. The survey group comprised surgeons in the United States who are members of the AAES. The AAES was selected as the survey population, because its members are specialized surgeons with a major interest in endocrine disorders. AAES membership is limited to surgeons who have been in practice for at least one year, are certified by the American Board of Surgery or an international equivalent, have attended at least one meeting before application, provide evidence that endocrine surgery is their major interest, and who devote a significant portion of their practice or research to endocrine disorders. The initial survey was mailed in November 2004, and a reminder postcard was sent 1 week later. If members did not respond within 2 weeks of the original mailing, another copy of the instructions and survey were mailed. A second reminder postcard was sent in early December 2004. The surveys had control numbers to ensure no member who completed the first survey received a second survey, and they were blinded to the responder. Design and content of questionnaire. A team of endocrine surgeons and of experts from the Department of Institutional Research designed the survey. Approval for data collection and analysis was obtained from The University of Texas M. D. Anderson Cancer Center’s institutional review board. The primary objective of the survey was to determine the management by AAES members of patients with PHPT. Secondary objectives were to determine the respondents’ practice characteristics and demographics. To address the primary objective, we assessed the respondents’ awareness of the NIH consensus guidelines for operation in PHPT, asking directly whether or not they knew about these guidelines, and, if so, for which year (1990, 2002, or both). In addition, we asked the AAES members if they would operate on patients who do not fulfill the consensus recommendations. Participants were asked directly whether they would operate on patients with serum calcium concentration above normal values or bone mineral density (BMD) below normal values but not as low as the values recommended by the guidelines or on patients who were older than the cut-off age suggested by the guidelines. In addition, participants were queried separately about whether they would operate on patients who do not fulfill the consensus recommendations but had “nonspecific” symptoms. To further determine whether preoperative localization of an adenoma would alter the respon-

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dents’ decision for operative intervention in patients with PHPT who do not fulfill the recommendations but had nonspecific symptoms, we combined the above presentations with positive or negative findings on preoperative sestamibi scan. Finally, the respondents were presented several different clinical scenarios and were asked to indicate their choice of treatment (operate, observe, or prescribe a calcium receptor agonist) for the specified situations within each scenario. Normal ranges for serum calcium concentration, PTH, and other biochemical markers were given for each scenario to serve as a reminder. Two of the scenarios pertained to multiple endocrine neoplasia type 1 (MEN1) patients with primary PHPT. To address the secondary objective, responders were asked the number of all endocrine and parathyroid operations carried out annually, number of years in practice, description of their practice, gender, and geographic location of practice. Statistical analysis. The data collected were entered into a database by the Department of Institutional Research and were analyzed using frequency distributions. All unknown or missing responses were removed from the analysis. The comparison between respondents’ characteristics and numeric variables was based on nonparametric analysis using Mann-Whitney U test, as appropriate. The comparison between respondents’ characteristics, and their choice of treatment disease was based on ␹2and Fisher exact test, as appropriate. All statistical calculations were carried out using SPSS for Windows, release 11.5 (SPSS Inc., Chicago, Ill). Differences were considered significant when the P value was ⬍0.05. RESULTS Participants’ demographic, practice, and specialty characteristics. Surveys were mailed to 257 AAES members of whom 96 (37%) responded. The characteristics of the survey respondents and their practices and specialties are summarized in Table I. Eighty-seven percent of the participants were male, and the median age at the time of the survey was 51 years (range, 38 to 83 years). Most respondents (62%) completed their surgical residency training 11 to 30 years ago, and the training sites were distributed across the United States. The majority of the participants reported that they practiced surgery for over 14 years (64%) and described their practice as academic (65%). The great majority (93%) of the respondents reported that they perform over 30 endocrine operations per year; 68% of the respondents perform over 30 parathyroidectomies per year (Table I).

Table I. Participants’ demographic, practice, and specialty characteristics Characteristic

Respondents, N (%)*

Gender, male/female Median age at time of survey (range) Years since surgical residency training was completed† ⱕ10 11–20 21–30 31–40 ⬎40 Geographic area of training in the United States† Northeast Southeast Southwest Midwest West Other Endocrine surgical cases per year, N† ⬍10 10–30 ⬎30 Parathyroidectomies per year, N† ⬍10 10–30 ⬎30 Primary surgical subspecialty† Endocrine surgery General surgery Surgical oncology Years practicing surgery (postresidency), N† ⬍5 5–9 10–14 ⬎14 Type of surgical practice† Group Academic Individual Other

77 (86.5)/12 (13.5) 51 years (38–83 years)

13 (15) 34 (38) 22 (24) 12 (13) 9 (10)

30 (33) 13 (15) 26 (29) 7 (8) 12 (13) 2 (2)

1 (1) 5 (6) 79 (93)

7 (8) 20 (24) 58 (68) 42 (53) 26 (33) 11 (14)

1 (1) 12 (13) 19 (22) 56 (64) 17 (19) 56 (65) 7 (8) 7 (8)

*Data are numbers of respondents except as otherwise noted. †Not all participants answered each question.

Over half (53%) of the respondents indicated that endocrine surgery is their primary subspecialty. Participants’ management of PHPT. Most (89%) of the respondents were aware of the NIH consensus guidelines for surgery for PHPT, and 85% were aware of the guidelines from both the 1990 and 2002 conferences. The majority of the respondents (88%) would operate on an asymp-

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Table II. Indications for parathyroidectomy in patients with asymptomatic PHPT who do not fulfill the NIH Consensus Guidelines for operative intervention Indication for operation Test abnormalities Serum calcium concentration above normal, but ⬍1 mg/dl above upper normal limits BMD below peak bone mass, but t-score ⬎⫺2.5 Nonspecific symptoms Neuropsychologic abnormalities* Depression Onset of menopause before age 40 years Cardiovascular abnormalities† Gastrointestinal symptoms and no MEN1‡ Patient age older than 50 years

Respondents who would operate, N (%)

Respondents, N

Almost always

Undecided

Almost never

85

48 (57)

26 (31)

11 (13)

85

51 (60)

28 (33)

6 (7)

84 82 82 83 83 84

67 (80) 52 (63) 31 (38) 46 (55) 61 (74) 51 (61)

13 (16) 24 (29) 33 (40) 26 (31) 12 (15) 30 (36)

4 (5) 6 (7) 18 (22) 11 (13) 10 (12) 3 (4)

*Eg, Weakness, easy fatigability, intellectual weariness, increased sleep requirements. †Eg, hypertension. ‡Eg, peptic ulcer, pancreatitis.

tomatic patient who fulfills the consensus recommendations for operative intervention for PHPT: a serum calcium concentration ⬎1 mg/deciliter (dl) above the upper normal limit, a BMD ⬍⫺2.5 standard deviations from normal, a 24-hour urine calcium excretion of ⬎400 mg, or age ⬍50 years. Fifty-seven percent of the respondents would operate on a patient who meets no other criteria yet has a serum calcium concentration above normal but ⬍1 mg/dl above the upper normal limit (Table II). Similarly, 60% of the respondents would operate on an asymptomatic patient with PHPT who has a BMD below normal but not as low as suggested by the NIH consensus guidelines (⫺2.5 SD) (Table II). Patient age over 50 years would not affect the decision to operate (Table II). In total, 60 (71%) of the 96 respondents indicated they would operate on an asymptomatic patient who did not fulfill the NIH recommendations for operative intervention for PHPT but has a serum calcium concentration above normal, BMD below normal, or age ⬎50 years. When respondents were asked if they would operate on a patient with PHPT who does not fulfill the NIH recommendations for operation but has various “nonspecific” symptoms, the majority (85%) indicated that they would often operate in four of the five clinical scenarios presented (Table II). Unspecified neuropsychologic abnormalities, depression, and gastrointestinal symptoms were found to be relatively stronger indications for operation (Table II). The results of preoperative localization studies affected the respondents’ decisions about whether to perform parathyroidectomy on patients with

PHPT and nonspecific symptoms (Table III). A positive sestamibi scan would encourage up to 92% of the respondents to favor operation, whereas up to 38% would change their minds and not advise an operation if the scan was negative. Patient age did not affect the respondents’ decision for operation in these patients (88% for a 39-year-old patient vs 80% for a 51-year-old patient). Surgeons were grouped as having a low-volume (ⱕ30 parathyroidectomies per year) or a high-volume (⬎30 parathyroidectomies per year) practice. Of the 58 respondents with a high-volume practice, 17 (29%) would most often operate on every asymptomatic patient with PHPT. In contrast, only 1 (4%) of the 27 evaluable respondents with a low-volume practice would operate on every asymptomatic patient with PHPT (P ⫽ 0.008). Furthermore, responders were grouped as having endocrine surgery as their primary subspecialty or another surgical subspecialty (General Surgery or Surgical Oncology). More endocrine surgeons would operate on a patient with PHPT who does not fulfill the NIH recommendations for operation but has various nonspecific symptoms, compared to those responders who have other surgical subspecialty (P ⫽ 0.08). In addition, the primary subspecialty of the responders was not associated with the choice of treatment for the specified situations within each presented scenarios. Although the surgeons who would operate on most patients were relatively younger compared to those who would not, this association did not reach statistical significance (P ⫽ 0.15). The respondents’ age was not associated with their decisions to operate or not on patients with PHPT who have non-

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Table III. Effects of sestamibi scan findings on decision-making for parathyroidectomy in patients with PHPT and unspecified symptoms who do not fulfill the NIH Consensus Guidelines for Operative Intervention Respondents who would almost always operate, n (%)

Respondents who would observe, n (%)

Nonspecific symptoms

Respondents, N

Sestamibi scan positive

Sestamibi scan negative

Sestamibi scan positive

Sestamibi scan negative

Neuropsychologic abnormalities Depression Early onset of menopause Late onset of menopause Cardiovascular abnormalities

85 84 84 or 83* 85 or 84† 85

77 (91) 77 (92) 74 (88) 68 (80) 73 (86)

45 (53) 55 (66) 47 (57) 39 (46) 44 (52)

8 (9) 7 (8) 10 (12) 17 (20) 11 (13)

39 (46) 27 (32) 36 (43) 44 (52) 39 (46)

*Total number of respondents to the scenario with early menopause and positive (84) or negative (83) sestamibi scan. †Total number of respondents to the scenario with late menopause and positive (85) or negative (84) sestamibi scan.

specific symptoms and a positive or a negative localizing sestamibi scan. In addition, surgeon age was not associated with the surgical volume of his/ her practice. Regarding calcium receptor agonists, ⬍2.5% of the respondents would consider these drugs in the management of asymptomatic PHPT. Respondents were asked to indicate if they would operate, prescribe a calcium receptor agonist, or observe patients with asymptomatic PHPT, a high-normal 24urinary calcium, a normal vitamin D level, and varying serum calcium concentrations and PTH levels. The majority (up to 87%) of respondents indicated that they would operate in the scenarios presented. In addition, respondents were asked if they would operate on a 49-year-old MEN1 patient with PHPT (not a reoperative case), a high-normal 24-hour urinary calcium excretion, normal serum vitamin D concentration, and varying serum calcium concentrations and PTH levels. When the serum calcium concentration was 10.2 mg/dl (normal 8.4 –10.2 mg/dl) and the PTH level was 288 pg/dl, 83% of the respondents indicated they would operate, whereas 16% indicated they would favor observation. The presence or absence of the MEN1 syndrome did not affect respondents’ decision for operation (79% of the respondents would operate on the same patient without MEN1). The respondents were also presented with an MEN1 patient who had a serum calcium concentration of 10.0 mg/dl and a PTH level of 145 pg/dl (normal PTH 50 –72 pg/dl); 49% of the respondents indicated they would operate, whereas 46% indicated they would observe the patient, and 5% were undecided. When respondents were asked if they would operate on a 49-year-old MEN1 patient with PHPT

(not a reoperative case), a high-normal 24-hour urinary calcium excretion, a normal vitamin D concentration, a serum calcium concentration of 10.6 mg/dl, and a PTH level of 100 pg/dl who also needs a distal pancreatectomy for a neuroendocrine neoplasm, 90% indicated they would treat the patient for the PHPT: 75% would perform staged procedures, and 15% would address operatively the parathyroid glands synchronously with the pancreatic operation. Only 10% of the respondents indicated that they would observe the patient for the PHPT and perform a distal pancreatectomy only. DISCUSSION The timing of operative intervention for PHPT is controversial, because many patients are diagnosed before the development of the classic overt symptoms.1,2,26,27 We surveyed endocrine surgeons regarding their opinions about the indications used for operative intervention because it was believed that they have a major influence on patients management and a unique appreciation for the risks of operative intervention.2,15–18 This survey showed that the majority of the respondents were aware of the NIH consensus guidelines regarding operations in PHPT (89%) and would usually (88%) operate on an asymptomatic patient with PHPT who fulfills these criteria. However, most respondents (71%) would also commonly operate on asymptomatic patients who do not fulfill the consensus criteria. Most endocrine surgeons believe that the NIH recommendations should be more liberal as there are no data to support the long-term efficacy of medical therapy or simple observation. Other researchers have demonstrated that in 25% to 62% of asymptomatic patients, PHPT will progress, usually with a decrease of ⬎10% in BMD at one or more

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sites over a 10-year period.11,23,28 One of the major changes over the past decade is the understanding of PHPT and the realization of the benefit of parathyroidectomy for patients with any bone fragility. The importance of treating bone disease, coupled with the advent of a minimally invasive outpatient operative approach, may explain this push to broaden the indications. In addition, the recognition that parathyroidectomy can be more effective than even biphosphonates as medical management is important. There are no data regarding the natural history of the recently recognized normocalcemic variant of PHPT, or the subtle, subjective effects of the disease. Recently, AACE and AAES published more liberal recommendations for parathyroidectomy in patients with asymptomatic PHPT.23 These recommendations might be of more value especially for surgeons who are not members of the AAES but who also deal with this disease. In the survey of endocrinologists conducted by Mahadevia et al,25 overall 39% of respondents referred “asymptomatic” PHPT patients for operative intervention, a mere 7% of participants referred ⬎90% of asymptomatic PHPT patients for operative intervention. Variation reflected 31% referred ⬍10% of such patients. Our survey of endocrine surgeons indicates that the practice patterns of the two specialties are different. However, the survey of Mahadevia et al25 was conducted in 1998, and therefore the newer 2002 NIH recommendations for surgery and conservative medical management of patients with asymptomatic PHPT were not available at that time. Two prior publications have been published in the surgical literature that support that the guidelines published do not predict severity of disease. In one, a prospective study of 95 patients was carried out. Patients were categorized into those patients that did meet criteria for operative intervention and those that did not. All underwent successful parathyroidectomy and substantial improvement in postoperative symptom assessment was appreciated.24 Additionally, Eigelberger et al20 evaluated prospectively 200 patients noting improvement in symptoms in those that did and did not meet consensus criteria. These robust studies have had an impact on the endocrine surgical community.20 Although most of the patients who are currently diagnosed with PHPT at first seem to be asymptomatic, previous studies have suggested that up to half of these patients have subtle, neurobehavioral symptoms not attributable to the disease.3,11,29,30 The finding that these symptoms often resolve or reverse after a successful parathyroidectomy supports that neuropsychologic

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abnormalities are part of the symptomatology.4,22,30,31 Unfortunately, the consensus guidelines currently do not address some of these frequent nonspecific symptoms. However, the tendency to offer operation to patients with these symptoms may represent the surgeons’ clinical experience that patients’ enjoy an improved quality of life after parathyroidectomy. The present survey found that most (85%) respondents would operate on the described patients with PHPT who do not fulfill the consensus recommendations for parathyroidectomy but have nonspecific symptoms. This practice pattern most likely reflects the belief that the benefits outweigh the risk, even for patients with disease that has not progressed to advanced stages. Neuropsychologic abnormalities, such as weakness and easy fatigability, depression, and gastrointestinal symptoms, proved strong indications for operative treatment in contrast to patient age (Table II). Although patients younger than 50 years have approximately three times the risk of disease progression than older patients, the long-term risks, as well as the incidence of fracture among patients who live with chronic hypercalcemia or with a persistent increase in serum PTH, are unknown.12 Parathyroidectomy is not only effective in treating PHPT but also safe, even in those patients ⬎70 years.28,32 Parathyroidectomy also eliminates the costly and burdensome measures of medical management. The consensus conference suggest that in patients who are going to be followed, serum calcium concentration should be measured every six months, whole bone densitometry of the lumbar spine, hip, and distal radius be repeated annually. Patients are also advised to maintain life-long adequate hydration, and to avoid thiazide diuretics and immobilization; all which can become intermittently unavoidable. Little is known about the deleterious effect of estrogen deficiency superimposed on the hyperparathyroid state.33 We queried the tendency to operate on patients experiencing premature menopause early in the disease process because of recent concerns about the effects of estrogen use. In postmenopausal women with PHPT who are unable or unwilling to undergo parathyroidectomy, previous studies indicate that estrogen replacement therapy decreases bone resorption and stabilizes BMD, although it is associated with only a small reduction in serum calcium concentration.34,35 Early menopause did not push surgeons to intervene operatively for otherwise “asymptomatic” disease. Based on the survey’s results, the decision to perform parathyroidectomy on asymptomatic patients with PHPT was not affected by the presence of the

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MEN1 syndrome. This result was unexpected to us, because PHPT in MEN1 exhibits some differences from sporadic PHPT with respect to the age at onset (earlier in MEN1), female-to-male ratio (1:1 in MEN1 vs 4:1 in sporadic), parathyroid pathology (multiglandular disease in MEN1 vs singular adenoma in sporadic), and rates of recurrence (higher in MEN1).36 Similar to patients with sporadic PHPT, MEN1 patients with PHPT most frequently have asymptomatic PHPT, and parathyroidectomy remains the only effective definitive treatment. The timing and the extent of surgical intervention remain controversial. A previous study recommended early parathyroidectomy in MEN1 patients with asymptomatic PHPT who have increased serum PTH levels and mild hypercalcemia as this may minimize lifetime exposure to excess PTH.17 Burgess et al37 have also advocated prompt therapy for asymptomatic PHPT in MEN1 patients with any degree of BMD below the mean for gender- and age-matched individuals because of concerns about the effects of sustained increased PTH in conjunction with osteopenia. This group found that bone mass reduction associated with PHPT is PTHdependent, supporting parathyroidectomy early in the course of PHPT. However, because of the high recurrence rate of MEN1-associated PHPT, the morbidity from cervical reoperation, and the risk for permanent hypoparathyroidism after parathyroidectomy, some experts recommend delaying operative treatment for symptomatic patients. Recurrence rate can be as high as 92% after subtotal parathyroidectomy or 50% after total parathyroidectomy.38 These facts emphasize the complexity regarding the decision balance for the surgical management of PHPT in MEN1 patients. Interestingly, the present survey found that if operative treatment for a pancreatic neuroendocrine neoplasm was indicated in a patient with coexisting asymptomatic PHPT, respondents would be more likely to address the parathyroid disease. The majority, however, would stage the procedures for the pancreas and the parathyroid glands. The present survey found that preoperative localization studies also affected respondents’ decision for parathyroidectomy in patients with nonspecific symptoms of PHPT, leading up to one third of the responders to change their minds and not advise an operation if the scan was negative. Improved imaging modalities, such as sestamibi, four-dimensional computed tomography (CT), magnetic resonance imaging (MRI), and high-resolution ultrasonography, are needed to localize an enlarged gland, especially in patients who had previous neck exploration or those who are to undergo a minimally invasive operative approach. Although such information may be of limited value to an experienced surgeon, the careful

preoperative review of such imaging studies often focuses extra attention on the relevant operative anatomy and has altered the operative planning. In the current era of minimally invasive parathyroidectomy, the indications for operation may reflect a tendency to be more liberal when a single adenoma has been localized successfully.12,39 We caution the surgeon/ endocrinologist/internist to truly confirm the diagnosis by excluding other causes of increased PTH in subtle cases where coexisting vitamin D deficiency or diuretic use may come into play. This study is limited by a lack of comparison among all demographic groups of surgeons. In addition, a reliability and validity analysis could not be conducted on the survey because of the survey format. The 37% of surgeons who responded to the survey may or may not represent the opinions of the entire AAES membership. The experience with parathyroid surgery expected of this group of responders (AAES members) may represent more comfort with the technical procedure than in less experienced or non-specialized surgeons. We recommend that future surveys be structured to allow for analysis of differences between respondent groups. In conclusion, our results suggest that the majority of the respondents to this survey would operate on seemingly “asymptomatic” patients with PHPT who do not fulfill all the NIH consensus criteria for parathyroidectomy. Our survey findings are concordant with recent recommendations of the AACE and AAES.23 Patient’s age and the presence or absence of the MEN1 syndrome did not affect the decision for operative intervention. Today, in experienced hands the morbidity of initial cervical exploration for PHPT is ⬍1% and is accompanied by a biochemical cure (success rate) of about 98%. Endocrine surgeons in the AAES group may be more confident performing parathyroidectomy and thus more likely to recommend intervention. REFERENCES 1. Heath H, Hodgson S, Kennedy M. Primary hyperparathyroidism. Incidence, morbidity, and potential economic impact in a community. N Engl J Med 1980;302:189-93. 2. Proceedings of the NIH Consensus Development Conference on diagnosis and management of asymptomatic primary hyperparathyroidism. Bethesda, Maryland, October 29-31, 1990. J Bone Miner Res 1991;6(Suppl):S1–166. 3. Marx SJ. Hyperparathyroid and hypoparathyroid disorders. N Engl J Med 2000;343:1863-75. 4. Pasieka JL, Parsons LL. Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. World J Surg 1998;22:513-8; discussion 8 –9. 5. Sheldon DG, Lee FT, Neil NJ, Ryan JA Jr. Surgical treatment of hyperparathyroidism improves health-related quality of life. Arch Surg 2002;137:1022-6; discussion 6 – 8. 6. Okamoto T, Kamo T, Obara T. Outcome study of psy-

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