Randomized controlled clinical trial of surgery versus no surgery in patients with mild asymptomatic primary...

Parathyroidectomy is the definitive therapy for patients with symptomatic primary hyperparathyroidism. However, the role of surgery in mild asymptomatic primary hyperparathyroidism remains controversial. Accordingly, we conducted a prospective, randomized, controlled clinical trial of parathyroidectomy to determine the benefits of surgery vs. adverse effects of no surgery. Fifty-three patients were randomly assigned to either parathyroidectomy (n = 25) or regular follow-up (n = 28). Bone mineral density (BMD), biochemical indices of the disease, quality of life, and psychological function were measured at 6- or 12-month intervals for at least 24 months. Twenty-three of the 25 patients randomized to parathyroidectomy had surgery within the specified time of the protocol and three of the 28 patients randomized to regular follow-up had parathyroidectomy during follow-up. After parathyroidectomy, there was an increase in BMD of the spine (1.2%/yr, P < 0.001), femoral neck (0.4%/yr, P = 0.031), total hip (0.3%/yr, P = 0.07), and forearm (0.4%/yr, P < 0.001) and an expected fall in serum total and ionized calcium, serum PTH, and urine calcium (P < 0.001 for all). In contrast, patients followed up without surgery lost BMD at the femoral neck (-0.4%/yr, P = 0.117) and total hip (-0.6%/yr, P = 0.007) but gained at the spine (0.5%/yr; P = ns) and forearm (0.2%/yr, P = 0.047), with no significant changes in biochemical indices of disease. Consequently, a significant effect of parathyroidectomy on BMD was evident only at the femoral neck (a group difference of 0.8%/yr; P = 0.01) and total hip (a group difference of 1.0%/yr; P = 0.001) but not at the spine (a group difference of 0.6%/yr) or forearm (a group difference of 0.2%/yr). Quality-of-life scores as measured by a 36-item short-form health survey showed significant declines in five of the nine domains (social functioning, physical problem, emotional problem, energy, and health perception) in patients followed up without surgery but in only one of the nine domains (physical function) in the patients who had parathyroidectomy. Consequently, a modest measurable benefit of parathyroidectomy was evident in social and emotional role function (P = 0.007 and 0.012, respectively). Psychological function as assessed by the symptom checklist revised did not change significantly in either group, except for a significant decline in anxiety (P = 0.003) and phobia (P = 0.024) in patients who had surgery in comparison with those who did not. We conclude that it is feasible to conduct a randomized, controlled clinical trial of parathyroidectomy in patients with mild asymptomatic primary hyperparathyroidism, and measurable benefits of surgery on BMD, quality of life, and psychological function can be demonstrated. However, the small but significant benefits of parathyroidectomy must be weighed against the risks of surgery in these otherwise healthy individuals.