The management of thyroid nodules in patients with primary hyperparathyroidism

Thyroid nodules are found in 12-52% of patients with primary hyperparathyroidism (pHPT). With the increasing use of minimally invasive parathyroidectomy (MIP), there is no standard approach for the management of incidental thyroid nodules in pHPT patients.

A survey was conducted of the American Association of Endocrine Surgeons. Information was obtained regarding parathyroidectomy practice patterns, including surgical technique, preoperative localization procedures, and algorithms used in the diagnosis/treatment of incidental thyroid nodules.

The survey response rate was 74%. Sixty-seven percent were high-volume parathyroid surgeons (>5/mo); the majority performed MIP. High-volume surgeons were more likely to use Sestamibi/single photon emitted computed tomography for preoperative localization (40% versus 24%; P = 0.011) and to disregard incidentally discovered thyroid nodules <1 cm (41% versus 22%; P = 0.023). They were less likely to evaluate nodules discovered intraoperatively by frozen section (28% versus 41%; P = 0.081), fine-needle aspiration (13% versus 24%; P = 0.078), or thyroidectomy (24% versus 40%; P = 0.03). Surgeons performing open parathyroidectomy were more likely than those who use MIP to biopsy nodules intraoperatively (32% versus 20%; P < 0.05) and perform simultaneous thyroidectomy (30% versus 10%; P < 0.001).

Experienced endocrine surgeons disagree about the optimal management of incidental thyroid nodules encountered during parathyroidectomy. Our data suggest that high-volume parathyroid surgeons are less aggressive in their evaluation of thyroid pathology in patients with pHPT. Variation in practice among this experienced group implies even greater variation in the broader surgical community, and in the quality and cost of care for patients with pHPT.