From the Guidelines
Surgical removal of the abnormal parathyroid gland(s) through parathyroidectomy is the definitive treatment for primary hyperparathyroidism, even in asymptomatic patients, due to the potential negative effects of long-term hypercalcemia. The treatment of primary hyperparathyroidism (PHPT) involves two accepted curative operative strategies: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) [ 1 ].
Key Considerations
- BNE is a bilateral operation where all parathyroid glands are identified and examined, and the diseased glands are resected [ 1 ].
- MIP is a unilateral operation that utilizes limited dissection for targeted removal of only the affected gland, requiring confident and precise preoperative localization of a single parathyroid adenoma [ 1 ].
- The role of imaging in PHPT is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery [ 1 ].
Post-Surgical Monitoring
- Post-surgical monitoring should include checking calcium levels within 24 hours and again 1-2 weeks later, with PTH levels measured 6 months post-surgery [ 1 ].
- Patients should be monitored for hypocalcemia, which can occur due to "hungry bone syndrome" where calcium rapidly deposits into previously demineralized bone.
Medical Management
- For patients who are poor surgical candidates, cinacalcet can be used to lower serum calcium levels, though it doesn't address the underlying bone disease [ 1 ].
- Bisphosphonates like alendronate may be considered for patients with significant bone loss.
Important Considerations
- PHPT is more common in women, with an incidence of 66 per 100,000 person-years, and 25 per 100,000 person-years in men [ 1 ].
- Most cases are sporadic, although hereditary causes exist, including multiple endocrine neoplasia types 1 and 2A as well as familial hyperparathyroidism [ 1 ].
From the Research
Diagnosis and Presentation of Primary Hyperparathyroidism
- Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the outpatient setting 2
- The condition can present with non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis, and nephrocalcinosis 2
- Most individuals with PHPT are asymptomatic and are diagnosed following routine biochemical screening 2, 3
- The clinical presentation of PHPT can vary and includes target organ involvement of the renal and skeletal systems, mild asymptomatic hypercalcemia, and high PTH levels with normal serum calcium values 4
Treatment and Management of Primary Hyperparathyroidism
- Parathyroidectomy is the only curative treatment for PHPT and is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae 3
- Surgery is advised in patients younger than 50 years old and in the presence of significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 2
- Medical management may be considered in patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention 2
- Medical interventions available for PHPT patients not undergoing parathyroidectomy include optimizing calcium and vitamin D intake, antiresorptive therapy for skeletal protection, and cinacalcet to lower serum calcium and PTH levels 2
Surgical Considerations for Primary Hyperparathyroidism
- Advances in preoperative localization exams and intraoperative PTH monitoring have improved parathyroidectomy techniques, with minimally invasive techniques suitable for most patients 5
- Special consideration is required for patients with normocalcemic primary hyperparathyroidism, pregnancy, reoperation for persistent or recurrent PHPT, parathyroid carcinoma, and familial and genetic forms of hyperparathyroidism 5
- Parathyroidectomy can result in an increase in bone mineral density and a reduction in nephrolithiasis 3