What is the management plan for a patient with primary hyperparathyroidism (PHPT), hyperparathyroidism (elevated Parathyroid Hormone (PTH)) and a history of vertebral fracture?

Management of Primary Hyperparathyroidism with Elevated PTH and History of Vertebral Fracture

Surgical parathyroidectomy is strongly indicated for this patient with primary hyperparathyroidism (PHPT), PTH of 115, and history of vertebral fracture to reduce fracture risk and improve bone mineral density. 1, 2

Indications for Surgery in This Patient

This patient meets clear surgical criteria for PHPT based on:

• History of vertebral fracture (major skeletal complication)
• Elevated PTH level (115)
• Likely significant bone involvement

The American Association of Endocrine Surgeons recommends parathyroidectomy for patients with PHPT who have:

• Any fragility fracture
• Significant bone mineral density reduction
• Evidence of bone disease 2

Pre-Surgical Evaluation

1. Imaging studies to localize abnormal parathyroid tissue:

   • Ultrasound of the neck
   • Dual-phase 99mTc-sestamibi scintigraphy with SPECT/CT (parathyroid scan)
   • The combination of these two tests provides high sensitivity for adenoma localization 1

2. Bone mineral density assessment:

   • DXA scan of lumbar spine, hip, and forearm
   • Patients with hyperparathyroidism should have all three sites measured 1
   • Vertebral fracture assessment (VFA) to document existing fractures

3. Laboratory workup:

   • Serum calcium and albumin
   • 25-OH Vitamin D level (to exclude hypovitaminosis D as a secondary cause)
   • Renal function tests
   • 24-hour urinary calcium excretion

Surgical Approach

• Minimally invasive parathyroidectomy (MIP) is preferred if preoperative imaging confidently localizes a single adenoma (80% of PHPT cases) 1

  • Benefits: shorter operating time, faster recovery, decreased costs
  • Requires intraoperative PTH monitoring to confirm removal of hyperfunctioning gland

• Bilateral neck exploration (BNE) should be used if:

  • Preoperative imaging is discordant or non-localizing
  • Suspicion for multigland disease (15-20% of cases) 1

Medical Management (If Surgery Delayed or Contraindicated)

If surgery must be delayed or is contraindicated, medical therapy can be considered:

1. Bisphosphonates:

   • Alendronate is the best-studied option for PHPT
   • Improves BMD at lumbar spine and hip (but not distal radius)
   • Does not normalize serum calcium 3, 4

2. Cinacalcet:

   • Effectively lowers serum calcium
   • Has minimal effect on PTH levels and does not improve BMD
   • Can be used primarily for hypercalcemia control 3, 4

3. Vitamin D supplementation:

   • Correct vitamin D deficiency with high-dose cholecalciferol (50,000 IU weekly for 8-12 weeks)
   • Target 25-OH vitamin D levels ≥50 nmol/L (20 ng/mL), preferably ≥75 nmol/L (30 ng/mL) 2, 4

Post-Treatment Monitoring

• After successful parathyroidectomy:

  • Expect significant BMD improvement, particularly in the first 6-12 months
  • Lumbar spine and hip typically show greater improvement than radius 3, 5
  • Up to 75% of patients show BMD improvement after surgery 5

• If managed medically:

  • Monitor serum calcium and PTH every 3-6 months
  • Annual bone density testing 2
  • Regular assessment of fracture risk

Key Considerations

• Fracture risk: PHPT increases fracture risk at both peripheral sites and spine, which can be reduced with parathyroidectomy 3, 6

• Bone recovery: After parathyroidectomy, bone resorption quickly decreases while formation continues, leading to rapid BMD improvement, especially at trabecular bone sites 3

• Surgical expertise: Parathyroidectomy should be performed by an experienced endocrine surgeon to maximize cure rates and minimize complications 1

• Age factor: Younger patients with severe PHPT may derive the greatest skeletal benefits from parathyroidectomy, but the positive bone response supports surgery across age groups 5