What is the treatment for parathyroid adenoma?

Treatment of Parathyroid Adenoma

Surgical excision of the abnormally functioning parathyroid tissue is the definitive treatment for parathyroid adenoma, even in asymptomatic patients, due to the potential negative effects of long-term hypercalcemia. 1

Surgical Options

Minimally Invasive Parathyroidectomy (MIP)

• Preferred approach when preoperative imaging confidently localizes a single adenoma 2
• Benefits include:
  • Shorter operating times
  • Faster recovery
  • Decreased perioperative costs 1
  • Cure rates of 95-98% when performed by experienced surgeons 2
• Requires:
  • Confident preoperative localization of a single adenoma
  • Intraoperative PTH monitoring to confirm removal of hyperfunctioning gland 1

Bilateral Neck Exploration (BNE)

• Traditional standard surgical method
• Indicated when:
  • Preoperative imaging is discordant or non-localizing
  • Multigland disease (MGD) is suspected
  • Previous failed surgery 1, 2
• Involves identification and examination of all parathyroid glands with resection of diseased glands 1

Preoperative Imaging

• Essential for surgical planning, especially for MIP approach
• Recommended modalities:
  • Ultrasound of the neck (sensitivity 76-80%, PPV 93%) 2
  • 4D-CT (sensitivity 62-88%, PPV 84-90%) 2
  • Sestamibi scan may be used, particularly before re-exploration surgery 1
• Imaging has no utility in confirming or excluding the diagnosis of hyperparathyroidism 1

Postoperative Care

• Monitor ionized calcium every 4-6 hours for first 48-72 hours, then twice daily until stable 1, 2
• If calcium levels fall below normal (<0.9 mmol/L or <3.6 mg/dL):
  • Initiate calcium gluconate infusion at 1-2 mg elemental calcium per kg body weight per hour 1
  • Adjust to maintain normal ionized calcium levels (1.15-1.36 mmol/L) 1
• When oral intake is possible:
  • Provide calcium carbonate 1-2 g three times daily
  • Add calcitriol up to 2 μg/day as needed 1
• Phosphate binders may need adjustment based on serum phosphorus levels 1

Non-Surgical Management

For patients who cannot undergo surgery or refuse surgical intervention:

Medical Therapy

• Calcimimetics (cinacalcet):

  • Start at 30 mg twice daily
  • Titrate every 2-4 weeks as needed 2, 3
  • FDA-approved for hypercalcemia due to primary hyperparathyroidism in patients who cannot undergo parathyroidectomy 3
  • Can reduce serum calcium by approximately 2.3 mg/dL from baseline 3

• Bone protection for patients with osteoporosis:

  • Bisphosphonates or denosumab 2

• Vitamin D supplementation for deficient patients:

  • 50,000 IU weekly for 8-12 weeks
  • Use with caution to avoid worsening hypercalcemia 2

Follow-up

• Check serum calcium and PTH at 6 months post-surgery to confirm cure 2
• Annual monitoring of calcium levels 2

Special Considerations

• Multigland disease accounts for 15-20% of primary hyperparathyroidism cases 1, 2
• Risk factors for multigland disease include MEN syndromes, lithium therapy, and previous radiotherapy 2
• Ectopic adenomas may require additional imaging if standard localization fails 2
• Persistent hyperparathyroidism is defined as failure to achieve normocalcemia within 6 months of surgery 1
• Recurrent hyperparathyroidism occurs after a normocalcemic interval of 6+ months post-surgery 1

While medical therapies exist, they are generally considered second-line options when surgery is contraindicated or refused, as parathyroidectomy remains the only definitive cure for parathyroid adenoma 4, 5.