From the Guidelines
Surgical excision of the abnormally functioning parathyroid tissue is the primary treatment for primary hyperparathyroidism (PHPT).
Treatment Options
- Bilateral neck exploration (BNE): a bilateral operation in which all parathyroid glands are identified and examined by the surgeon, who resects the diseased glands.
- Minimally invasive parathyroidectomy (MIP): a unilateral operation utilizing limited dissection for targeted removal of only the affected gland, which is less invasive than BNE and often performed when a single adenoma is present 1.
Indications for Surgery
Surgery is typically indicated for symptomatic patients and patients with:
- Osteoporosis
- Impaired kidney function (GFR < 60 mL/min/1.73 m²)
- Kidney stones
- Hypercalciuria
- Patients ≥ 50 years of age
- Calcium levels more than 0.25 mmol/L above the upper limit of normal 1.
Role of Imaging
Imaging plays a crucial role in localizing the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery, but has no utility in confirming or excluding the diagnosis of PHPT 1.
Postoperative Care
Persistent PHPT is defined as failure to achieve normocalcemia within 6 months of initial parathyroidectomy, whereas recurrent PHPT is defined as hypercalcemia occurring after a normocalcemic interval of 6 months or more after parathyroidectomy, and parathyroid reoperations are surgically challenging with lower cure rates and higher complication rates 1.
From the Research
Treatment Options for Primary Hyperparathyroidism (PHPT)
- The only curative treatment for PHPT is surgery 2, 3, 4, 5, 6
- Surgical intervention should establish a risk-benefit balance, minimize the risk of persistent and recurrent disease, and provide the highest cure rate without increasing the risk of complications 2
- The choice of surgery in PHPT may vary depending on whether the patient has hereditary HPT or thyroid disease requiring surgical treatment, preoperative localization studies, and the findings in these studies, the possibilities of using intraoperative PTH, and the preference of the surgeon 2
Surgical Approaches
- The two main approaches in the surgical treatment of PHPT are bilateral neck exploration (BNE) and minimal invasive parathyroidectomy (MIP) 2
- BNE is a consistently valid option that has excellent results in the surgical treatment of PHPT and is considered the gold standard 2
- MIP is the ideal approach in selected patients with clinically and radiologically considered a single-gland disease 2
Benefits and Risks of Parathyroidectomy
- Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up 6
- Parathyroidectomy may have little or no effect on serious adverse events or hospitalization for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as bone mineral density, all-cause mortality, and quality of life 6
Special Considerations
- Normocalcemic primary hyperparathyroidism, pregnancy, reoperation for persistent or recurrent PHPT, parathyroid carcinoma, and familial and genetic forms of hyperparathyroidism require special consideration during surgical treatment for PHPT 4
- Parathyroid cancer is extremely rare, and the diagnosis is often made intra-operatively or on final pathology, and recurrence is common 5