From the Guidelines
Surgical removal of the parathyroid adenoma (parathyroidectomy) is the recommended treatment for patients with hypercalcemia and elevated parathyroid hormone (PTH) levels, as it offers a definitive cure with high success rates (>95%) and prevents long-term complications such as osteoporosis, kidney stones, and neuropsychiatric symptoms. The management of parathyroid adenoma with hypercalcemia and elevated PTH levels involves a multidisciplinary approach, including localization studies, surgical intervention, and postoperative care. Before surgery, localization studies such as sestamibi scan and neck ultrasound should be performed to identify the adenoma, as imaging has no role in confirming or excluding the diagnosis of primary hyperparathyroidism, but is essential for preoperative localization of the abnormally functioning gland or glands 1.
Preoperative Care
The patient should maintain adequate hydration and avoid calcium supplements or vitamin D prior to surgery. This is crucial in preventing further elevation of calcium levels and reducing the risk of complications during surgery.
Surgical Intervention
There are two accepted curative operative strategies for primary hyperparathyroidism: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. MIP is often preferred as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs, but requires confident and precise preoperative localization of a single parathyroid adenoma to guide the surgical approach. Intraoperative PTH monitoring is used to confirm removal of the hyperfunctioning gland.
Postoperative Care
Postoperatively, calcium levels should be monitored closely as temporary hypocalcemia may occur due to suppression of the remaining normal parathyroid glands. Calcium carbonate 1000-2000 mg daily and vitamin D supplementation (typically calcitriol 0.25-0.5 mcg daily) may be needed temporarily after surgery to manage hypocalcemia. If surgery is contraindicated, medical management options include cinacalcet to lower calcium levels, bisphosphonates for bone protection, and continued monitoring 1. However, surgery is preferred due to its high success rates and ability to resolve the underlying cause of hypercalcemia.
Key Considerations
- The role of imaging in primary hyperparathyroidism is to localize the abnormally functioning gland or glands with high accuracy and high confidence to facilitate targeted curative surgery 1.
- Parathyroid reoperations are surgically challenging, with lower cure rates than first-time surgery and higher complication rates, emphasizing the importance of accurate preoperative localization and careful surgical planning 1.
- The patient's quality of life and potential long-term complications should be considered when deciding on the management approach, with surgery offering a definitive cure and prevention of long-term complications.
From the FDA Drug Label
Cinacalcet tablets are indicated for the treatment of hypercalcemia in adult patients with primary HPT for whom parathyroidectomy would be indicated on the basis of serum calcium levels, but who are unable to undergo parathyroidectomy [see Clinical Studies (14.3)]. The recommended starting oral dose of cinacalcet tablets is 30 mg twice daily. The dose of cinacalcet tablets should be titrated every 2 to 4 weeks through sequential doses of 30 mg twice daily, 60 mg twice daily, and 90 mg twice daily, and 90 mg 3 or 4 times daily as necessary to normalize serum calcium levels The management of parathyroid adenoma with hypercalcemia and elevated parathyroid hormone (PTH) level is to treat with cinacalcet.
- The recommended starting dose is 30 mg twice daily.
- The dose should be titrated every 2 to 4 weeks to normalize serum calcium levels.
- The goal is to achieve a normalized serum calcium level. 2
From the Research
Management of Parathyroid Adenoma with Hypercalcemia and Elevated PTH Level
- The management of parathyroid adenoma with hypercalcemia and elevated parathyroid hormone (PTH) level can involve various treatment options, including surgical and non-surgical approaches 3.
- Surgical removal of one or more parathyroid glands is a common treatment for parathyroid adenoma, but minimally invasive procedures such as percutaneous radiofrequency ablation (RFA) under ultrasonographic guidance are also gaining popularity 3.
- RFA has been shown to be a safe and effective therapeutic option in the treatment of parathyroid adenoma, with significant decreases in serum calcium and PTH levels observed after the procedure 3.
- In cases of refractory hypercalcemia, denosumab has been used as a treatment option, particularly in patients with parathyroid carcinoma 4, 5.
- Denosumab has been shown to be effective in reducing calcium levels and controlling hypercalcemia in patients with parathyroid carcinoma, and its use has been endorsed in the management of hypercalcemia in patients with parathyroid carcinoma and other conditions with PTH-induced hypercalcemia 4, 5.
- Cinacalcet, a calcimimetic agent, has also been used to treat hypercalcemia in patients with primary hyperparathyroidism, including those with liver cirrhosis 6.
- The goals of surgery for parathyroid carcinoma are resection with negative margins, and adjuvant therapy with chemotherapy or external beam radiation has not been proven to affect disease-free or overall survival 7.
Treatment Options
- Percutaneous radiofrequency ablation (RFA) under ultrasonographic guidance
- Surgical removal of one or more parathyroid glands
- Denosumab
- Cinacalcet
Considerations
- The diagnosis of parathyroid carcinoma is often made only after parathyroidectomy, and the diagnosis should be suspected when calcium or PTH levels are high 7.
- Recurrence is common in parathyroid carcinoma, and reoperation is recommended for resectable recurrent disease 7.
- Palliation with calcimimetic pharmacotherapy can aid with management of symptomatic hypercalcemia in recurrent or persistent disease after parathyroidectomy 7.