From the Guidelines
The indication for surgical management in this patient with primary hyperparathyroidism is her history of osteoporosis, as it represents an end-organ complication of hyperparathyroidism that can be addressed by parathyroidectomy, potentially stabilizing or improving bone mineral density and reducing the risk of fractures. This 68-year-old female presents with laboratory findings consistent with primary hyperparathyroidism (elevated calcium of 10.6 mg/dL and elevated PTH of 106 pg/mL), and while she is currently asymptomatic, her osteoporosis is a significant concern. According to the most recent clinical guidelines, patients with primary hyperparathyroidism who have osteoporosis or fragility fractures should be referred for parathyroidectomy, even if they lack other symptoms 1. The chronic elevation of PTH contributes to bone resorption and can worsen existing osteoporosis. Surgical removal of the abnormal parathyroid gland(s) would address the underlying cause of calcium dysregulation. Other indications for surgery would include significantly higher calcium levels (>1 mg/dL above normal), kidney stones, reduced kidney function, age under 50, or symptoms directly attributable to hypercalcemia, but in this case, the osteoporosis alone is sufficient to warrant surgical intervention. The American Association of Endocrine Surgeons guideline for management of PHPT supports surgical intervention in patients with osteoporosis, as it is a curative treatment that can improve bone health and reduce the risk of fractures 1.
Some key points to consider in the management of this patient include:
- The importance of addressing osteoporosis as an end-organ complication of hyperparathyroidism
- The role of parathyroidectomy in stabilizing or improving bone mineral density and reducing the risk of fractures
- The need for careful evaluation of the patient's overall health and medical history to determine the best course of treatment
- The importance of using clinical guidelines, such as those from the American Association of Endocrine Surgeons, to inform treatment decisions 1.
In terms of the surgical approach, there are two accepted curative operative strategies for PHPT: bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) 1. The choice of surgical approach will depend on the individual patient's needs and circumstances, and should be determined in consultation with a qualified surgeon. Overall, the goal of surgical management in this patient is to address the underlying cause of her osteoporosis and improve her overall health and quality of life.
From the Research
Indications for Surgical Management
The patient's condition, characterized by hypercalcemia and elevated parathyroid hormone levels, suggests primary hyperparathyroidism (PHPT) [ 2, 3 ]. The following are indications for surgical management of this patient's condition:
- Presence of nephrolithiasis or nephrocalcinosis, which are strong indicators of underlying PHPT [ 2 ]
- Osteoporosis, which is a common manifestation of PHPT [ 3, 4 ]
- Vertebral fractures, which can be asymptomatic in patients with PHPT [ 3 ]
- Hypercalciuria, which can increase the risk of nephrolithiasis and osteoporosis [ 3 ]
- Elevated parathyroid hormone levels with hypercalcemia, which is a characteristic feature of PHPT [ 2, 3, 5 ]
Specific Considerations for this Patient
Given the patient's age, medical history, and current symptoms, the following factors should be considered:
- The patient's osteoporosis, which may be exacerbated by PHPT [ 4 ]
- The patient's lack of symptoms, which is common in asymptomatic PHPT [ 3, 5 ]
- The patient's normal levels of vitamin D, phosphorus, albumin, and creatinine, which suggests that the hypercalcemia is likely due to PHPT rather than other causes [ 5 ]