From the Guidelines
Surgery (parathyroidectomy) is indeed the definitive treatment for this condition, as it offers the best chance for cure with success rates exceeding 95% when performed by experienced surgeons. This appears to be a case of primary hyperparathyroidism that is not responding to bisphosphonate therapy. The persistently elevated PTH despite normal calcium levels and adequate vitamin D supplementation while on alendronate for over a year strongly suggests autonomous parathyroid gland function. Bisphosphonates like alendronate can help manage bone density but do not address the underlying cause of primary hyperparathyroidism, which is typically a parathyroid adenoma (80-85% of cases) 1.
Key Considerations
- Preoperative localization studies such as sestamibi scanning and ultrasound should be performed to identify the abnormal gland(s) 1.
- The patient's age of 76 is not a contraindication to surgery if she is otherwise healthy enough for the procedure.
- Following surgery, calcium levels should be monitored, and temporary calcium supplementation may be needed as the remaining normal parathyroid glands resume proper function.
- If surgery is contraindicated due to comorbidities, medical management with cinacalcet (a calcimimetic) could be considered as an alternative approach.
Rationale
The most recent and highest quality study, published in 2021, supports the use of surgery as the definitive treatment for primary hyperparathyroidism 1. This study highlights the importance of preoperative localization and the high success rates of surgery when performed by experienced surgeons. The patient's condition, with persistently elevated PTH despite normal calcium levels and adequate vitamin D supplementation, suggests autonomous parathyroid gland function, which is typically addressed through surgical intervention.
Treatment Approach
Given the patient's condition and the evidence supporting surgical intervention, parathyroidectomy is the recommended treatment approach. This approach offers the best chance for cure and should be considered as the primary treatment option. Medical management may be considered as an alternative approach if surgery is contraindicated due to comorbidities.
From the Research
Diagnosis and Treatment of Primary Hyperparathyroidism
- Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia, characterized by elevated or inappropriately normal serum levels of parathyroid hormone (PTH) 2.
- The patient's condition, with elevated PTH and normal calcium, phosphorous, and magnesium levels, as well as correct vitamin D levels, is consistent with PHPT 3, 2.
- The fact that the patient has been on alendronate for over a year and PTH is not responding suggests that medical management may not be effective in this case 4.
Indications for Surgery
- Parathyroidectomy is advised in patients with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis 3.
- Surgery is also recommended in patients with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae 5.
- In this case, the patient's osteoporosis and elevated PTH levels despite medical management may indicate a need for surgical intervention 3, 5.
Medical Management
- Medical therapy, including antiresorptive drugs and cinacalcet, can increase bone density and reduce serum calcium levels, but may not be effective in all patients 6, 4.
- Alendronate, denosumab, vitamin D, and estrogen therapy have been shown to increase bone density, while cinacalcet can reduce serum calcium and PTH levels 4.
- However, medical therapy is not a substitute for parathyroidectomy, and surgery is usually the preferred treatment for patients with PHPT who meet the surgical criteria 3, 5.