From the Guidelines
Surgical management of a parathyroid adenoma is indicated for patients with symptomatic primary hyperparathyroidism, asymptomatic patients who meet specific criteria, or those with parathyroid cancer, as it directly removes the source of excess parathyroid hormone (PTH) production, which normalizes calcium metabolism 1. The main indications for surgical management include serum calcium levels greater than 1 mg/dL above the upper limit of normal, kidney dysfunction (creatinine clearance <60 mL/min), kidney stones, bone involvement (osteoporosis with T-score <-2.5 at any site or vertebral fracture), age under 50 years, and hypercalciuria >400 mg/day. Some key points to consider when deciding on surgical management are:
- The presence of symptoms related to target organ involvement, such as bone demineralization, fractures, nephrolithiasis, nephrocalcinosis, muscle weakness, or neurocognitive disorders 1
- The potential negative effects of long-term hypercalcemia, even in asymptomatic patients 1
- The importance of preoperative localization studies, such as sestamibi scan, ultrasound, or 4D-CT, to identify the adenoma and guide the surgical approach 1
- The preference for minimally invasive parathyroidectomy when a single adenoma is confidently localized, offering shorter operative time and faster recovery compared to traditional bilateral neck exploration 1
- The high success rate of surgery in resolving hyperparathyroidism, with rapid normalization of calcium and PTH levels postoperatively, especially when performed by experienced surgeons 1
From the Research
Indications for Surgical Management
The indications for surgical management of a parathyroid adenoma include:
- Patients younger than 50 years old 2
- Significant hypercalcemia 2, 3
- Impaired renal function 2
- Renal stones 2, 3
- Osteoporosis 2, 3
- Symptomatic patients with nephrolithiasis, significant osteoporosis, bone pain, and constitutional symptoms 3
- Patients with markedly abnormal laboratory values, including a calcium level of 12.0 mg/dL or 24-hr urinary calcium >400 mg/day 3
Surgical Considerations
Surgery is always appropriate in suitable surgical candidates 2, and parathyroidectomy is a simple, safe, and effective solution that reduces the morbidity of symptomatic primary hyperparathyroidism patients 4. Preoperative localization studies, such as ultrasonography (USG) and sestamibi nuclear medicine scan, can affirm the diagnosis and intraoperative biochemical confirmation can clinch the adequacy of resection 5, 4, 3.
Patient Selection
Patients with mild asymptomatic disease, contraindications to surgery, or failed previous surgical intervention may be considered for medical management 2. The NIH criteria can be used for decision regarding surgery 4.