From the Guidelines
Hyperparathyroidism diagnosis and management should prioritize biochemical testing, including serum calcium and parathyroid hormone (PTH) levels, followed by imaging studies for localization, with the goal of surgical intervention for symptomatic cases or those meeting specific surgical criteria, as outlined in the most recent guidelines 1.
Clinical Presentation and Diagnosis
Hyperparathyroidism can present with a range of symptoms related to elevated calcium levels, including fatigue, weakness, depression, bone pain, kidney stones, abdominal pain, constipation, and cognitive issues. The diagnostic workup begins with laboratory tests to confirm elevated serum calcium and PTH levels. According to the American College of Radiology Appropriateness Criteria for parathyroid adenoma 1, biochemical testing is the cornerstone of diagnosis, with serum calcium levels typically exceeding 10.5 mg/dL and PTH levels above 65 pg/mL.
Imaging and Localization
Imaging studies play a crucial role in the localization of parathyroid adenomas before surgery. The first-line imaging method is often a sestamibi scan, which may be complemented by ultrasound of the neck. In cases where initial imaging is inconclusive, CT or MRI may be utilized. The choice of imaging modality is guided by the need for precise localization to facilitate targeted surgical approaches, such as minimally invasive parathyroidectomy (MIP), which offers benefits including shorter operating times, faster recovery, and decreased perioperative costs 1.
Treatment and Management
The definitive treatment for symptomatic hyperparathyroidism or cases meeting surgical criteria (such as calcium levels more than 1 mg/dL above normal, age under 50, presence of osteoporosis, or kidney complications) is parathyroidectomy. For asymptomatic patients, monitoring may be appropriate, but the potential long-term effects of hypercalcemia, including renal failure, osteoporosis, and cardiovascular disease, necessitate careful consideration of surgical intervention. Post-diagnosis monitoring should include regular measurements of calcium and PTH levels, renal function assessment, and bone density scans every 1-2 years to manage potential complications effectively.
Surgical Approaches
There are two accepted curative operative strategies for primary hyperparathyroidism (PHPT): bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP). BNE is traditionally the standard method but is typically reserved for cases with discordant or nonlocalizing preoperative imaging or a high suspicion of multigland disease. MIP, on the other hand, is less invasive and preferred for patients with a single adenoma, offering the benefits of shorter operating times and faster recovery, as supported by recent guidelines 1. The choice between these surgical approaches depends on the accuracy of preoperative localization and the presence of multigland disease.
Key Considerations
- Biochemical testing is essential for the diagnosis of hyperparathyroidism.
- Imaging studies are critical for the localization of parathyroid adenomas.
- Surgical intervention is the definitive treatment for symptomatic cases or those meeting specific surgical criteria.
- Monitoring is crucial for managing potential long-term complications in asymptomatic patients or post-surgery.
- The choice of surgical approach (BNE vs. MIP) depends on preoperative localization accuracy and the presence of multigland disease, with recent guidelines supporting MIP for single adenomas 1.
From the Research
Hyperparathyroid Symptoms
- Non-specific signs and symptoms of hypercalcemia, skeletal fragility, nephrolithiasis, and nephrocalcinosis are common presentations of primary hyperparathyroidism (PHPT) 2
- Many individuals with PHPT are asymptomatic and are diagnosed through routine biochemical screening 2
Workup and Diagnosis
- Primary hyperparathyroidism is the most common cause of hypercalcemia in the outpatient setting 2
- Secondary hyperparathyroidism can be caused by decreased calcium intake, and a calcium challenge can be used to confirm the diagnosis 3
- Laboratory tests, such as intact parathyroid hormone (iPTH) levels, corrected serum calcium levels, serum phosphate levels, and 25-hydroxy vitamin D levels, are used to diagnose and monitor hyperparathyroidism 2, 3
Treatment and Management
- Parathyroidectomy is recommended for patients with significant hypercalcemia, impaired renal function, renal stones, or osteoporosis, as well as those under 50 years old 2
- Medical management, including optimization of calcium and vitamin D intake, antiresorptive therapy, and cinacalcet, may be considered for patients with mild asymptomatic disease or contraindications to surgery 2
- Calcium supplementation can effectively treat secondary hyperparathyroidism caused by insufficient calcium intake or absorption 3