Current Understanding and Treatment of Primary Hyperparathyroidism

Abstract

There have been four major events over the last century that have contributed to the better understanding and treatment of primary hyperparathyroidism: the routine measurement of serum calcium with recognition of hypercalcemia, the secured diagnosis with measurement of elevated parathyroid hormone (PTH) levels, the preoperative localization of hypersecreting parathyroid gland(s), and the use of intraoperative measurement of PTH dynamics. Targeted parathyroidectomy guided by intraoperative parathyroid hormone monitoring (IPM) through a small cervical incision has replaced traditional bilateral neck exploration (BNE) as the initial approach in the surgical treatment of patients with primary hyperparathyroidism at many medical centers worldwide. Preoperative Tc-99m-sestamibi localization scans and/or ultrasound serve as an important prerequisite for successful targeted parathyroidectomy. Operative success rates are further improved by IPM before and after removal of all abnormal parathyroid glands. When intraoperative PTH levels are reduced by more than 50% from the highest pre-incision or pre-excision PTH level after resection of an abnormal gland, successful operative resection is assured with a predictive cure rate of > 95%. The advantages of targeted parathyroidectomy in the ambulatory setting include improved cosmetic results, decreased postoperative pain, shorter operative time, decreased hospitalization and rapid postoperative recovery with a success rate comparable to BNE. This article reviews the current understanding and treatment of primary hyperparathyroidism. PRIMARY HYPERPARATHYROIDISM