Mild Primary Hyperparathyroidism: A Literature Review

Abstract

The biochemical profile of classic primary hyperparathyroidism (pHPT) consists of both elevated calcium and parathyroid hormone levels. The standard of care is parathyroidectomy unless prohibited by medical comorbidities. Because more patients are undergoing routine bone density evaluation and neck imaging studies for other purposes, there is a subset of people identified with a biochemically mild form of the pHPT that expresses itself as either elevated calcium or parathyroid hormone levels. These patients often do not fall into the criteria for operation based on the National Institutes of Health consensus guidelines, and they can present a challenge of diagnosis and management. The purpose of this paper is to review the available literature on mild pHPT in an effort to better characterize this patient population and to determine whether patients benefit from parathyroidectomy. Evidence suggests that there are patients with mild pHPTwho have overt symptoms that are found to improve after parathyroidectomy. There is also a group of patients with biochemically mild pHPT who are found to progress to classic pHPT over time; however, it is not predictable which group of patients this will be. Early intervention for this group with mild pHPT may prevent progression of bone, psychiatric, and renal complications, and parathyroidectomy has proven safe in appropriately selected patients at high volume centers. The Oncologist 2014;19:919-929 Implications for Practice: Mild primary hyperparathyroidism (pHPT) is a disease that is being diagnosed with increased frequency; however, recommendations for treatment are not uniform. Current NIH guidelines do not recommend parathyroidectomy for these patients if they are asymptomatic; however, upon focused questioning, many of these patients are found to have subtle symptoms.The biochemically mild nature of the disease has been found to delay diagnosis and treatment, but after it is identified, surgery has shown to provide an improvement in quality of life and bone health. Although the current body of literature suggests that patients with mild pHPT benefit from parathyroidectomy, careful patient and surgeon selection is critical to ensuring safety and efficacy. Universal acceptance of parathyroidectomy in this subset of patients will require more high quality, prospective studies and improved definitions of long-term cure.

Clinical Study on Safety and Efficacy of Microwave Ablation for Primary Hyperparathyroidism

“…Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder, and its incidence increases with age (1). The prevalence of PHPT in patients over 65 years of age is 1.5%, and the incidence in postmenopausal women is 2.1-3.4% (2). Nephrolithiasis is the most common overt symptom, and although skeletal disease is rare, the incidence of osteoporosis with related fractures is increasing.…”

Psychotic depression due to primary hyperparathyroidism

“…Medical treatment to reduce serum calcium such as forced saline hydration, forced diuresis, intravenous bisphosphonate (pamidronate) 16 and cinac a l c e t , a c a l c i u m -l o w e r i n g medication, can lead to improved psychiatric symptoms. 8 Several studies have highlighted that parathyroidectomy leads to the definitive resolution of psychotic symptoms caused by hypercalcaemia related to hyperparathyroidism, [16][17][18][19][20] and can improve health-related quality of life. 21 This case study highlights complex neuropsychiatric phenomena seen with hypercalcaemia, which, if promptly identified and treated, can lead to resolution of symptoms and improved quality of life.…”

Improving diagnostic recognition of primary hyperparathyroidism with machine learning

“…Parathyroidectomy benefits PHPT patients by not only correcting their biochemical disease, but also, preventing the progression of PHPT-related complications, including worsening bone mineral density and fragility fractures 33–36 . Compared to observation, Almqvist et al determined that early parathyroidectomy reduced patients’ long-term risk of hip and other bone fractures 37 .…”

“…Accumulating studies provide evidence that mild PHPT patients benefit from parathyroidectomy despite not meeting formal consensus criteria for surgical intervention 23,33,34,42,47,49,50 as the new AAES surgical guidelines discuss in detail (21). Moreover, the incidence of mild PHPT is on the rise 51 .…”