“…In particular, extra-parathyroid imaging, comprising of renal ultrasonography and dualenergy X-ray absorptiometry, is used to assess for PTH- Intraoperative suspicion of local invasion and/or regional metastasis* albumin-corrected calcium levels >3 mmol/L* 3 rd /2 nd generation PTH assay ratio >1* Palpable neck mass (lesion > 3 cm)* Infiltration and/or calcifications on neck ultrasound* Suspicion of metastatic disease on sestamibi and/or CT scan* PTH >3 times the upper limit of normal Significant bone and/or kidney involvement Positive personal or family history (HPT-JT) Concomitant jaw tumor Hoarseness and/or neck pain disease (10,11,21,22,(75)(76)(77). Both parathyroid adenomas and carcinomas present as uniglandular parathyroid proliferations (11,13,14,26,32,44,70,72,73). Thus, at the time of intraoperative consultation, the distinction between parathyroid adenoma and carcinoma is often difficult or even impossible, if the tumor does not show grossly evident invasion into surrounding organs (1,8,11,14,17,19,73).…”