Recent advances in the understanding and management of primary hyperparathyroidism

Abstract

Primary hyperparathyroidism is a hormonal disorder whose prevalence is approximately 1–2% in the United States of America. The disease has become more recognizable to clinicians in an earlier phase and, at present, patients can be diagnosed with “classic”, “normocalcemic”, “normohormonal”, or “mild, asymptomatic” primary hyperparathyroidism. Surgery, with a focused parathyroidectomy when possible, or a four-gland exploration, is the only way to cure the disease. Cure is determined by use of intra-operative parathyroid hormone monitoring with long-term cure rates ranging from 90–95%. Newer adjuncts to surgery include CT or PET imaging and near-infrared immunofluorescence. This article highlights updates in parathyroid disease and advances in parathyroid surgery; it does not provide a comprehensive summary of the disease process or a review of surgical indications, which can be found in the AAES guidelines or NIH Symposium on primary hyperparathyroidism.

The effect of chronic kidney disease on intraoperative parathyroid hormone: A linear mixed model analysis

“…However, two additional variants of PHPT are now recognized: NC and NH. 24 NC HPT is characterized by normal calcium and elevated PTH without secondary causes of PTH elevation. NH HPT is characterized by elevated calcium with a paradoxically normal or unsuppressed PTH.…”

Factors That Affect the Sensitivity of Imaging Modalities in Primary Hyperparathyroidism

“…Novel techniques including but not limited to 4D-CT, 11 C-choline PET/CT, and 18 F-flurocholine PET/CT have been reported to have satisfactory high sensitivities, which are worth trying. In the end, localization should not be used to decide if a patient should proceed with surgery [31]. Bilateral exploratory surgery should always be taken into consideration in patients without confirmed localization.…”

Primary hyperparathyroidism

“…1. Classic PHPT: condition with symptoms and signs specifi c to disease with high PTH and calcium [3].…”

“…2. Normocalcemic PHPT: Clinical form where total and ionized calcium levels are normal when PTH is high [3]. In order to make this sub-diagnosis, the level of vitamin D should be normal (> 20 ng/ml) and the other causes of secondary hyperparathyroidism production by increasing the activity of 1 alpha hydroxylase enzyme, active vitamin D leads to an increase in calcium absorption from the small intestine.…”