When to decide surgery?

Surgery is the ONLY way to cure Primary Hyperparathyroidism (pHPT)

• Parathyroidectomy – surgery to remove the bad parathyroid gland(s).
  • Surgery “is indicated, and is the preferred treatment, for all patients with symptomatic pHPT.” – American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary hyperparathyroidism.
    • Classic symptoms include:
      • Groans – GI symptoms of nausea / vomiting, constipation, heartburn / indigestion.
      • Bones – bone and joint pain.
      • Stones – kidney stones.
      • Psychiatric overtones – fatigue, depression, confusion, memory loss.
  • Surgery is also indicated regardless of symptoms when:
    • Blood calcium levels are > 1.0 mg/dl above high range of normal (varies by lab test).
    • Evidence of kidney stones or calcification of the kidney (nephrocalcinosis) on imaging (kidney ultrasound or abdominal CT).
      • Following surgery new kidney stone formation decreases dramatically.
      • All pre-existing kidney stones still need to be past.
    • Hypercalciuria – 24-hour urine calcium > 400 mg/dl (urine collection).
    • Impaired kidney function – Glomerular filtrate rate (GFR) < 60 ml/min (blood test).
      • This does not resolve with surgery but should help to prevent further worsening.
    • Osteoporosis on DEXA (bone density scan), fragility fracture (unexpected broken bone considering nature of trauma, eg a short fall), vertebral compression fracture on imaging.
      • Parathyroidectomy improves bone mineral density and reduces future fracture risk.
    • Age 50 years or younger at diagnosis.
      • Consideration being made to extend this to age 65 in the next updated guidelines (Revisiting Age Criterion for Surgery in Asymptomatic pHPT. Otolaryngology – Head and Neck Surgery, Volume 169, #2, August 2023).
    • Concern for parathyroid carcinoma.
      • Calcium levels > 13.0, PTH levels > 1,000, palpable mass, discomfort, and/or evidence of local invasion on imaging.
    • Patients unwilling or unable to comply with observation protocols (see ‘Non-surgical management’ section in the left column topics).
    • Concern for neurocognitive or neuropsychiatric symptoms.
      • Depression, confusion, memory loss.
    • Consider in patients with history of cardiovascular disease (heart attack, coronary artery disease, high blood pressure, stroke, congestive heart failure, and diabetes).
      • Surgery to cure pHPT may lower risk for cardiovascular disease.
    • Consider in patients with muscle weakness, fatigue (decreased functional capacity), and abnormal sleep patterns.
  • Surgery “should be considered for most asymptomatic patients with pHPT.” – American Association of Endocrine Surgeons Guidelines for Definitive Management of Primary hyperparathyroidism.
    • More cost effective than observation or medication treatment.
    • ‘Asymptomatic’ patients frequently report improved quality of life following surgery.
    • “Long-term hypercalcemia should be avoided because of potential deleterious effects.”
    • Disease severity for many asymptomatic patients will progress over time.
    • Surgery improves bone mineral density and reduces future fracture risk, even in patients with normal or osteopenia bones.
• Surgical outcomes / cure rates are the highest and complication rates are the lowest when surgery is performed by a high-volume surgeon (> 50 parathyroidectomy surgeries per year).
• To learn more about Parathyroidectomy (surgery to cure Primary Hyperparathyroidism) click here.