Consensus Guidelines for Recommendation of Surgical Treatment
Operative management is clearly indicated for all patients with classic symptoms or complications of primary hyperparathyroidism (PHPT). The recommendation of surgical treatment for seemingly asymptomatic patients with PHPT, however, remains controversial. Although the benefits of successful operative management are recognized in terms of correcting the disordered calcium metabolism in the preponderance of patients undergoing parathyroidectomy, concern remains about exposing such patients to the risks of operation (albeit low) for a disease that may be minimally problematic for at least half of them.
A consensus conference organized by the National Institute of Health (NIH) in 1990 attempted to define a rational basis for recommending parathyroidectomy for asymptomatic patients. A follow- up conference of the NIH and the National Institute of Diabetes and Digestive and Kidney Diseases in 2002 recommended parathyroidectomy for the following patients: (1) those <50 years of age, (2) who cannot participate in appropriate follow-up, (3) with a serum calcium level >1.0 mg/dL above the normal range, (4) with urinary calcium >400 milligrams/24 hours, (5) with a 30% decrease in renal function, or (6) with complications of PHPT, including nephrocalcinosis, osteoporosis (T-score <2.5 standard deviation (SD) at the lumbar spine, hip, or wrist), or a severe psychoneurologic disorder.
Other authorities have recommended more liberal guidelines in managing PHPT based on the inability to determine predictably whether complications or progression of the disorder will develop in a specific patient. Furthermore, long-term follow-up of patients with PHPT not treated surgically is time-consuming, costly, and unacceptable to many patients. Such patients must avoid dehydration and excessive calcium intake. The most common evolving sequelae of PHPT in asymptomatic patients include ongoing bone loss, nephrolithiasis, and renal colic. In addition, patients with PHPT are at risk for indolent cardiovascular complications with left ventricular hypertrophy, neurobehavioral impairment, and associated diminished quality of life. Hypercalcemia also complicates the management of other medical problems, such as congestive heart failure. Living with PHPT as a long-term metabolic disorder with a potential for multiple associated health problems may be unacceptable for many patients when a straightforward durable surgical cure can be readily achieved in most cases. In this context, we believe that operative management should be considered and recommended for all asymptomatic patients with PHPT who have a reasonable life expectancy and suitable operative and anesthesia risk factors. Consultation with an experienced endocrinologist and surgeon can help clarify the patient's risk-to-benefit ratio in this regard.
Conclusions and Recommendations
PHPT remains a relatively common disorder of calcium metabolism that is readily cured by a low-risk operation in 95 to 98% of patients when performed by a qualified surgeon. Operative management is the treatment of choice for all symptomatic patients and all asymptomatic patients younger than age 50 years or for patients who cannot participate in adequate medical follow-up. Operative management should also be considered for all other asymptomatic patients with suitable risk and a reasonable life expectancy.
