Author:

Abstract:

As more and more cases of primary hyperparathyroidism are being detected by screening for serum calcium concentration, the majority of patients are asymptomatic or present symptoms which are difficult to ascribe to hyperparathyroidism. Long-term follow-up has provided evidence that most asymptomatic patients who do not undergo parathyroidectomy, will not develop symptomatic complications. In some asymptomatic patients, however, the disease progresses over time. These observations and the lack of reliable predictors of the rate of progression in most patients reinforce the need for a careful monitoring in asymptomatic patients who do not undergo surgery. Biannual measurements of serum calcium concentrations and annual measurements of urinary calcium excretion and bone mineral density should be performed in all patients who are managed conservatively. In patients with symptomatic or complicated primary hyperparathyroidism, parathyroidectomy can be expected to result in biochemical cure and increased bone density, both at the lumbar spine and the femoral neck, and thus should be considered. Criteria for surgery include: a significant hypercalcaemia (> 12 mg/dl), marked hypercalciuria (> 400 mg per day), low bone density, unexplained renal insufficiency or an episode of acute primary hyperparathyroidism. Parathyroidectomy should also be considered in elderly patients with primary hyperparathyroidism who are vitamin D deficient. Radionuclide scanning has become the initial non-invasive study of choice when parathyroid gland localization is necessary before parathyroidectomy; this is generally for fragile patients and reoperative cases. In a subset of older individuals, surgery may not be an option because of coexisting medical problems even though surgical indications are present.