Workup and Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common cause of hypercalcemia characterized by excessive secretion of parathyroid hormone (PTH) from one or more parathyroid glands. Most patients are asymptomatic at presentation; however, PHPT may affect the musculoskeletal, renal, gastrointestinal, neurocognitive, and cardiovascular systems. The diagnosis is biochemical: hypercalcemia and an elevated or inappropriately normal PTH level supports the diagnosis. Most cases of PHPT are caused by a solitary parathyroid adenoma. Less frequently, PHPT may be due to multiple adenomas or four-gland hyperplasia. Definitive management is with parathyroidectomy, although nonoperative surveillance can be appropriate for selected patients with asymptomatic or milder disease. If parathyroidectomy is indicated, preoperative parathyroid imaging should be performed in an attempt at localization and to assess for thyroid pathology. For patients with positive localization, image-directed focused parathyroidectomy with intraoperative PTH monitoring is a common surgical strategy. Alternatively, bilateral neck exploration with parathyroidectomy after visualization of all four glands is historically the gold standard and still widely performed today. In patients with four-gland hyperplasia, subtotal parathyroidectomy is performed. Treatment of PHPT with parathyroidectomy results in high rates of cure with low risk of complication and improvement in patient health across multiple metrics.