Primary hyperparathyroidism is one of the most common causes of abnormally high blood calcium levels. Medications such as estrogen and bisphosphonates will not cure primary hyperparathyroidism, but may decrease calcium or parathyroid hormone (PTH) levels and improve bone density. Parathyroidectomy is the only known cure for primary hyperparathyroidism and is currently viewed as the optimal treatment strategy. In the hands of experienced endocrine surgeons, success rates approach 95% to 98%, according to available databases.
Persistent primary hyperparathyroidism occurs when calcium levels and PTH levels do not return to normal within 6 months of a parathyroid operation. This usually happens because all of the abnormal parathyroid tissue was not removed at the first operation. This may result when inexperienced surgeons miss the diseased gland, in the presence of an ectopic gland located in a difficult-to-find location, or when patients have multiple abnormal glands.
“Just because a patient has a hyperparathyroidism does not mean they will need surgery in all cases.”
When calcium and PTH levels are initially normal after parathyroid surgery but become abnormal again after 6 months, patients have recurrent primary hyperparathyroidism. This type of hyperparathyroidism usually happens when one or more of the remaining glands become hyperactive. Parathyroid cancer can cause either persistent or recurrent primary hyperparathyroidism, but less than 1% of patients with primary hyperparathyroidism will be diagnosed with parathyroid cancer.
Considering Reoperative Parathyroid Surgery
Both persistent and recurrent primary hyperparathyroidism may require reoperative parathyroid surgery. Patients who have had significant surgery in the cervical region—particularly total thyroidectomy—should be considered as if they were undergoing a reoperation because they pose technical challenges that have resulted in suboptimal cure and complication rates in the past. Remedial parathyroid surgery under general anesthesia is the most common surgery used for persistent or recurrent hyperparathyroidism, but more and more outpatient settings are performing minimally invasive procedures. About 85% of de novo patients are candidates for the less invasive surgery.
Comprehensive Patient Reviews
Before considering a reoperation, physicians should conduct a meticulous review of patients’ historical, biochemical, imaging, and operative data to confirm the diagnosis. Not all patients with hyperparathyroidism will require surgery. The review of patients should also be completed to evaluate the possibility of familial forms of hyperparathyroidism and to confirm the indications for surgery. Once patients are deemed as appropriate surgical candidates, sequential imaging is required to yield a roadmap to guide surgical intervention.
Reoperative procedures for hyperparathyroidism require an experienced parathyroid surgeon who is armed with intraoperative abilities to locate the offending parathyroid gland or glands. They must be able to remove these glands while minimizing collateral injury, particularly to the recurrent laryngeal nerves. These patients are at increased risk of postoperative hypocalcemia, a condition that can be life-threatening.
Experience With Hyperparathyroidism Procedures
It’s critical that physicians put together a strong game plan for patients with hyperparathyroidism. This requires knowing what procedures were performed previously, whether they failed, and why they may have failed. The entire care team needs to work collaboratively to achieve success in these patients. An experienced endocrine team can diagnose persistent or recurrent hyperparathyroidism, localize residual abnormal parathyroid glands, and perform surgical interventions with success. When in doubt, physicians should work with endocrinologists to research which doctors are performing the most hyperparathyroidism procedures annually to ensure that they have appropriate training. The American Association of Endocrine Surgeons can be of help by providing information on board-certified specialists by geographic area.
Readings & Resources (click to view)
Udelsman R. Approach to the patient with persistent or recurrent primary hyperparathyroidism. J Clin Endocr Metabol. 2011;96:2950-2958. Available at:http://jcem.endojournals.org/content/96/10/2950.abstract.
Caron NR, Sturgeon C, Clark OH. Persistent and recurrent hyperparathyroidism. Curr Treat Options Oncol. 2004;5:335-345.
Wells SA Jr, Debenedetti MK, Doherty GM. Recurrent or persistent hyperparathyroidism. J Bone Miner Res. 2002;17(Suppl 2):N158-N162.
Schreinemakers JM, Pieterman CR, Scholten A, Vriens MR, Valk GD, Rinkes IH. The optimal surgical treatment for primary hyperparathyroidism in MEN1 patients: a systematic review. World J Surg. 2011;35:1993-2005.