Medication
Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (HPTH). The surgical approach to patients with primary HPTH has evolved since the first successful parathyroidectomy performed by Felix Mandl in 1925.
Procedures
Objective: In general it is thought that recurrence of primary hyperparathyroidism is a rare event. To our knowledge, however, only one large patient series has been reported with a mean of more than 7 years of follow-up.
Therapy
Restricting dietary calcium intake is not advised for people with hyperparathyroidism. The Institute of Medicine recommends 1,000 milligrams (mg) of calcium a day for adults ages 19 to 50 and men ages 51 to 70. That calcium recommendation increases to 1,200 mg a day for women age 51 and older and men age 71 and older.
Self-care
Hyperparathyroidism occurs when the parathyroid glands make too much parathyroid hormone (PTH). The parathyroid glands are four pea-sized endocrine glands located in your neck, near or attached to the back of your thyroid.
Nutrition
What is the curative treatment for primary hyperparathyroidism?
Is recurrence of primary hyperparathyroidism a rare event?
Should people with hyperparathyroidism restrict dietary calcium intake?
What is hyperparathyroidism?
Can you have hyperparathyroidism without tumor?
In primary hyperparathyroidism, one or more parathyroid glands produce more PTH than needed, raising calcium levels above the normal range. Usually, the cause is a benign (noncancerous) tumor, or adenoma, in a single parathyroid gland. Occasionally, adenomas grow on more than one parathyroid gland.
What are 3 treatment options for hyperparathyroidism?
Medications to treat hyperparathyroidism include the following:Calcimimetics. A calcimimetic is a drug that mimics calcium circulating in the blood. ... Hormone replacement therapy. ... Bisphosphonates.
What is the definitive treatment for hyperparathyroidism?
Importance Primary hyperparathyroidism (pHPT) is a common clinical problem for which the only definitive management is surgery. Surgical management has evolved considerably during the last several decades.
Can you have hyperparathyroidism without an adenoma?
Based on a review8 published in 1980, the mean annual incidence of primary hyperparathyroidism is 51 cases per 100 000. In review of our experience, 14% of these do not have an adenoma that can be found using sestamibi imaging or US.
When should you have surgery for hyperparathyroidism?
If you have primary or tertiary hyperparathyroidism—in which one or more of the parathyroid glands contain an adenoma, a benign tumor—your doctor may recommend surgery to remove the overactive parathyroid gland. Most commonly, only one parathyroid gland is overactive and needs to be removed.
What happens if you don't treat hyperparathyroidism?
Sometimes hyperparathyroidism makes people miserable within the first year or two of having high blood calcium (see our page on symptoms of hyperparathyroidism). Other times it can go 10 years without causing too much problems other than fatigue, bad memory, kidney stones, and osteoporosis.
Who is a candidate for parathyroid surgery?
Dr. Krishnamurthy: The current recommendation by experts is that most patients with primary hyperparathyroidism are candidates for parathyroidectomy, provided that there is no contraindication to surgery. Parathyroidectomy is the only way to cure hyperparathyroidism.
What is the criteria for parathyroid surgery?
Indications for surgery include the following : Serum calcium >1 mg/dL above the upper limit of the reference range. Bone mineral density T-score at or below -2.5 (in perimenopausal or postmenopausal women and in men aged 50 years or older) at the lumbar spine, total hip, femoral neck, or distal 1/3 radius.
What is the success rate of parathyroid surgery?
Well, two things. First, most parathyroid operations are straightforward and can be completed with an excellent success rate by surgeons who perform parathyroid surgery more than once per month. Second, the role of the expert parathyroid surgeon is to raise the success rate from 90-95% long-term to 97-99% long-term.
Is there medication for parathyroid disease?
Medications. Medications called calcimimetics can decrease the amount of PTH produced by the parathyroid glands. A drug called Cinacalcet is approved for the treatment of secondary HPT caused by dialysis and primary HPT caused by parathyroid cancer.
What kind of doctor treats parathyroid disease?
Endocrinology. Endocrinologists are typically the first line in establishing a diagnosis of parathyroid disease and setting up a treatment plan, and they help coordinate your care with other specialists.
Should you take vitamin D if you have hyperparathyroidism?
Conclusion: Vitamin D deficiency exacerbates primary hyperparathyroidism and vice versa. With care, vitamin D supplementation can safely be given to selected patients with asymptomatic primary hyperparathyroidism and is suggested before deciding on medical or surgical management.
What are the different types of hyperparathyroidism?
There are three types of hyperparathyroidism: primary, secondary, and tertiary.
What are the symptoms of secondary hyperparathyroidism?
Secondary Hyperparathyroidism. With this type, you may have skeletal abnormalities, such as fractures, swollen joints, and bone deformities. Other symptoms depend on the underlying cause, such as chronic kidney failure or severe vitamin D deficiency.
How to get PTH level back to normal?
Treatment involves bringing your PTH level back to normal by treating the underlying cause. Methods of treatment include taking prescription vitamin D for severe deficiencies and calcium and vitamin D for chronic kidney failure. You might also need medication and dialysis if you have chronic kidney failure.
What happens when your calcium levels are too low?
When your calcium levels are too low, your parathyroid glands respond by increasing the production of PTH. This causes your kidneys and intestines to absorb a larger amount of calcium. It also removes more calcium from your bones. PTH production returns to normal when your calcium level goes up again.
What are some inherited disorders that affect several glands throughout the body?
have certain inherited disorders that affect several glands throughout the body, such as multiple endocrine neoplasia. have a long history of calcium and vitamin D deficiencies. have been exposed to radiation from cancer treatment. have taken a drug called lithium, which mainly treats bipolar disorder.
Why is my calcium level low?
Most cases of secondary hyperparathyroidism are due to chronic kidney failure that results in low vitamin D and calcium levels.
How to prevent kidney stones?
Your primary care provider will also recommend watching how much calcium and vitamin D you get in your diet. You’ll also need to drink plenty of water to reduce your risk of kidney stones. You should get regular exercise to strengthen your bones. If treatment is necessary, surgery is the commonly used treatment.
Is each treatment choice a risk?
Each treatment choice has its own risks and benefits. Make sure you understand the possible benefits, along with which risks are greatest for you. Find out how each treatment choice may affect your long-term health.
Can high calcium cause hyperparathyroidism?
In mild cases, when there are no symptoms from high calcium and the calcium level is not very high, a doctor may suggest watchful waiting. That means doing regular tests to look for signs that hyperparathyroidism is getting worse or causing other health problems and needs more treatment.
Can hyperparathyroidism be treated with surgery?
When hyperparathyroidism is causing health problems from high calcium levels, doctors usually recommend surgery. Removing the problem parathyroid gland (s) is the only treatment that can cure this condition. Surgery can also be an option for people who don't yet have symptoms but are concerned about possible bone or kidney problems in the future.
How long does it take for hyperparathyroidism to recur?
Recurrence rate was determined with reasonable precision in this large patient series, and recurrence of hyperparathyroidism cannot be considered to be extremely rare, but it may occur more than 20 years after treatment in both single and multiple gland disease.
Is hyperparathyroidism a recurrence?
Recurrence of hyperparathyroidism; a long-term follow-up after surgery for primary hyperparathyroidism
What is the most reliable procedure for parathyroid sestamibi?
Currently, the most reliable and practical procedure is technetium 99m sestamibi scanning.
Which imaging is least reliable for multiglandular disease?
These imaging procedures are least reliable in patients with multiglandular disease. Ultrasound and computed tomographic scanning are less sensitive; however, they are commonly used as confirmatory tests in association with sestamibi scanning.
Can parathyroidism be cured?
Approximately 90% of patients with primary hyperparathyroidism (PHPT) are cured by parathyroidectomy at the initial neck exploration. Those not cured either remain hypercalcemic in the immediate postoperative period or develop hypercalcemia after a long period of normocalcemia. Almost all cases of hypercalcemia after neck exploration for PHPT are evident early in the postoperative period and are caused either by an overlooked parathyroid adenoma or an incomplete resection of hyperplastic parathyroid tissue. Less commonly, the surgeon has failed to recognize, and adequately treat, parathyroid carcinoma, or the diagnosis of PHPT was incorrect and there is another cause of the hypercalcemia. A successful neck exploration for PHPT is primarily dependent on the experience of the operating surgeon, the anatomic location of the parathyroid glands, either in "normal" or "ectopic" sites, and the presence of a single enlarged parathyroid gland as opposed to multiglandular disease or parathyroid carcinoma. In cases where an enlarged parathyroid gland is not identified at operation, noninvasive or invasive radiographic imaging procedures are useful in localizing the gland. Currently, the most reliable and practical procedure is technetium 99m sestamibi scanning. This technique identifies an enlarged parathyroid gland in 65-80% of cases. Single photon emission computed tomography (SPECT) in association with sestamibi scanning increases the sensitivity of the procedure to 85%. These imaging procedures are least reliable in patients with multiglandular disease. Ultrasound and computed tomographic scanning are less sensitive; however, they are commonly used as confirmatory tests in association with sestamibi scanning. When noninvasive imaging procedures fail to identify an enlarged parathyroid gland, invasive procedures, such as selective arteriography, are performed. Whereas invasive procedures are useful, they are associated with significant morbidity. Reoperations for persistent or recurrent hyperparathyroidism, compared with the initial operations, are associated with higher complication rates. In 90% of cases, the abnormal pathology can be reached through a cervical incision. The success rate of the reoperation depends primarily on the results of the localization procedure and whether the patient has a single enlarged parathyroid gland or multiglandular disease. Resection of a single enlarged gland is curative in virtually all patients. If, however, the patient has multiple gland disease, the operation is successful less often, especially in those with certain familial endocrinopathies.
What is Hyperparathyroidism and Why Should I Cure it?
Hyperparathyroidism is a 100% curable disease that is caused by over function of one or more of the parathyroid glands. Parathyroid glands are four small glands in the neck that help regulate calcium levels in the blood. The glands monitor our calcium level and produce parathyroid hormone (PTH) to help keep it at a normal level.
Dr. Lucas Watkins, MD, MBA, FACS
Dr. Lucas Watkins joined our team several years ago from Tallahassee FL and Florida State University. He received his formal training in endocrine surgery at Yale University where he worked closely with Dr Tobias Carling.
What is the only curative treatment for primary hyperparathyroidism?
Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (HPTH). The surgical approach to patients with primary HPTH has evolved since the first successful parathyroidectomy performed by Felix Mandl in 1925. 1,2During that operation, a single parathyroid adenoma was resected after a bilateral neck exploration and identification of all four parathyroid glands. 1Since then, bilateral neck exploration with resection of enlarged parathyroid glands has emerged as the standard operation performed for primary HPTH. It is associated with a more than 95% cure rate and minimal morbidity in the hands of an experienced endocrine surgeon. 3,4However, because over 80% of primary HPTH cases are due to a single parathyroid adenoma, many have questioned the need for bilateral neck explorations and have proposed directed, unilateral approaches termed “minimally invasive parathyroidectomies.”5–8While these minimally invasive procedures may differ slightly in the technical details of the operation, they all rely on preoperative localization, usually with high quality Tc-99m sestamibi-SPECT scanning, and share a common goal of resecting a single, enlarged parathyroid gland.
What is the best surgical approach for patients with primary HPTH?
The question to be answered, then, is: “What is the best surgical approach for patients with primary HPTH?” Minimally invasive parathyroidectomy is the ideal surgical treatment for patients with primary HPTH and single-gland disease. In addition to the lower incidence of transient hypocalcemia, as shown by Bergenfelz et al, 12minimally invasive parathyroidectomy , as demonstrated by many, including Udelsman 2,9,10and Irvin, 7,11is associated with lower costs, shorter hospital stays, and quicker recovery time. Furthermore, as previously shown by Udelsman 8and LoGerfo, 14these less invasive procedures can be performed under regional anesthesia in the form of a superficial cervical block. This allows assessment of recurrent laryngeal nerve function by monitoring the patient’s voice during surgery.
What scans are used to detect primary HPTH?
At our institution, once the diagnosis of primary HPTH has been biochemically confirmed, we preoperatively localize all patients starting with a Tc-99m sestamibi-SPECT scan. If the sestamibi scan suggests a single parathyroid lesion, we proceed with a minimally invasive approach under regional anesthesia utilizing several adjuncts, including a gamma probe to facilitate intraoperative adenoma localization and intraoperative parathyroid hormone measurements 11to confirm cure and rule out a second adenoma or multigland disease. If the sestamibi scan is negative, we generally perform a second localization study with thallium-pertechnetate subtraction scanning, which in our experience detects a single adenoma in an additional 10% to 15% of patients with a negative sestamibi scan (Sippel et al, manuscript submitted). If both scans are negative, we then perform a standard bilateral neck exploration.
Is parathyroidectomy minimally invasive?
A word of caution about minimally invasive parathyroidectomy: this procedure may not be available at all institutions due to a lack of one or more of the critical components for the operation. The most important component is a surgeon with experience in parathyroid surgery. In my opinion, surgeons should not be performing less invasive approaches unless they know how to do standard bilateral explorations well. Second, high-quality localization is necessary to select patients with single-gland disease. In our experience, a combination of Tc-99m sestamibi-SPECT and/or thallium-pertechnetate subtraction scanning with intraoperative gamma probe allows localization of about 75% of patients with primary HPTH who are candidates for the minimally invasive procedure. Third, the intraoperative parathyroid hormone assay is crucial to rule out multigland disease intraoperatively. 7Approximately 10% to 15% of patients with sestamibi scans suggesting a single enlarged gland will have multigland disease. 8Excising a single gland without intraoperative parathyroid hormone testing results in cure rates less than 90%, which is inferior to the more than 95% success rate reported with standard bilateral neck exploration. Finally, we must keep in mind our mission to train future surgeons. As more minimally invasive parathyroidectomies are performed, residents will get less exposure to bilateral explorations.
How many patients were cured of parathyroid adenomas after ethanol ablation?
Other studies published in the 1990s had similarly disappointing results. One study [iii] followed 27 patients who received ethanol ablation for parathyroid adenomas. Fifteen patients showed an initial cure after ablation. On following these patients, though, 4 out of those 15 developed recurrent disease within 2 years, for an overall cure rate of 41%. The Mayo Clinic published their results from 36 patients in 1998 [iv]. Initial results were satisfactory, but at 16 months out, only a third of patients were still cured. Two thirds still had primary hyperparathyroidism despite ablation.
Is parathyroidectomy a new procedure?
This isn’t a new procedure. Doctors were attempting it in the 1980s, with mixed results. There are still scattered attempts to use it, but in general it is not widely practiced. Standard parathyroidectomy, or surgically removing the diseased parathyroid glands, remains the preferred treatment. It has incredibly high cure rates and is very safe.
Does ethanol ablation help with calcium?
For some of these patients, ethanol ablation was successful, in that it helped to lower their calcium levels. Half of the patients required multiple injections. Unsurprisingly, recurrence was common. Within 3 years of the initial injection, 90% again had high calcium levels. But, the authors noted, repeat injections were usually just as successful as the first. For patients who have a lifelong parathyroid condition, these repeated injections are a viable method of long-term management.
Can ethanol be used for endocrine neoplasia?
Ethanol ablation may be useful in one small group: those rare individuals with multiple endocrine neoplasia (MEN) who have already had a subtotal parathyroidectomy (three of four parathyroids have already been removed) and have recurrent disease in the last parathyroid remnant. Patients with MEN1 develop parathyroid hyperplasia, or overgrowth of all four parathyroids, and this is a lifetime condition. The treatment is surgical; removing three parathyroid glands and part of the fourth, leaving behind a piece of the last gland. The remnant is left there to prevent permanent hypOparathyroidism, characterized by a lack of parathyroid hormone and an inability to keep calcium levels from dropping too low. Recurrent hypERparathyroidism can occur when the remnant grows large again. Treatment for that usually involves another operation, to trim back the gland. Repeat operations are more difficult, since the gland is surrounded by scar tissue, and have higher rates of complications. For patients with MEN1, hyperparathyroidism is usually a chronic disease, which is controlled and managed but never entirely cured.
Can you have a parathyroidectomy if you are not healthy?
Despite the poor results of “chemical parathyroidectomy” it may still be helpful in select situations. Advocates of the procedure argue that it can be used for patients who are “not surgical candidates,” meaning they are not healthy enough to undergo the operation. In my experience, there are very few patients who are in such bad shape that they cannot have parathyroid surgery. It is a quick (around 30 minutes on average) and safe outpatient procedure that I’ve done on many elderly people with heart disease, lung disease, kidney failure, and other serious medical conditions. I have never had a patient who truly could not get parathyroid surgery because of their other medical conditions, though theoretically it could happen.
Does ethanol ablation help with hyperparathyroidism?
One early study published in 1989 [i] looked at 18 patients with primary hyperparathyroidism who received ethanol ablation of their parathyroid tumors. While twelve patients (67%) showed improvement in their calcium and PTH levels, only 8 patients (44%) had normal calcium levels 6 months after injection. In addition, the procedure had a high complication rate: four patients (22%!) had recurrent laryngeal nerve injuries from the injection, causing vocal cord paralysis and difficulty speaking. One of these was permanent! For comparison, the rate of recurrent laryngeal nerve injury for an experienced parathyroid surgeon performing a parathyroidectomy should be well under 1%. While it might seem that injection of the parathyroid would be safer than open surgery, this was not the case.
