Research leads to new surgical guidelines for parathyroidectomy.

Tertiary hyperparathyroidism occurs more than primary or secondary hyperparathyroidism but it is rare and is seen in patients with renal disease and post kidney transplant. Because it is a rare problem, guidelines for surgical treatment and prognosis have not been well repeated in the past. This study establishes guidelines for parathyroid surgical intervention.

In a scholarly and systematic review, Dr. Michael Friedman and associates studied outcomes of hundreds of patients with tertiary hyperparathyroidism who underwent a parathyroidectomy (removal of the parathyroid gland). Control of symptoms and hypercalcemia cure rates were as high as 94% in many studies.

Review methods: A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms (“tertiary hyperparathyroidism” OR “3HPT”) AND “parathyroidectomy”. Articles were analyzed regarding their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management.

Results: Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. Most studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches.

Conclusion: Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a N50% drop in PTH level even if PTH remains above normal.

Additionally, “success” or “cure” is defined as normal calcium levels regardless of whether PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.