Parathyroid Adenoma

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Presentation :

Risk stratification:
- Bone mineral density (BMD) with DEXA imaging of the nondominant distal one-third of the radius, which can be particularly affected in patients with hyperparathyroidism
- Although parathyroid imaging with sestamibi or neck ultrasonography may localize an adenoma and help plan surgical intervention, these modalities do not determine if surgery is indicated.
- In the absence of a history of calcium nephrolithiasis, kidney imaging may be indicated to exclude occult stones if this finding would change management
Changes in specific end points during monitoring that lead to a recommendation for parathyroid surgery include serum calcium level greater than 1 mg/dL (0.25 mmol/L) above the upper limit of normal; changes in kidney function (creatinine clearance <60 mL/min or clinical development of a kidney stone or by imaging); a T-score of less than −2.5 at the lumbar spine, total hip, femoral neck, or distal one-third of the radius, or a significant reduction in BMD; and vertebral fracture by radiography, CT, MRI, or vertebral fracture assessment.

Medical management:
- Limiting dietary calcium intake to approximately 1000 mg/day.
- Measurement of 25-hydroxyvitamin D and cautious correction of vitamin D deficiency is important. Repletion is recommended for patients with levels less than 20 ng/mL to a goal range of 20 to 30 ng/mL
Surgery results in a 95% cure rate and less than 1% rate of complications with an experienced surgeon.
- Preoperative correction of vitamin D deficiency is important to minimize postoperative hypocalcemia, which is the result of relative hypoparathyroidism and reduced PTH-mediated production of 1,25-dihydroxyvitamin D.
- In severe cases, postoperative hypocalcemia may occur in response to a rapid flux of calcium into bone (hungry bone syndrome).
- Patients with mild primary hyperparathyroidism commonly require calcium supplementation for up to 1 week after parathyroidectomy until residual parathyroid tissue normalizes serum calcium concentrations.
- Reassessment of BMD 1 year after parathyroidectomy may show improvement in BMD, especially at the spine.