The diagnosis and management of asymptomatic primary hyperparathyroidism revisited.

Abstract

Primary hyperparathyroidism (PHPT) is a common endocrine disease, especially in countries where multichannel biochemical screening, including the serum calcium measurement, is routinely used. As a result of the introduction of the automated serum screening chemistry panel in the United States in the early 1970s, the prevalence and incidence of the disease was shown to be much higher than previous estimates (1). In addition, the clinical profile had shifted from a symptomatic disorder, with hypercalcemic symptoms, kidney stones, overt bone disease, or a specific syndrome of neuromuscular dysfunction, toward a less symptomatic or even asymptomatic state. The modern clinical profile of asymptomatic PHPT, at least in North America and in many other parts of the world, is best characterized as a disorder in which there are neither signs nor symptoms traditionally associated with hypercalcemia or PTH excess. However, there are clearly different presentations of the disease in different countries. In parts of Europe and in developing nations, disease presentation is more typically reported with overt signs and/or symptoms (2). In light of the shift in the clinical profile of PHPT, it was no longer clear in 1990 whether parathyroid surgery should be recommended for all patients with this disease. Other issues related to medical management, surveillance, and criteria for diagnosis and/or recommendations for surgery all led to the convening of a Consensus Development Conference on the Management of Asymptomatic Primary Hyperparathyroidism (3). This conference, held at the National Institutes of Health (NIH) in October 1990, was sponsored by the Office of Medical Applications of Research and the National Institute of Diabetes and Digestive and Kidney Diseases. The conference was a watershed moment in the history of this disorder because it identified the new asymptomatic profile, raised questions as to who could be monitored safely without surgery, issued guidelines to surgical and nonsurgical management, and described a blueprint for further research. It was clear then, and has become even clearer since, that greater understanding of this disease was going to require thoughtful observation, prospective studies, and greater insight into its pathogenesis as part of the overall quest for new knowledge. The next 10 yr experienced a resurgence of research along these lines and led to the recognition in the early 2000s that another conference was needed to update the field and to reconsider those previous guidelines for surgical or medical management. The second international workshop on the management of asymptomatic primary hyperparathyroidism was subsequently held at the NIH in April 2002. Following a format that included formal presentations, discussions, and the convening of an expert panel, this conference led to a revised set of principles and guidelines for diagnosis as well as for surgical vs. nonoperative medical management of patients with asymptomatic PHPT (4). At both the first and second conferences, parathyroid surgery was recognized as the only definitive therapy for PHPT and was acknowledged tobealwaysanoption, evenamong thosewhodid not meet guidelines for surgery. This point deserves emphasis. On the other hand, it was also recognized that individuals who met guidelines for surgery might not be candidates for parathyroid surgery if they or their physicians declined or if medical issues were contravening. It is also worth emphasizing that these two conferences were focused upon management decisions for asymptomatic PHPT. There was never any debate, nor should there be now, about those who already demonstrate clear target organ complications of PHPT such as kidney stones, fractures, or overt neuromuscular disease. Serum calcium concentrations that are associated with symptoms and signs of hypercalcemia also invariably should lead to a recommendation for parathyroid surgery. These symptomatic patients with symptomatic PHPT should have parathyroid surgery. Over the past 6 yr, still further changes have emerged in the presentation and other aspects of PHPT, culminating in the most recent workshop that forms the basis of the supplement to this

DOI: 10.1210/jc.2008-1757

Cite this paper

@article{Khan2009TheDA, title={The diagnosis and management of asymptomatic primary hyperparathyroidism revisited.}, author={Aliya Aziz Khan and John P. Bilezikian and John T. Potts}, journal={The Journal of clinical endocrinology and metabolism}, year={2009}, volume={94 2}, pages={333-4} }