Algorithmic Surgical Management of Primary Hyperparathyroidism and Its Variants: A Scoping Review.

Area of Science:

• Endocrinology
• Surgical Management
• Medical Decision-Making

Background:

• Primary hyperparathyroidism (PHPT) presents with diverse clinical manifestations.
• Successful surgical management requires integrating current literature into a decision-making framework.
• Variant forms, including normocalcemic hyperparathyroidism (NCPHPT) and normohormonal hyperparathyroidism (NHPHPT), present unique challenges compared to classic PHPT (CPHPT).

Purpose of the Study:

• To compare the diagnostic workup and therapeutic strategies for variant PHPT (NCPHPT, NHPHPT) versus classic PHPT (CPHPT).
• To evaluate localization studies, surgical considerations, the utility of intraoperative parathyroid hormone (IOPTH) monitoring, and surveillance protocols.
• To identify knowledge gaps hindering optimal management of variant PHPT presentations.

Main Methods:

• A systematic literature search of PubMed and Google Scholar was performed from June 11, 2024, to March 17, 2025.
• Included were peer-reviewed English-language studies on adult PHPT surgical management, adhering to PRISMA ScR guidelines.
• Twenty-seven studies were included after independent screening by two reviewers; data were synthesized to guide future research.

Main Results:

• 4D computed tomography (4DCT) and positron emission tomography (PET) scans demonstrated the highest accuracy for imaging in both classic and variant PHPT, especially in multiglandular disease.
• Failure to achieve a ≥50% drop in IOPTH levels or maintain levels below 40 pg/mL post-operatively are identified risk factors for persistent or recurrent hyperparathyroidism.

Conclusions:

• PHPT exhibits varied presentations necessitating tailored management approaches.
• This review identifies critical knowledge gaps that require further investigation to enhance the care of patients with variant PHPT.
• Prospective validation of the summarized algorithmic approach is recommended to improve long-term patient outcomes.