Medical and radiologic evaluation and operative treatment of primary hyperparathyroidism

The diagnosis of primary hyperparathyroidism (HPT) relies principally on repeated measurements of total serum calcium and determination of intact parathyroid hormone. A careful patient history and routine blood chemistry will generally verify symptoms in the common patient with HPT, who should be a candidate for surgery. The operative treatment in primary HPT is efficient, with reported high success rate, minimal complications and frequent alleviation of symptoms. Nonoperative medical surveillance should preferentially be considered in elderly patients with borderline increases in serum calcium of around 2.7 mmol/L or less, who in fact constitute a major proportion of hypercalcemic individuals detected at population screening. The patients in whom an operation is deferred should lack any symptoms or complications associated with primary HPT known to benefit from surgery, and this includes the commonly encountered neurobehavioral disability. Surveillance may also occasionally be chosen for really old individuals, when expected improvement fails to justify operative risks. In keeping with the generally liberal indications for parathyroid surgery, surveillance may be time limited if the patients develop disability or display a rise in serum calcium during follow-up.