Clinical Report: SIUEC Guidelines for Surgical Management of Primary Hyperparathyroidism

Overview

The United Italian Society of Endocrine Surgery (SIUEC) has issued updated guidelines for the diagnosis and surgical management of primary hyperparathyroidism (pHPT). These recommendations emphasize the importance of accurate laboratory and imaging diagnostics to guide minimally invasive or traditional surgical approaches, aiming to optimize patient outcomes and reduce complications.

Background

Primary hyperparathyroidism is a common endocrine disorder requiring precise diagnosis and surgical intervention. The SIUEC, formed from two Italian endocrine surgery societies, developed these guidelines to standardize care across Italy, incorporating advances in diagnostic imaging and surgical techniques. The guidelines address diagnostic testing, patient preparation, surgical strategies, postoperative care, and follow-up. They aim to support endocrine surgeons with evidence-based protocols while respecting individualized clinical judgment.

Data Highlights

Key Findings

• Laboratory assessment for pHPT includes serum calcium, intact PTH, and 25-OH-Vitamin D as first-tier tests, with additional tests like 24-hour calciuria and creatinine clearance as second-tier.
• Genetic testing is recommended in selected cases to identify familial syndromes such as MEN1, MEN2A, and others.
• Preoperative localization is essential for surgical planning but does not diagnose pHPT; imaging includes neck ultrasound and functional nuclear medicine studies.
• Minimally invasive parathyroidectomy is preferred when two concordant localization studies or one positive study with intraoperative PTH monitoring are available.
• Neck ultrasound performed by an experienced surgeon shows high sensitivity (87%) and specificity (88%) for identifying hyperfunctioning parathyroids.
• [99mTc]Tc-MIBI SPECT-CT has an overall detection rate of 88%, but sensitivity is lower in multiglandular disease compared to single-gland disease.

Clinical Implications

Clinicians should employ a tiered diagnostic approach combining laboratory and imaging studies to accurately localize hyperfunctioning parathyroids before surgery. Minimally invasive parathyroidectomy should be considered when localization studies are concordant, reducing operative time and complications. In cases of negative or discordant imaging, bilateral exploration remains the standard to ensure cure. Genetic testing is important for younger patients or those with familial risk factors.

Conclusion

The SIUEC guidelines provide a comprehensive, evidence-based framework for the surgical management of primary hyperparathyroidism, emphasizing precise diagnostics and tailored surgical approaches to improve patient outcomes. Adoption of these protocols can enhance standardization and quality of care among endocrine surgeons.

References

1. SIUEC 2023 -- Guidelines for the Surgical Management of Primary Hyperparathyroidism
2. U.E.C. CLUB 2014 -- Diagnostic, Therapeutic and Healthcare Management Protocols in Parathyroid Disease
3. Meta-analysis 2017 -- Detection Rate of [99mTc]Tc-MIBI Scintigraphy in pHPT