Clinical Scorecard: Guidelines for the Surgical Management of Primary Hyperparathyroidism: Recommendations from the United Italian Society of Endocrine Surgery (SIUEC)

At a Glance

Key Highlights

• Diagnosis requires both laboratory assessment (serum calcium, intact PTH, vitamin D) and localization studies (neck ultrasound, [99mTc]Tc-MIBI scintigraphy, Choline-PET).
• Minimally invasive parathyroidectomy is preferred when concordant localization studies are positive or intraoperative PTH monitoring is available; otherwise, bilateral exploration is recommended.
• Imaging studies have limitations; negative or discordant results increase the likelihood of multiglandular disease.

Guideline-Based Recommendations

Diagnosis

• Perform first-tier laboratory tests: serum calcium (total or ionized), intact PTH (second- or third-generation assay), and 25-OH vitamin D.
• Conduct second-tier tests including 24-hour calciuria, phosphaturia, and creatinine clearance for differential diagnosis.
• In patients under 30 years or with family history, assess for familial syndromes using genetic testing (RET, CASR, MEN1, CDC73).
• Use neck ultrasound and functional imaging ([99mTc]Tc-MIBI scintigraphy with SPECT-CT or Choline-PET) for localization of hyperfunctioning parathyroids.
• Recognize that localization studies do not diagnose pHPT but guide surgical strategy.

Management

• Indicate minimally invasive parathyroidectomy when two concordant localization studies are positive or one positive study with intraoperative PTH monitoring.
• Perform bilateral parathyroid exploration when localization studies are negative, discordant, or multiglandular disease is suspected.
• Prepare patients adequately for surgery following established therapeutic pathways.

Monitoring & Follow-up

• Use intraoperative PTH measurement to confirm removal of hyperfunctioning tissue during minimally invasive surgery.
• Postoperative management should include monitoring for complications and biochemical normalization.
• Follow outpatient care protocols for initial management and long-term follow-up.

Risks

• Increased risk of multiglandular disease with negative or discordant imaging studies.
• Potential complications related to surgical dissection, emphasizing the benefit of minimally invasive approaches when appropriate.

Patient & Prescribing Data

Patients with primary hyperparathyroidism undergoing surgical treatment in Italy.

Minimally invasive surgery reduces operative time and complications; surgical approach guided by localization studies and intraoperative PTH monitoring.

Clinical Best Practices

• Ensure comprehensive laboratory and imaging assessment before surgery.
• Favor minimally invasive parathyroidectomy when localization studies are concordant and intraoperative PTH is available.
• Perform bilateral exploration in cases of negative or discordant imaging to maximize cure rates.
• Utilize surgeon-performed neck ultrasound for detailed anatomical evaluation.
• Incorporate genetic testing in young patients or those with familial syndromes.
• Provide clear patient information and structured postoperative follow-up.

References

• SIUEC Thyroid Surgery Protocol
• II Consensus Conference on Parathyroid Management 2014
• Serum Calcium and Ionized Calcium Measurement
• Vitamin D Assessment in pHPT
• Genetic Testing for Familial Hyperparathyroidism
• Localization Techniques in pHPT
• Minimally Invasive Parathyroidectomy Indications
• Bilateral Parathyroid Exploration
• Imaging Limitations in Multiglandular Disease
• Endocrine Surgeon-Performed Neck Ultrasound
• [99mTc]Tc-MIBI Scintigraphy Meta-Analysis
• SPECT-CT Sensitivity in pHPT