Secular trends in the incidence of primary hyperparathyroidism over five decades (1965-2010)

Adolescent primary hyperparathyroidism

Adolescent primary hyperparathyroidism (PHPT) is a rare endocrine disorder bearing distinctions from the adult form. This review examines its unique aspects, focusing on clinical presentation, genetic etiologies, genotype-phenotype correlations, and therapeutic management. Adolescent PHPT often has a genetic basis, whether familial, syndromic, or apparently sporadic, and identifying the underlying genetic cause is important for patient care. The clinical presentation is predominantly symptomatic worldwide. Unique manifestations in this age group include rickets, short stature, and slipped capital femoral epiphysis. Genotype-specific differences are evident in the adolescent PHPT characteristics. Diagnostic evaluation requires careful interpretation of biochemical and dual-energy X-ray absorptiometry findings using age and gender-specific reference ranges, with targeted screening for syndrome-associated neoplasms. Surgery remains the cornerstone of management. Current knowledge gaps in their management include treatment protocols for multiple endocrine neoplasia type 1-associated PHPT, the efficacy and safety of nonsurgical options, and long-term post-surgical outcomes.

Adenoma weight: the only predictive factor for multiple gland disease in primary hyperparathyroidism

BACKGROUND

Predicting a multiple gland disease (MGD) in primary hyperparathyroidism (pHPT) remains challenging. This study aimed to evaluate predictive factors for MGD.

METHODS

A retrospective chart review was performed of 1211 patients with histologically confirmed parathyroid adenoma or hyperplasia between 2007-2016. Localization diagnostics, laboratory parameters, and the weight of the resected parathyroid glands were evaluated concerning their predictive value of a multiple-gland disease.

RESULTS

A number of 1111 (91.7%) had a single-gland disease (SGD), and 100 (8.3%) a multiple-gland disease (MGD). US and MIBI scans were comparable for either negative or positive adenoma localization and suspected MGD. While the PTH level was similar, the calcium level was higher in SGD (2.8 mmol/L versus 2.76 mmol/L, P=0.034). MGD had a significantly lower gland weight (0.78 g versus 0.31 g; P<0.001). A gland weight of 0.418 grams was a predictive factor for MGD with a sensitivity of 72% and a specificity of 66%.

CONCLUSIONS

Only the weight of the resected parathyroid adenoma was meaningful in predicting MGD. A cut-off value of 0.418 g can differentiate SGD from MGD.

Impact of parathyroidectomy on inflammatory and cardiovascular risk parameters in primary hyperparathyroidism: a retrospective analysis

BACKGROUND

Parathyroidectomy has been shown to reduce cardiovascular risk factors in some studies, although findings on these parameters remain inconsistent.

OBJECTIVES

This study aimed to evaluate inflammatory and cardiovascular risk markers in patients with Primary Hyperparathyroidism (PHPT) before and one month after successful parathyroidectomy (PTX).

METHODS

We retrospectively analyzed PHPT patients who visited the outpatient clinic between 2015 and 2020. Patient demographics, hemogram data, calcium, parathormone (PTH), vitamin D, high-density lipoprotein (HDL), mean platelet volume (MPV), neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-HDL ratio (MHR) were recorded and compared pre- and postoperatively.

RESULTS

The analysis revealed significant postoperative increases in platelet, MPV, HDL, PLR, and vitamin D levels (p = 0.001, p = 0.001, p = 0.001, p = 0.024, p = 0.001, respectively). Conversely, PTH, calcium, NLR, and MHR levels significantly decreased (p = 0.001, p = 0.001, p = 0.011, p = 0.019, respective-ly). Correlation analysis demonstrated a negative association between postoperative PTH and vitamin D (p = 0.010, r = -0.292**) and a positive association between postoperative PTH and both calcium (p = 0.008, r = 0.309**) and NLR (p = 0.046, r = 0.227**). Multivariable regression analysis demonstrated that postoperative PTH levels were significantly associated with calcium (B = 39.82, Beta = 0.321, p = 0.0469), NLR (B = 110.02, Beta = 0.428, p = 0.0384), baseline comorbidity scores (B = -30.54, Beta = -0.287, p = 0.0361), and preoperative inflammation levels (B = 25.69, Beta = 0.311, p = 0.0386).

CONCLUSION

Our findings highlight a potential link between PHPT and inflammatory-cardiovascular risk, with parathyroidectomy exerting a beneficial effect within the first month post-surgery. The study also suggests that these risk factors may be modifiable with timely surgical intervention.

CLINICAL TRIAL NUMBER

Not applicable.

Analysis of Clinical and Biochemical Parameters and the Effectiveness of Surgical Treatment in Patients with Primary Hyperparathyroidism: A Single-Center Study

Background: Primary hyperparathyroidism (PHPT) causes an imbalance of calcium-phosphate metabolism in the form of hypercalcemia and hypophosphatemia, leading to dysfunction in various organs. The main cause is a benign tumor of the parathyroid gland (adenoma), leading to excessive and uncontrolled secretion of parathyroid hormone (PTH). Difficulties in diagnosing PTHP are also compounded by the possibility of asymptomatic course at the early disease stages. The gold standard treatment involves removing the pathological gland, while pharmacological options are reserved for candidates ineligible for surgery. Methods: In our study, we assessed the effectiveness of surgical treatment and the factors influencing outcomes and complications by analyzing the records of 125 patients with PHPT who underwent parathyroidectomy at the University Centre of General and Oncological Surgery of the Wroclaw Medical University from 2008 to 2017. We considered sociodemographics, laboratory results, comorbidities, complications, procedure details, and outcomes. The procedures included 93 open minimally invasive parathyroidectomies (OMIPs), 11 unilateral neck explorations, and 21 bilateral neck explorations. Results: Single-gland pathology was common (101 patients), while 24 had involvement of two glands. The left inferior parathyroid gland was the most frequently affected (n = 65; 43.6%). Histopathological examination consistently indicated the presence of parathyroid adenoma in all patients. Complications following parathyroidectomy were observed in 11 (8.8%) patients. Calcium normalization after six months was observed in 119 patients (95.2%). The surgical technique, the location of the adenoma, and the sex and age of the patient did not appear to affect the effectiveness of treatment. Conclusions: Parathyroidectomy is highly effective in treating PHPT, irrespective of patient age, sex, or gland location. It leads to decreased serum PTH and total calcium levels while increasing the inorganic phosphate concentration.

Chapter 1: Epidemiology of primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a frequent disease. Prevalence continues to rise in Europe, long after the advent of automated calcemia meters, while incidence has stabilized. The disease is much more common in women, at around 75% of cases, and is more prevalent with advancing age, and particularly post-menopause.

Unmasking Latent Primary Hyperparathyroidism in Guillain-Barré Syndrome: A Case Report and Literature Review

Primary hyperparathyroidism (PHPT), a common endocrine disorder, is often diagnosed in its asymptomatic stage. We report the case of a 79-year-old woman with Guillain-Barré syndrome (GBS) who developed progressive hypercalcemia, initially suspected to be immobilization hypercalcemia (IH). However, the detection of elevated intact parathyroid hormone (PTH) confirmed that the hypercalcemia was not solely due to prolonged immobilization associated with GBS but rather due to previously latent PHPT becoming clinically apparent. Treatment with elcatonin and zoledronate inhibited bone resorption, while cinacalcet suppressed PTH secretion, collectively normalizing serum calcium levels and alleviating symptoms. This case illustrates how prolonged immobilization in GBS can enhance bone resorption, leading to IH and unmasking latent PHPT. Recognizing this mechanism underscores the importance of routine calcium monitoring, PTH screening in high-risk patients, and timely intervention to prevent complications, particularly in immobilized or ageing populations.

Effect of surgical treatment on left ventricular strain in patients with primary hyperparathyroidism: A meta-analysis of echocardiographic study

AIM

Current evidence on the effects of parathyroidectomy (PTX) on myocardial deformation in patients with primary hyperparathyroidism (PHPT) is scanty and based on a few studies. The aim of this meta-analysis was to provide a comprehensive and updated information on this issue.

DATA SYNTHESIS

Following the PRISMA guidelines, systematic searches were conducted across bibliographic databases (Pub-Med, OVID, EMBASE and Cochrane library) to identify eligible studies from inception up to September 30th, 2024. Searches were limited to clinical investigations published in English reporting data on LV mechanics (i.e. global longitudinal strain, GLS) in patients with PHPT before and after PTX. The statistical difference of the echocardiographic variables of interest collected at baseline and after PTX, such as left ventricular ejection fraction (LVEF) and GLS was calculated by standardized mean difference (SMD) with 95 % confidence interval (CI) by using random-effects models. Four studies including 126 patients with PHPT undergoing PTX, in whom LV mechanics had been assessed by speckle tracking echocardiography before and after six months from surgery, were considered. Baseline pooled average LVEF values were 59.5 ± 1.7 % and corresponding values after PTX 60.3 ± 1.2 %, (SMD: 0.16 ± 0.09, CI: -0.01/0.34, p = 0.07). Baseline and after surgical procedure values for GLS were -18.9 ± 0.28 % and -20.4 + 0.28 %, (SMD: 0.55 ± 0.10, CI: 0.37/0.74, p < 0.001). Meta-regression analysis showed a significant relationship between changes in serum PTH and GLS (p = 0.004).

CONCLUSIONS

Our findings suggest that PTX impacts favourably on LV mechanics, and, more importantly, the assessment of LV changes in this setting should include GLS and no longer rely on conventional echocardiographic parameters such as LVEF.

Primary Hyperparathyroidism: Clinical, Biochemical, and Radio-Pathological Profiles of 804 Patients - A Retrospective Study from South India

Introduction

Primary hyperparathyroidism (PHPT) is a common endocrine disorder with variable clinical presentation. We intend to describe the clinical, biochemical, and radio-pathological profiles of PHPT patients managed over 13 years from South India.

Methods

We analysed all patients who underwent evaluation and surgery for PHPT from July 2011 to April 2024.

Results

A total of 862 PHPT patients underwent parathyroidectomy, with female preponderance (61.2%). Analysis was done on 804 patients (>20 years of age) excluding adolescent and paediatric age groups. The mean age was 43.8 years. The presentation in decreasing order of frequency was weakness and fatigue (84.2%); bone pain (35%); renal disease (20.8%) in the form of nephrolithiasis, nephrocalcinosis, or renal dysfunction; and neuropsychiatric manifestations (23.8%). Pathological fractures were observed in 4.5%, hypercalcaemic crisis in 2.6% of patients, and 1% had MEN I (Multiple Endocrine Neoplasia) syndrome. The mean albumin adjusted serum calcium level was 12.3 ± 1.01 mg/dl, and the median serum PTH level was 338 (80-3864) pg/ml. The sensitivity of the ultrasound neck and 99mTc Sestamibi scan was 97.5% and 98.3%, respectively, with a concordance of 93.4%. 25% underwent bilateral neck exploration and parathyroidectomy. Lesions were ectopic in 20 (2.4%) patients. The mean parathyroid gland weight was 1.45 ± 0.75 g. Histopathology revealed parathyroid adenoma (93.5%), parathyroid hyperplasia (1.6%), and parathyroid carcinoma (2.2%). The cure rate was 99.3%, while three patients had persistent disease. Hungry bone syndrome was observed in 12.1%.

Conclusion

There is a changing trend in the clinical and biochemical profiles of PHPT patients in India to a milder form of the disease. The incidence of parathyroid carcinoma was slightly higher compared to a few other centres in India.

The association of Medicaid expansion and parathyroidectomy for benign disease: Insurance status remains an important factor in access to high-volume centers

BACKGROUND

Medicaid expansion has been associated with improved access to surgical care at high-volume centers. Its impact on parathyroidectomy, however, is unclear. We evaluated the association between Medicaid expansion and parathyroidectomy at high- and low-volume centers.

METHODS

The Vizient Clinical Data Base was queried for parathyroidectomies. Patients were grouped by insurance status and pre- and post-Medicaid expansion periods. Hospitals were stratified into tertiles (T1-T3) by operative volume (T1 = highest-volume centers). Odds of parathyroidectomy and a difference-in-differences analysis were conducted.

RESULTS

In total, 31,983 patients were identified. Patients were predominantly privately insured (49.9%). Uninsured and Medicaid patients had increasing odds of operation at lower-tertile centers (odds ratio: T1 = ref; uninsured: T2 = 10.0, T3 = 15.8; Medicaid: T2 = 6.2, T3 = 13.5; P < .001). Medicare patients, however, were less likely to undergo operation at lower-volume centers (odds ratio: T2 = 0.89, P < .001; T3 = 0.92, P = .002). Privately insured patients were the least likely to receive care at low-volume centers (odds ratio: T3 = 0.7, P < .001). Medicaid patients in nonexpansion states had 12-16 times higher odds of parathyroidectomy at lower-volume hospitals than their counterparts in expansion states (expansion/nonexpansion states: pre-expansion T3 = 2.3/28.0; postexpansion T3 = 1.3/21.4). Expansion was associated with an increase in the proportion of parathyroidectomy for Medicaid patients, with larger gains seen at higher-volume centers (T1 = 5.0%, P = .01; T2 = 3.1%, P = .001; T3 = 2.7%, P = .03). Expansion was not associated with changes in payor distribution for uninsured, Medicare, or privately insured patients.

CONCLUSIONS

Medicaid expansion was associated with an increase in parathyroidectomy for Medicaid patients at high-volume centers. However, in nonexpansion states, access to surgical treatment at high-volume centers remains limited for uninsured and underinsured patients.

Post-surgical Persistent Hyperparathyroidism Successfully Treated with Parathyroid Radiofrequency Ablation: A Case Report

BACKGROUND

Currently, parathyroidectomy is the standard treatment for Primary Hyperparathyroidism (PHPT). Surgical treatment is often effective, although not free of complications and relapses. Minimally invasive techniques, such as Microwave Ablation (MWA) and Radiofrequency Ablation (RFA), are an alternative to surgery in selected patients. We have, herein, reported on the successful use of RFA in a patient with post-surgical persistent hyperparathyroidism.

CASE PRESENTATION

A 54-year-old woman was referred to our Center for mild hypercalcemia with exams revealing Primary Hyperparathyroidism (PHPT). Neck ultrasound and Technetium- 99 Methoxy-isobutyl-isonitrile (99mTc-MIBI) scintigraphy scanning revealed a suspicious right parathyroid hyperplasia/adenoma. She underwent parathyroidectomy and histological examination showed a parathyroid nodular hyperplasia. During the follow-up, she suffered from persistent hyperparathyroidism due to a left parathyroid hyperplasia. Thus she was treated with RFA. Blood tests after the procedure showed the remission of the disease 7 months post-treatment.

CONCLUSION

A minimally invasive technique for PHPT may represent a valid alternative to surgery, especially in patients with an elevated surgery-related risk. More studies are necessary to investigate the benefit of RFA as a first-line treatment in PHPT.

Femoral neck fracture in a senile patient with primary hyperparathyroidism: A case report

RATIONALE

As a rare cause of femoral neck fracture, usually, hyperparathyroidism is missed diagnosed by orthopedist. Patient can present with various disappearance of clinical manifestations. Primary hyperparathyroidism in senile male population is commonly an asymptomatic disorder discovered incidentally through routine lab testing. Here, this study reports a case of femoral neck fracture in a senile patient with primary hyperparathyroidism.

PATIENTS CONCERNS

A 70-year-old male patient with a known right femoral neck fracture associated with primary hyperparathyroidism.

DIAGNOSES

A neck ultrasound (US) and computed tomography revealed a solid mass below the right lobe of the thyroid. X-ray plain and computed tomography confirmed right femoral neck fracture and multiple bone lesions. The routine lab testing showed hypercalcemia and hyperkalemia.

INTERVENTIONS

Before undergoing total hip arthroplasty surgery, patient was temporarily treated with hydration, diuretics, and calcitonin. Besides, the patient underwent parathyroidectomy of the enlarged parathyroid gland. Oral calcium preparations were routinely used for prevention of hypocalcemia.

OUTCOMES

After completing all surgery, the patient was discharged without any complications including hypercalcemia and hyperkalemia.

LESSONS

Femoral neck fracture associated with primary hyperparathyroidism is a rare presentation. This case highlights that hypercalcemia and multiple osteopathy should be considered in the differential diagnosis in patients with pathological fracture caused by micro-traumatic injury.

A Case of Primary Hyperparathyroidism With a Hypercalcemic Crisis Resulting in Distinct Bone Mineral Redistribution

Primary hyperparathyroidism (PHPT) is generally detected early, but this case involves a rare hypercalcemic crisis associated with a parathyroid adenoma. A 66-year-old man presented with extreme fatigue and loss of appetite. Serum calcium and parathyroid hormone (PTH) levels were elevated to 22.5 mg/dL and 3100 pg/mL, respectively. After the initial management of hypercalcemia, parathyroidectomy confirmed a benign adenoma. This case demonstrates a notable redistribution of bone minerals, with a significant decrease in cortical bone density but preservation, and even enhancement, of trabecular bone density. This redistribution highlights the complex dual action of PTH on bone metabolism, emphasizing the need for careful monitoring in severe PHPT cases.

Dual concentric echo sign of ultrasound in primary hyperparathyroidism: The clinical and histopathologic features and differentiation from lymph nodes

Context

Ultrasound (US) is the most economical and widely used method for detecting lesions in parathyroid regions. Identifying typically parathyroid adenomas as hypoechoic nodules with clear margins. However, 10 % of lesions exhibit atypical features, such as the dual concentric sign, and the cognition of them still needs to be improved.

Objective

To promote understanding of clinical and histopathological features for parathyroid lesions with the dual concentric echo sign and to investigate its pathogenesis and methods for distinguishing from cervical lymph nodes to improve US diagnostic accuracy.

Methods

Retrospectively, patients were categorized into three groups: Group 1, with 36 patients showing parathyroid lesions with dual concentric echo signs; Group 2, with 40 patients displaying classic hypoechoic parathyroid lesions; and Group 3, comprising 36 patients with identified lymph nodes, which were all examined from January 2018 to December 2019. The clinical data on demographics, clinical symptoms, serum levels, histopathologic findings, and US image characteristics were thoroughly reviewed.

Results

According to the clinical data, no significant differences in demographics or lesion sizes were observed in Group 1 and Group 2 (p > 0.05). No significant variances were noted in biochemical markers, including PTH, T-25OHD, and ALP. However, a notable difference was identified in adjusted serum calcium levels, which were significantly lower in Group 1 compared to Group 2 (p < 0.05). Additionally, the proportion of asymptomatic patients was significantly higher in Group 1 compared to Group 2 (p < 0.05). Pathological examination revealed that all lesions with dual concentric echo signs were parathyroid adenomas. The isoechoic central region predominantly corresponded to areas of loose edema, while the hypoechoic peripheral layer was primarily associated with chief and/or oncocytic cells. By comparing the ultrasonography of Groups 1 and 3, the parathyroid lesions with dual concentric echo signs exhibited significant distinctions from lymph nodes in size, blood flow classification, vascular distribution, and anatomical location (p < 0.05).

Conclusion

The parathyroid lesions with dual concentric echo signs in US corresponded to specific histopathological manifestations and relatively mild clinical features in the patients, this finding may increase the likelihood of incidental detection of parathyroid lesions by US. Attention to the details of size, location, and blood flow, especially, may aid US physicians in differentiating parathyroid adenomas from cervical lymph nodes.

Secular trends in the incidence and treatment patterns of primary hyperparathyroidism in Korea: a nationwide cohort study

Data on epidemiology and secular trend in primary hyperparathyroidism (PHPT) in adults are relatively limited in Asian countries. This study aims to provide an overview of the secular trends in incidence, clinical characteristics, and treatment patterns of PHPT in South Korea. We used Korea's National Health Insurance Claim database (2005-2020) to identify newly diagnosed PHPT cases. Individuals with age below 19, fewer than 2 E21.0 diagnoses, fewer than 2 PTH measurements, secondary hyperparathyroidism, undergoing dialysis or kidney transplantation within a year of diagnosis, parathyroidectomy (PTX) within a year prior to the diagnosis code, and diagnosis of multiple endocrine neoplasm or parathyroid carcinoma were excluded from the analysis. A total of 6837 patients with PHPT (PTX, n = 2989; non-surgery, n = 3848) were compared with 1:10 age- and sex-matched controls (n = 68 370). The mean age of patients with PHPT was 56.0 years, with 77.4% being women. The annual incidence of PHPT increased from 0.23/100 000 persons in 2005 to 1.75 in 2020, with higher rate in women than in men. Compared with 2005-2010 (n = 675), the number of newly diagnosed PHPT cases increased up to 3.1-fold (n = 2119) in 2011-2015 and 6.0-fold (n = 4043) in 2016-2020 periods. Among all patients with PHPT, 43.7% of patients underwent PTX, with decrement of proportion of bilateral surgery among PTX group across time (11.9% in 2005-2010 to 8.9% in 2016-2020, P for trend .033). Among all patients with PHPT, non-surgery group increased from 41.6% in 2005-2010 to 58.0% in 2016-2020 (P for trend <.001). Patients with PHPT had higher odds of osteoporosis (odds ratio [OR] 7.03), renal stones (OR 10.55), chronic kidney diseases (OR 7.42), and cardiovascular, metabolic, and neurological conditions after adjustment for comorbidity index. In summary, the incidence of PHPT increased from 2005 to 2020 with predominance of non-surgical treatment, which calls for research focus on improving non-surgical management.

Ultrafast intraoperative parathyroid hormone monitoring system: prospective, multicentre, clinical validity study

BACKGROUND

Intraoperative parathyroid hormone (PTH) monitoring is a proven and reliable adjunct to parathyroid surgery, able to improve the outcomes and efficiency of the diagnostic and therapeutic pathway for patients with primary hyperparathyroidism. This study evaluated the innovative, compact, fully automated NBCL CONNECT Analyzer, which can measure whole-blood PTH in 5 min.

METHODS

A prospective multicentre study was conducted in stages: results reviews, recommendations, and implementation of improvements to the mechanical design, components of cartridges, calibration, and sampling protocols. Patients undergoing parathyroidectomy had PTH levels measured on the Analyzer and main laboratory platforms, either Roche or Abbott. The Miami criterion of a 50% drop in PTH concentration was used to define biochemical cure during surgery, and normal postoperative calcium level as cure of primary hyperparathyroidism. Measurements on the Analyzer were done by laboratory staff in London and nurses in Stuttgart. The Pearson coefficient (R) and Wilcoxon test were used for statistical analysis.

RESULTS

Some 234 patients (55 male, 179 female) with a median age of 58.5 (age full range 15-88) years underwent parathyroidectomy (195 minimally invasive, 38 bilateral neck exploration, 1 thoracoscopic; 12 conversions) for primary hyperparathyroidism between November 2021 and July 2022. Primary hyperparathyroidism was cured in 225 patients (96.2%). The sensitivity, specificity, and overall accuracy of the Analyzer assay in predicting biochemical cure were 83.9, 100, and 84.8% in phase 1; 91.2, 100, and 91.3% in phase 2; and 98.6, 100, and 98.6% in phase 3. There were no false-positive results (positive predictive value 100%). Correlations between Analyzer measurements and those obtained using the Roche device were very strong (R = 0.98, P < 0.001 in phase 1; R = 0.92, P < 0.001 in phase 2; R = 0.94, P < 0.001 in phase 3), and correlations for Analyzer readings versus those from the Abbott platform were strong (R = 0.82, P < 0.001; R = 0.89, P < 0.001; R = 0.91, P < 0.001). The Analyzer showed continued good mechanical performance, with stable and repeatable operations (calibrations, quality controls). Introducing a stricter sampling protocol and improvements in the clot-detecting system led to a decrease in the number of clotted samples and false-negative results. Outcomes were not affected by measurements performed either by nurses or laboratory staff.

CONCLUSION

Intraoperative PTH monitoring during parathyroid surgery can be done accurately, simply, and quickly in whole blood using the Analyzer.

Systematic review of the risk of urolithiasis following parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTX) is the conclusive therapy for primary hyperparathyroidism (PHPT), but its effect on the risk of urolithiasis is inconclusive. We comprehensively reviewed the currently available research to investigate the impact of PTX on the likelihood of urolithiasis among individuals suffering PHPT.

METHODS

Internet-based articles in English language released on Cochrane, PubMed, Scopus, Web of knowledge, and Embase up to September, 2023 were comprehensively reviewed. Each publication in contrast to the incidence, occurrence, or recurrence of urolithiasis after PTX versus medical treatment in PHPT patients was included. The outcome with pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) was examined employing DerSimonian and Laird's model of random effects. To determine the range of the real effect size of a future study in 95% of all populations, a prediction interval (PI) was also established.

RESULTS

Finally, ten studies involving 74,190 patients were included. Results from randomized-controlled trials (RCTs) and observational studies (OSs) both revealed that PTX did not substantially lessen the vulnerability of urolithiasis among individuals with PHPT (RCTs: pooled relative risk [RR] 0.42, 95%CI 0.13-1.41, p = 0.163; OSs: pooled RR 1.37, 95%CI 0.96 to 1.97, p = 0.084). The PI (RCT: 0.03 to 5.96; OSs: 0.44-4.20) containing 1.0 suggested the possibility of consistent results in future studies. Subgroup and sensitivity analyses supported the above findings, and no evidence showed publication bias.

CONCLUSION

Our analysis from the available RCTs or OSs did not give adequate or exact proof that the average effect of PTX lowers the incidence of urolithiasis among PHPT persons based on the random-effects model. Future research shall take into account the common effect of PTX as well as the prerequisites of preventive stone procedures, which will further help us assess the effectiveness of PTX in reducing kidney calculus comorbidity and develop techniques to avoid stone sequelae in these individuals.

The Ca∗Cl/P Ratio: A Novel and More Appropriate Screening Tool for Normocalcaemic or Overt Primary Hyperparathyroidism

OBJECTIVE

The main purpose of this study was to explore the diagnostic performance of the Ca∗Cl/P ratio for primary hyperparathyroidism (PHPT), especially normocalcaemic PHPT (NPHPT), to assist health care providers in making reliable and rapid clinical identifications.

METHODS

From January 1, 2013, to March 31, 2023, 230 PHPT patients, including 65 with NPHPT and 230 sex- and age-matched controls, were enrolled in this retrospective study. Differences between hypercalcaemic PHPT (HPHPT) and NPHPT and between them and their respective controls were analyzed. The diagnostic accuracy of the Ca∗Cl/P ratio, Ca/P ratio, Cl/P ratio and albumin-corrected calcium was assessed by the area under the receiver operating characteristic curve.

RESULTS

Compared with corresponding controls, NPHPT and HPHPT patients both had significantly higher Ca ∗ Cl/P ratios (271.64 ± 51.74 vs 192.71 ± 26; 419.91 ± 139.11 vs 199.14 ± 36.75, P < .001). In the overall cohort, the ROC-AUC of the Ca∗Cl/P ratio (0.964, 95% CI = 0.943-0.979) for diagnosis of PHPT patients was superior to albumin-corrected calcium (0.959, 95% CI = 0.934-0.973), the Ca/P ratio (0.956, 95% CI = 0.934-0.973), and the Cl/P ratio (0.923, 95% CI = 0.895-0.946). A Ca ∗ Cl/P ratio above 239.17 mmol/L, with sensitivity (0.952), specificity (0.922), PPV (0.924), NPV (0.951) and accuracy (0.937), can distinguish PHPT patients from healthy individuals. Furthermore, the Ca ∗ Cl/P ratio yielded a sensitivity of 0.831, specificity of 0.938, PPV of 0.931, NPV of 0.847 and accuracy of 0.885 for NPHPT.

CONCLUSION

The Ca∗Cl/P ratio provides excellent diagnostic power for diagnosis of PHPT, especially NPHPT.

Molecular Genetic Aspects of Sporadic Multiglandular Primary Hyperparathyroidism

Multiglandular primary hyperparathyroidism (MGD) represents a rare form of primary hyperparathyroidism (PHPT). MGD is associated with hereditary PHPT, but the sporadic MGD is more common and affects a similar patient profile as single gland parathyroid disease (SGD). The distinction between SGD and MGD is of great clinical importance, especially for the strategy of parathyroidectomy. Based on the limited knowledge available, MGD is likely to be a genetically heterogeneous disease resulting from the interaction of germline and somatic DNA mutations together with epigenetic alterations. Furthermore, these events may combine and occur independently in parathyroid tumors within the same individual with MGD. Gene expression profiling has shown that SGD and MGD may represent distinct entities in parathyroid tumorigenesis. We are waiting for studies to analyze exactly which genes are different in SGD and MGD in order to identify potential biomarkers that can distinguish between the two forms of the disease.

Phenotypic Profiling and Molecular Mechanisms in Hyperparathyroidism-jaw Tumor Syndrome

CONTEXT

Hyperparathyroidism-jaw tumor (HPT-JT) syndrome is a heritable form of primary hyperparathyroidism caused by germline inactivating mutations in CDC73 encoding parafibromin and is associated with an increased risk of parathyroid cancer. There is little evidence to guide the management of patients with the disease.

OBJECTIVE

(1) Characterize the natural history of HPT-JT, (2) correlate genotype and histology of parathyroid tumors with parafibromin immunostaining, (3) understand molecular changes downstream to CDC73 loss.

DESIGN

Retrospective study of patients with HPT-JT syndrome (genetically confirmed or affected first-degree relatives). Independent review of uterine tumor from 2 patients and staining for parafibromin on parathyroid tumors from 19 patients (13 adenomas, 6 carcinomas) was performed. RNA-sequencing was performed in 21 parathyroid samples (8 HPT-JT-related adenomas, 6 HPT-JT-related carcinomas, and 7 sporadic carcinomas with wild-type CDC73).

RESULTS

We identified 68 patients from 29 kindreds with HPT-JT with median age at last follow-up of 39 [interquartile range, 29-53] years. A total of 55/68 (81%) developed primary hyperparathyroidism; 17/55 (31%) had parathyroid carcinoma. Twelve of 32 (38%) females developed uterine tumors. Of the 11 patients who had surgical resection for uterine tumors, 12/24 (50%) tumors were rare mixed epithelial mesenchymal polypoid lesions. Four of 68 patients (6%) developed solid kidney tumors; 3/4 had a CDC73 variant at p.M1 residue. Parafibromin staining of parathyroid tumors did not correlate with tumor histology or genotype. RNA-sequencing showed a significant association of HPT-JT-related parathyroid tumors with transmembrane receptor protein tyrosine kinase signaling pathway, mesodermal commitment pathway, and cell-cell adhesion.

CONCLUSIONS

Multiple, recurrent atypical adenomyomatous uterine polyps appear to be enriched in women with HPT-JT and appear characteristic of the disease. Patients with CDC73 variants at p.M1 residue appear predisposed to kidney tumors.

CLINICAL TRIAL NUMBER

NCT04969926.

Stable Incidence and Increasing Prevalence of Primary Hyperparathyroidism in a Population-based Study in Scotland

CONTEXT

Previous studies, including our own, have demonstrated a highly variable incidence of primary hyperparathyroidism (PHPT) from year to year.

OBJECTIVE

We planned to provide a current estimate of the incidence and prevalence of PHPT in a community-based study.

METHODS

A population-based retrospective follow-up study was conducted in Tayside (Scotland) from 2007 to 2018. Record-linkage technology (demography, biochemistry, prescribing, hospital admissions, radiology, and mortality data) was used to identify all patients. Cases of PHPT were defined as those with at least 2 raised serum corrected calcium concentration CCA (> 2.55 mmol/L) and/or hospital admissions with PHPT diagnoses and/or surgery records with parathyroidectomy during the follow-up period. The number of prevalent and incident cases of PHPT per calendar year by age and sex were estimated.

RESULTS

A total of 2118 people (72.3% female, mean age 65 years) were identified with an incident case of PHPT. The overall prevalence of PHPT over the 12 years of the study was 0.84% (95% CI, 0.68%-1.02%), steadily increasing from 0.71% in 2007 to 1.02% in 2018. From 2008, the incidence of PHPT was relatively stable from 4 to 6 cases per 10 000 person-years, declining from 11.5 per 10 000 person-years in 2007. The incidence varied from 0.59 per 10 000 person-years (95% CI, 0.40%-0.77%) for those aged 20 to 29 years, to 12.4 per 10 000 person-years (95% CI, 11.2%-13.3%) in those aged 70 to 79 years. Incidence of PHPT was 2.5 times higher in women than in men.

CONCLUSION

This study is the first showing a relatively steady annual incidence of PHPT at 4 to 6 per 10 000 person-years. This population-based study reports a PHPT prevalence of 0.84%.

Molecular and Clinical Spectrum of Primary Hyperparathyroidism

Recent data suggest an increase in the overall incidence of parathyroid disorders, with primary hyperparathyroidism (PHPT) being the most prevalent parathyroid disorder. PHPT is associated with morbidities (fractures, kidney stones, chronic kidney disease) and increased risk of death. The symptoms of PHPT can be nonspecific, potentially delaying the diagnosis. Approximately 15% of patients with PHPT have an underlying heritable form of PHPT that may be associated with extraparathyroidal manifestations, requiring active surveillance for these manifestations as seen in multiple endocrine neoplasia type 1 and 2A. Genetic testing for heritable forms should be offered to patients with multiglandular disease, recurrent PHPT, young onset PHPT (age ≤40 years), and those with a family history of parathyroid tumors. However, the underlying genetic cause for the majority of patients with heritable forms of PHPT remains unknown. Distinction between sporadic and heritable forms of PHPT is useful in surgical planning for parathyroidectomy and has implications for the family. The genes currently known to be associated with heritable forms of PHPT account for approximately half of sporadic parathyroid tumors. But the genetic cause in approximately half of the sporadic parathyroid tumors remains unknown. Furthermore, there is no systemic therapy for parathyroid carcinoma, a rare but potentially fatal cause of PHPT. Improved understanding of the molecular characteristics of parathyroid tumors will allow us to identify biomarkers for diagnosis and novel targets for therapy.

Effects of successful parathyroidectomy on neuropsychological and cognitive status in patients with asymptomatic primary hyperparathyroidism

PURPOSE

Besides typical clinical symptoms, primary hyperparathyroidism (pHPT) is associated with impaired quality of life and cognitive status. The aim of this study was to evaluate the quality of life and cognitive impairment in patients with pHPT, before and after parathyroidectomy.

METHODS

We conducted a panel study, which included asymptomatic pHPT patients scheduled for parathyroidectomy. Besides demographic and clinical data, patients' quality of life and cognitive capacity were recorded before, 1 month, and 6 months following parathyroidectomy using the Short Form 36 questionnaire (RAND-36), Beck Depression Inventory (BDI), Depression Anxiety Stress Scales (DASS), Mini-Mental State Examination (MMSE), and Symptom Check List 90-revised version (SCL90R).

RESULTS

During a 2-year follow-up, 101 patients entered the study (88 women), with an average age of 60.7 years. The Global score of RAND-36 test ameliorated by almost 50% 6 months after parathyroidectomy. The most sustained subscores of the RAND-36 test were role functioning/physical and health change, with an improvement of more than 125%. According to the BDI, DASS depression subscore, and SCL90R depression subscore, the extent of depressive symptoms reduction was approximately 60% 6 months postoperatively. The level of anxiety was reduced by 62.4%, measured by both the DASS and SCL90R anxiety subscores. The stress level was almost halved according to the DASS stress subscore (from 10.7 to 5.6 points). The results of the MMSE test showed a significant improvement postoperatively, for 1.2 points (4.4%). A worse preoperative score of each tool was related to the higher magnitude of improvement 6 months after parathyroidectomy.

CONCLUSION

A considerable number of pHPT patients, even without other typical symptoms, show signs of impaired quality of life and neurocognitive status preoperatively. After a successful parathyroidectomy, there is an improvement in quality of life, declined levels of depression, anxiety, and stress, as well as amelioration of cognitive status. Patients with more impaired quality of life and pronounced neurocognitive symptoms may expect more benefits from the surgery.

Morbidity Associated With Primary Hyperparathyroidism-A Population-based Study With a Subanalysis on Vitamin D

CONTEXT

Primary hyperparathyroidism (PHPT) is associated with increased risk of morbidity and death, and vitamin D levels are a potentially confounding variable.

OBJECTIVE

The aim of this study was to assess morbidity and mortality associated with primary hyperparathyroidism (PHPT).

METHODS

In this population-based retrospective matched cohort study, data linkage of biochemistry, hospital admissions, prescribing, imaging, pathology, and deaths was used to identify patients across the region of Tayside, Scotland, who had PHPT from 1997 to 2019. Cox proportional hazards models and hazards ratios (HR) were used to explore the relationship between exposure to PHPT and several clinical outcomes. Comparisons were made with an age- and gender-matched cohort.

RESULTS

In 11 616 people with PHPT (66.8% female), with a mean follow-up period of 8.8 years, there was an adjusted HR of death of 2.05 (95% CI, 1.97-2.13) for those exposed to PHPT. There was also an increased risk of cardiovascular disease (HR = 1.34; 95% CI, 1.24-1.45), cerebrovascular disease (HR = 1.29; 95% CI, 1.15-1.45), diabetes (HR = 1.39; 95% CI, 1.26-1.54), renal stones (HR = 3.02; 95% CI, 2.19-4.17) and osteoporosis (HR = 1.31; 95% CI, 1.16-1.49). Following adjustment for serum vitamin D concentrations (n = 2748), increased risks for death, diabetes, renal stones, and osteoporosis persisted, but not for cardiovascular or cerebrovascular disease.

CONCLUSION

In a large population-based study, PHPT was associated with death, diabetes, renal stones, and osteoporosis, independent of serum vitamin D concentration.

Persistence and Recurrence of Hypercalcemia After Parathyroidectomy Over 5 Decades (1965-2010) in a Community-based Cohort

BACKGROUND

There is limited long-term follow-up of patients undergoing parathyroidectomy. Recurrence is described as 4% to 10%. This study evaluated persistence and recurrence of hypercalcemia in primary hyperparathyroidism after parathyroidectomy.

METHODS

Single-institution retrospective (1965-2010) population-based cohort from Olmsted County (MN) of patients undergoing surgery for primary hyperparathyroidism. Patients' demographic data, preoperative and postoperative laboratory values, clinical characteristics, surgical treatment, and follow-up were noted.

RESULTS

A total of 345 patients were identified, 75.7% female, and median age 58.4 years [interquartile range (IQR): 17.6]. In all, 68% of patients were asymptomatic and the most common symptoms were musculoskeletal complaints (28.4%) and nephrolithiasis (25.6%). Preoperative median serum calcium was 11 mg/dL (IQR: 10.8-11.4 mg/dL), and median parathyroid hormone was 90 pg/mL (IQR: 61-169 pg/dL). Bilateral cervical exploration was performed in 38% and single gland resection in 79% of cases. Median postoperative serum calcium was 9.2 mg/dL (IQR: 5.5-11.3). Nine percent of patients presented persistence of hypercalcemia, and recurrence was found in 14% of patients. Highest postoperative median serum calcium was 10 mg/dL (IQR: 6-12.4), and median number of postoperative calcium measurements was 10 (IQR: 0-102). Postoperative hypercalcemia was identified in 37% of patient. Fifty-three percent were attributed to secondary causes, most commonly medications, 22%. Three percent of patients required treatment for postoperative hypercalcemia. Median time to recurrence and death were 12.2 and 16.7 years, respectively.

CONCLUSION

Recurrent hypercalcemia after successful parathyroidectomy is higher than previously reported. Most cases are transient and often associated to other factors with only the minority requiring treatment. Long-term follow-up of serum calcium should be considered in patients after successful parathyroidectomy.

Pediatric primary hyperparathyroidism: Surgical pathology and long-term outcomes in sporadic and familial cases

BACKGROUND

Primary Hyperparathyroidism (PHPT) is rare in pediatric patients. Data regarding surgical outcomes are scarce.

METHODS

Single-center retrospective review (1994-2020) of patients ≤21 years undergoing surgery for PHPT.

RESULTS

66 patients were identified (61% female, 17 ± 3 years). 71% of patients were symptomatic at diagnosis. 32% of patients had known familial syndromes, most commonly MEN-1. 23% of patients without a known mutation had genetic testing, 22% positive. 56% of the total and 19% of the familial cohort underwent focused exploration. Single gland disease was found in 19% of familial vs 85% of sporadic cases, p < 0.00001. Persistence was 9%, all in the sporadic group, p = 0.11. Recurrence was 15%: 38% in the familial vs 2% in the sporadic groups, p=0.0004. Time to recurrence was 59 months (Q1-38, Q3-95), familial 61 vs 124 months sporadic, p=0.001.

CONCLUSION

Pediatric PHPT is frequently sporadic, although 5% of apparent sporadic cases are secondary to syndromes. Familial cases have higher rates of recurrence, requiring closer follow-up.

Prevalence and associated risk factors of simple renal cysts in primary hyperparathyroidism

PURPOSE

Previous studies have pointed to the role of parathormone (PTH) in the development of simple renal cysts. However, there is insufficient evidence related to simple renal cysts in primary hyperparathyroidism (PHPT). Therefore, this study aimed to evaluate the prevalence and risk factors associated with renal cysts in PHPT patients.

METHODS

In this retrospective study, we included 235 patients treated surgically for PHPT and 147 control subjects. The clinical and physical examination findings, laboratory test results, and neck and urinary system ultrasonography examination findings were evaluated. Postoperative parathyroid adenoma volume and weight were also recorded.

RESULTS

Simple renal cysts were found in 53 PHPT patients (22.6%) and in 15 control subjects (10.2%) (p = 0.002). Kidney stones were found in 33 PHPT patients (14%) and in only seven control subjects (4.8%) (p = 0.004). The presence of PHPT and high PTH levels independently supported the development of a simple renal cyst. Advanced age was determined as a risk factor for the development of simple renal cysts, and the presence of kidney stones was an independent predictor of simple renal cysts in PHPT patients. There was no relationship between the presence of simple renal cysts and the volume and weight of parathyroid adenoma.

CONCLUSION

A diagnosis of PHPT, high PTH levels, advanced age, and kidney stones are independent risk factors for simple renal cysts in PHPT patients. These patients should be evaluated regularly for complications of renal cysts and nephrolithiasis.

Parathyroidectomy for primary hyperparathyroidism: A retrospective analysis of localization, surgical characteristics, and treatment outcomes

OBJECTIVE

To evaluate parathyroidectomy for primary hyperparathyroidism (PHPT) regarding localization, surgical characteristics, and treatment outcomes.

METHODS

Seventy-eight patients who underwent parathyroidectomy for PHPT were retrospectively reviewed. The results were analyzed according to intraoperative localization technique (IOLT), intraoperative parathyroid hormone (IOPTH) monitoring, and intraoperative nerve monitoring (IONM). The localization accuracy of ultrasonography (US), computed tomography (CT), and single-photon emission computed tomography (SPECT)-CT with sestamibi Tc99m was evaluated.

RESULTS

Parathyroidectomy was successfully completed in all 78 patients, achieving 100% surgical cure. For 60 patients with IOPTH monitoring, 10-min IOPTH decreased >50% from baseline in 57 (95.0%), and they achieved surgical cure. In the remaining three (5.0%) patients with ≤50% decrease in 10-min IOPTH, 20-min IOPTH decreased >50% from baseline in two (3.3%) patients, achieving surgical cure without additional neck exploration. There were no differences in surgical cure and complications as a function of IOLT use or IOPTH monitoring. Operating time was significantly shorter with IOLT and IOPTH monitoring than without (IOLT: 70.9 min vs. 88.0 min, p = 0.013; IOPTH: 74.9 min vs. 91.9 min, p = 0.037). All 78 patients had adenoma including one patient with a double adenoma. Vocal cord paralysis was not observed in our series, regardless of IONM. US, CT, and SPECT-CT localized the pathological parathyroid gland accurately in 88.1%, 85.5%, and 86.8% of patients, respectively (p = 0.894).

CONCLUSION

The surgical outcomes of parathyroidectomy for PHPT were excellent regardless of IOLT and IOPTH monitoring. However, these techniques can maximize the performance of parathyroid surgery by reducing operating time and rescuing challenging cases.

The Eucalcemic Patient With Elevated Parathyroid Hormone Levels

Primary hyperparathyroidism (PHPT) is classically characterized by hypercalcemia with elevated or inappropriately normal parathyroid hormone (PTH) levels. Elevated PTH levels in the presence of normal calcium levels are not infrequently found during the evaluation of metabolic bone disorders or kidney stone disease. This can be caused by secondary hyperparathyroidism (SHPT) or normocalcemic primary hyperparathyroidism (NPHPT). NPHPT is due to autonomous parathyroid function whereas SHPT is caused by a physiologic stimulation to PTH secretion. Many medical conditions and medications can contribute to SHPT, and differentiation between SHPT and NPHPT may be difficult. Cases are presented to illustrate examples. In this paper, we review the distinction between SHPT and NPHPT as well as end organ effects of NPHPT and outcomes of surgery in NPHPT. We suggest that the diagnosis of NPHPT be made only after careful exclusion of causes of SHPT and consideration of medications that can increase PTH secretion. Further, we advise a conservative approach to surgery in NPHPT.

Degraded Bone Microarchitecture in Women with PHPT-Significant Predictor of Fracture Probability

Introduction

Patients with primary hyperparathyroidism (PHPT) experience bone mineral density (BMD) loss and trabecular bone score (TBS) alteration, which current guidelines recommend assessing. Considering TBS alongside BMD for a 10-year fracture risk assessment (FRAX) may improve PHPT management.

Design

Retrospective, cross-sectional study composed of 49 Caucasian females (62 ± 10.6 years, 27.7 ± 0.87 kg/m²) with PHPT and 132 matched control subjects (61.3 ± 10.5 years, 27.5 ± 0.49 kg/m²) evaluated in 3 years. We assessed lumbar spine (LS) and femoral neck (FN) BMD, T and Z scores (GE Healthcare Lunar Osteodensitometer) and TBS (iNsight 1.8), major osteoporotic fracture (MOF), and hip FRAX.

Results

Patients with PHPT had statistically lower mean values for lumbar spine bone mineral density (LS BMD) (0.95 ± 0.25 vs 1.01 ± 0.14 g/cm², P = .01), LS T-scores (-2 ± 0.2 vs -1.4 ± 0.1 SD, P = .009), LS Z scores (-0.9 ± 0.19 vs -0.1 ± 0.11 SD, P = .009), femoral neck bone mineral density (FN BMD) (0.79 ± 0.02 vs 0.83 ± 0.01 g/cm², P = .02), FN T-scores (-1.8 ± 0.13 vs -1.5 ± 0.07 SD, P = .017), FN Z scores (-0.51 ± 0.87 vs -0.1 ± 0.82 SD, P = .006), and TBS (0.95 ± 0.25 vs 1.01 ± 0.14 g/cm², P = .01) compared with control subjects. 22.4% of patients with PHPT had degraded microarchitecture (TBS < 1.2) vs. 7.6% in control group (χ² = 0.008). PHPT proved to be a covariate with unique contribution (P = .031) alongside LS BMD (P = .040) in a linear regression model [R ² = 0.532, F(4,16) = 4.543] for TBS < 1.2. TBS adjustment elevated MOF FRAX both for PHPT (4.35  ± 0.6% vs 5.25% ± 0.73%, P < .001) and control groups (4.5  ± 0.24% vs 4.7% ± 0.26%, P < .001) compared with BMD-bases FRAX, but also increased differently between the 2 study groups (1.1-folds for PHPT patients and 1.04 for control subjects, P = .034).

Conclusion

Compared with control, TBS-adjusted FRAX provides significantly higher MOF risk than BMD-based FRAX in PHPT women.

Rare duplication of the CDC73 gene and atypical hyperparathyroidism-jaw tumor syndrome: A case report and review of the literature

BACKGROUND

Hyperparathyroidism jaw-tumor syndrome (HPT-JT) is the rarest familial cause of primary hyperparathyroidism, with an incidence <1/1000000, caused by a pathogenic variant in the CDC73 (or HRPT2) gene that encodes parafibromin, a protein involved in many cellular mechanisms. Patients with HPT-JT have a 15-20% of risk of developing parathyroid carcinoma, whereas it accounts for only 1% of all cases of primary hyperparathyroidism. Patients also develop jaw tumors in 30% of cases, kidney abnormalities in 15% of cases, and uterine tumors in 50% of patients.

CASE REPORT

Here are report two atypical cases of HPT-JT with variable expressivity in the same family. In front of an isolated primary hyperparathyroidism at 28 years of age of incidental discovery following a weight gain, the propositus benefited a first-line panel by Next-Generation Sequencing of the genes involved in familial hyperparathyroidism: CaSR, CDC73, MEN1, and RET. Genetic testing revealed the presence of a pathogenic germline variation CDC73: c.687_688dup; p.Val230Glufs*28, found only in nine families in the literature and allowing the diagnosis of HPT-JT. Given a history of primary hyperparathyroidism at 52 years and adenomyosis, the patient's mother also underwent a genetic analysis that found her daughter's variation and established her inherited trait.

CONCLUSION

In view of the clinical and genotypic heterogeneity, we confirm the interest of using an extended gene panel for the diagnosis of familial primary hyperparathyroidism. CDC73 variations could be more frequent than described in the literature. The association of primary hyperparathyroidism with uterine involvement could be a new indication for analysis.

Residual risks of comorbidities after parathyroidectomy in a nationwide cohort of patients with primary hyperparathyroidism

PURPOSE

Primary hyperparathyroidism (PHPT) is a common endocrine disorder with increasing incidence, while epidemiologic data in Asian population has been lacking. Therefore, we aimed to identify the incidence, prognosis, and prognostic factors of PHPT patients who underwent parathyroidectomy in Korea.

METHODS

In this retrospective nationwide cohort, patients with PHPT were defined as those with diagnostic codes of PHPT and procedural codes for parathyroidectomy, excluding chronic renal failure or secondary hyperparathyroidism based on National Health Insurance Services database in Korea in 2002-2018. Main primary outcomes were all-cause mortality, cardiovascular, and cerebrovascular events.

RESULTS

A total of 5561 patients were diagnosed with PHPT and had parathyroidectomy. The mean age was 54.5 years, and 71.8% were women. The age-standardized incidence was 10.1/100,000 person-year in 2018, rising from 1.7/100,000 person-year in 2002. During a mean of 5.9 years, history of cardiovascular disease, mood disorder, and genitourinary stone had increased risks of mortality with hazard ratios (HRs) of 1.59 (95% confidence interval [CI] 1.10-2.29), 1.43 (CI 1.14-1.80), and 1.40 (CI 1.09-1.80), respectively. History of hypertension, cerebrovascular disease, diabetes mellitus, and mood disorder were risk factors for cardiovascular events with HRs of 1.42 (CI 1.22-1.66), 1.29 (CI 1.05-1.58), 1.22 (CI 1.07-1.40), and 1.14 (CI 1.00-1.29), respectively. Mood disorder was a significant risk factor for cerebrovascular events (HR 1.30, CI 1.11-1.52).

CONCLUSION

The incidence of PHPT patients who underwent parathyroidectomy has been rising in Korea as reported in other countries. Patients with complications, especially mood disorder, had increased cardiovascular and cerebrovascular events and mortality risks.

Large parathyroid adenomas: Potential mechanisms to reconcile adenoma size and disease phenotype

Parathyroid adenomas weighing more than 3.5 g are reported variously as "atypical", "large" or "giant" parathyroid adenomas. All such adenomas are rare variants accounting for no more than 1.5% of all parathyroid adenomas. Large parathyroid adenomas are often associated with more severe form of the disease, including osteitis fibrosa cystica (OFC) and share many biochemical, histological, and molecular features of both benign and malignant parathyroid neoplasms, and are considered a distinct clinical entity. However, the pathogenesis of oversized parathyroid adenomas and the often-associated skeletal phenotype remains unclear. We present 5 cases of primary hyperparathyroidism (PHPT) with OFC, an uncommon manifestation of contemporary PHPT, associated with larger parathyroid adenomas, seen in the Bone and Mineral Disorders Clinic of the Henry Ford Health in the last 30 years to illustrate the critical role of vitamin D nutrition in the pathogenesis of both the OFC and adenoma size. The estimated prevalence of OFC was very low 0.2%, 5 of the >3000 surgically confirmed cases of PHPT seen during this time. The mean ± SD values were: age: 36.8 ± 22.1 years (4 of the 5 <36years), serum calcium 11.6 ± 1.1 mg/dl, alkaline phosphatase 799 ± 487 IU/L, PTH 1440 ± 477 pg/ml, 25-hydroxyvitamin D 13.0 ± 8.9 ng/ml, 1,25-dihyroxyvitamin D 26.5 ± 13.7 pg/ml, urine calcium 562 ± 274 mg/day, and parathyroid adenoma weight 4.53 ± 2.2 g. Parathyroidectomy led to the resolution of both the biochemical indices and OFC in each patient without recurrence over >10 years of follow-up. Because OFC is a very rare in the West, but very common areas of endemic vitamin D deficiency, we also examined the relationship between vitamin D nutrition, as assessed by serum 25-hydroxyvitamin D level, and parathyroid adenoma weight as well as prevalence of OFC in two large secularly diverse cohorts of patients with PHPT (Detroit, USA and Chandigarh, India). Based on this relationship and the relative prevalence of OFC in these two large cohorts, we propose that vitamin D nutrition (and perhaps calcium nutrition) best explains both the adenoma size and prevalence of OFC.

Serum Calcium/Phosphorus Ratio in Biochemical Screening of Primary Hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism is a common endocrine disease and most cases are asymptomatic. Currently, in a hypercalcemic patient, the first laboratory investigation is serum primary hyperparathyroidism measurement. However, the primary hyperparathyroidism level cannot be measured in many primary healthcare centers in our country. In addition, serum calcium levels are normal in normocalcemic primary hyperparathyroidism patients, even if most centers have serum calcium levels measured. Therefore, a simple and inexpensive laboratory biochemical marker is required for the diagnosis of primary hyperparathyroidism. Recently, the calcium/phosphorus ratio has been proposed as a suitable tool for diagnosing primary hyperparathyroidism. This study aimed to investigate the diagnostic value of serum calcium/phosphorus ratio in primary hyperparathyroidism screening.

METHODS

A total of 462 patients followed in our clinic with a diagnosis of primary hyperparathyroidism were reviewed in this retrospective study. Out of these patients, 148 with normal levels of serum parathyroid hormone, calcium, and phosphorus were selected as the control group. Serum calcium, corrected calcium, phosphorus, albumin, parathyroid hormone, 25-hydroxyvitamin D, and creatinine were evaluated. The diagnostic accuracy of the calcium/phosphorus ratio was investigated using receiver operating characteristic curve analysis.

RESULTS

There were 404 (87.4%) females and 58 (12.6%) males in the primary hyperparathyroidism group. Calcium, parathyroid hormone, and calcium/phosphorus ratio were significantly higher in primary hyperparathyroidism than in controls (p<0.001 for each). Receiver operating characteristic curve analyses identified a cutoff value of 2.59 (3.35 if calcium and phosphorus are measured in mg/dL) for the calcium/phosphorus ratio, with a sensitivity of 90.5% and specificity of 93.2% (p<0.001).

CONCLUSION

The calcium/phosphorus ratio is a simple and inexpensive method for primary hyperparathyroidism screening when a cutoff value of 2.59 is used.

Epidemiology, Pathophysiology, and Genetics of Primary Hyperparathyroidism

In this narrative review, we present data gathered over four decades (1980-2020) on the epidemiology, pathophysiology and genetics of primary hyperparathyroidism (PHPT). PHPT is typically a disease of postmenopausal women, but its prevalence and incidence vary globally and depend on a number of factors, the most important being the availability to measure serum calcium and parathyroid hormone levels for screening. In the Western world, the change in presentation to asymptomatic PHPT is likely to occur, over time also, in Eastern regions. The selection of the population to be screened will, of course, affect the epidemiological data (ie, general practice as opposed to tertiary center). Parathyroid hormone has a pivotal role in regulating calcium homeostasis; small changes in extracellular Ca++ concentrations are detected by parathyroid cells, which express calcium-sensing receptors (CaSRs). Clonally dysregulated overgrowth of one or more parathyroid glands together with reduced expression of CaSRs is the most important pathophysiologic basis of PHPT. The spectrum of skeletal disease reflects different degrees of dysregulated bone remodeling. Intestinal calcium hyperabsorption together with increased bone resorption lead to increased filtered load of calcium that, in addition to other metabolic factors, predispose to the appearance of calcium-containing kidney stones. A genetic basis of PHPT can be identified in about 10% of all cases. These may occur as a part of multiple endocrine neoplasia syndromes (MEN1-MEN4), or the hyperparathyroidism jaw-tumor syndrome, or it may be caused by nonsyndromic isolated endocrinopathy, such as familial isolated PHPT and neonatal severe hyperparathyroidism. DNA testing may have value in: confirming the clinical diagnosis in a proband; eg, by distinguishing PHPT from familial hypocalciuric hypercalcemia (FHH). Mutation-specific carrier testing can be performed on a proband's relatives and identify where the proband is a mutation carrier, ruling out phenocopies that may confound the diagnosis; and potentially prevention via prenatal/preimplantation diagnosis. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop

The last international guidelines on the evaluation and management of primary hyperparathyroidism (PHPT) were published in 2014. Research since that time has led to new insights into epidemiology, pathophysiology, diagnosis, measurements, genetics, outcomes, presentations, new imaging modalities, target and other organ systems, pregnancy, evaluation, and management. Advances in all these areas are demonstrated by the reference list in which the majority of listings were published after the last set of guidelines. It was thus, timely to convene an international group of over 50 experts to review these advances in our knowledge. Four Task Forces considered: 1. Epidemiology, Pathophysiology, and Genetics; 2. Classical and Nonclassical Features; 3. Surgical Aspects; and 4. Management. For Task Force 4 on the Management of PHPT, Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology addressed surgical management of asymptomatic PHPT and non-surgical medical management of PHPT. The findings of this systematic review that applied GRADE methods to randomized trials are published as part of this series. Task Force 4 also reviewed a much larger body of new knowledge from observations studies that did not specifically fit the criteria of GRADE methodology. The full reports of these 4 Task Forces immediately follow this summary statement. Distilling the essence of all deliberations of all Task Force reports and Methodological reviews, we offer, in this summary statement, evidence-based recommendations and guidelines for the evaluation and management of PHPT. Different from the conclusions of the last workshop, these deliberations have led to revisions of renal guidelines and more evidence for the other recommendations. The accompanying papers present an in-depth discussion of topics summarized in this report. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Performance of quantitative measurements in [18F]fluorocholine positron emission tomography/computed tomography for parathyroid imaging (P2TH study)

Objective

[¹⁸F]Fluorocholine positron emission tomography/computed tomography (PET/CT) is used frequently in addition to [^99mTc]Tc-Sestamibi scintigraphy and ultrasonography for the location of hyperfunctioning parathyroid glands. The aim of this study is to evaluate the performance of quantitative criteria in [¹⁸F]fluorocholine PET/CT for localization of hyperfunctioning parathyroid glands. The secondary objective is to highlight a correlation between the detection rate of [¹⁸F]fluorocholine PET/CT and serum parathyroid hormone (PTH) level.

Materials and methods

In two academic centers, we retrospectively included patients with biological hyperparathyroidism (HPT) and who had [¹⁸F]fluorocholine PET/CT. After a visual analysis, to measure the overall performance of [¹⁸F]fluorocholine PET/CT, a blind reading was carried out with standardized measurements of maximum standardized uptake value (SUV_max), liver ratio, thyroid ratio, and size ratio. We analyzed the quantitative criteria of [¹⁸F]fluorocholine PET/CT compared to the histological results, in particular to identify differences between adenomas and hyperplasias. We compared the performance of each quantitative criterion to the overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of [¹⁸F]fluorocholine PET/CT. The detection rate of hyperfunctioning parathyroid glands was calculated in subgroups of serum PTH level.

Results

The quantitative criteria in [¹⁸F]fluorocholine PET/CT were measured for 120 patients (135 lesions). The areas under the receiver operating characteristic (ROC) curve representing SUV_max and liver ratio were significantly increased. The optimal cut-off values represented by the maximum Youden index was >4.12 for SUV_max and >27.4 for liver ratio. Beyond certain threshold values of SUV_max (>4.12) or liver ratio (>38.1), all the lesions were histologically proven adenomas. SUV_max and liver ratio were significantly higher for adenomas than for hyperplasias and differential diagnosis (p = 0.0085 and p = 0.0002). The positivity of [¹⁸F]fluorocholine PET/CT was correlated with PTH level. Detection rates were 55.56, 75.56, and 87.5%, respectively, for serum PTH < 70, 70 to 120, and >120 ng/ml.

Conclusion

Semi-quantitative measurements (SUV_max and liver ratio) should be considered as additional tools in interpretation of [¹⁸F]fluorocholine PET/CT. These quantitative parameters have lower overall performance but higher specificity than overall visual analysis in identifying an adenoma. Above certain threshold values, all lesions are adenomas. [¹⁸F]fluorocholine PET/CT confirms excellent performance for the detection of hyperfunctional parathyroids. For serum PTH levels < 70 ng/ml, the detection rate of [¹⁸F]fluorocholine PET/CT is strongly decreased.

Immunohistochemical Profile of Parathyroid Tumours: A Comprehensive Review

Immunohistochemistry remains an indispensable tool in diagnostic surgical pathology. In parathyroid tumours, it has four main applications: to detect (1) loss of parafibromin; (2) other manifestations of an aberrant immunophenotype hinting towards carcinoma; (3) histogenesis of a neck mass and (4) pathogenetic events, including features of tumour microenvironment and immune landscape. Parafibromin stain is mandatory to identify the new entity of parafibromin-deficient parathyroid neoplasm, defined in the WHO classification (2022). Loss of parafibromin indicates a greater probability of malignant course and should trigger the search for inherited or somatic CDC73 mutations. Aberrant immunophenotype is characterised by a set of markers that are lost (parafibromin), down-regulated (e.g., APC protein, p27 protein, calcium-sensing receptor) or up-regulated (e.g., proliferation activity by Ki-67 exceeding 5%) in parathyroid carcinoma compared to benign parathyroid disease. Aberrant immunophenotype is not the final proof of malignancy but should prompt the search for the definitive criteria for carcinoma. Histogenetic studies can be necessary for differential diagnosis between thyroid vs. parathyroid origin of cervical or intrathyroidal mass; detection of parathyroid hormone (PTH), chromogranin A, TTF-1, calcitonin or CD56 can be helpful. Finally, immunohistochemistry is useful in pathogenetic studies due to its ability to highlight both the presence and the tissue location of certain proteins. The main markers and challenges (technological variations, heterogeneity) are discussed here in the light of the current WHO classification (2022) of parathyroid tumours.

Three pediatric patients with primary hyperparathyroidism caused by parathyroid adenoma

Primary hyperparathyroidism (PHPT) is a hypercalcemia disorder with inappropriately normal or increased serum parathyroid hormone (PTH) levels resulting from excessive secretion of PTH from one or more of the parathyroid glands. PHPT is uncommon in infants and children, with an estimated incidence of 2-5 cases per 100,000 persons. Patients with PHPT usually present with bone pain, urolithiasis, or nephrolithiasis, as well as nonspecific symptoms such as fatigue and weakness. Asymptomatic hypercalcemia may also be detected incidentally. Only a few cases of pediatric PHPT have been reported in Korea. We present three patients (a 9-year-old girl, a 14-year-old boy, and a 14-year-old girl) with PHPT who manifested variable clinical features of hypercalcemia. The first and second patients each had a parathyroid adenoma and presented with abdominal pain caused by pancreatitis and a ureter stone, respectively. The third patient had an ectopic mediastinal parathyroid adenoma and presented with gait disturbance and weakness of the lower extremities. All of the patients underwent surgical resection of parathyroid adenoma, and their serum calcium levels subsequently normalized without medication.

Parathyroidectomy in the elderly is beneficial and safe with similar improvements in postoperative bone mineral density

BACKGROUND

This study evaluated bone health outcomes of parathyroidectomy in elderly primary hyperparathyroidism (pHPT) patients.

METHODS

A retrospective review was performed of parathyroidectomy patients with pHPT at a single institution from 2010 to 2019. Bone mineral density (BMD) improvements at postoperative dual-energy X-ray absorptiometry (DEXA) scans were analyzed between groups aged ≥75 and < 75 years using 1:1 matching on preoperative BMD.

RESULTS

Patients ≥75 had BMD improvements through the second postoperative DEXA scans. While mean T-scores slightly improved in the ≥75 group during the study period, T-score improvement was more significant in the <75 group at first and third postoperative DEXA scans with +0.7 < 75 and +0.1 improvements ≥75 by the third DEXA (p = 0.026). Postoperative fragility fracture rates were similar in the ≥75 group, but significantly improved in patients <75 (10.4% preoperatively to 1.4% postoperatively, p = 0.020). Both cohorts had low complication rates with recurrent laryngeal nerve injury and permanent hypocalcemia of <1% (p = 0.316).

CONCLUSIONS

Postoperative BMD improvement was similar between the two cohorts with no difference in complication rates suggesting parathyroidectomy is safe and effective in the elderly.

The Effect of the Frequently Used Cinacalcet for pHPT during the COVID-19 Pandemic on Perioperative Decrease in Parathyroid Hormone

Background: Cinacalcet is a calcimimetic drug that has increasingly been used as a bridging therapy for primary hyperparathyroidism (pHPT), especially during the COVID-19 pandemic. The aim of our study was to investigate if preoperative cinacalcet therapy affects intraoperative parathyroid hormone (IOPTH) monitoring during parathyroidectomy, which is an important indicator for the success of surgery. Methods: In this single-center retrospective analysis, we studied the outcomes of 72 patients who underwent surgery for pHPT. We evaluated two groups: those with cinacalcet therapy before operation—the cinacalcet group (CG)—and those without medical therapy preoperatively (non-CG). In order to perform a between-group comparison of time trends, we fit a linear mixed-effects model with PTH as the response variable and predictors PTH levels preoperatively, group (cinacalcet yes/no), time, the group-by-time interaction, and a random intercept (per subject). Results: Our cohort included 51 (71%) women and 21 (29%) men, who were operated upon for pHPT in the period from January 2018 until August 2021. All patients were diagnosed with pHPT and 54% of the cohort were symptomatic for hypercalcemia. Moreover, 30% of the patients were treated with cinacalcet as a bridging therapy preoperatively, and this increased during the COVID-19 pandemic, as 64% of this group were treated in the last two years. Calcium values were significantly different before (p < 0.001) and after (p = 0.0089) surgery, but calcium level change did not differ significantly between the CG and non-CG. Parathyroid hormone (PTH) levels dropped significantly in both groups during 10 min IOPTH monitoring (p < 0.001), but there was no significant difference between the two groups (p = 0.212). Conclusions: In the examined patient cohort, the use of cinacalcet did not affect the value of IOPTH monitoring during surgery for pHPT.

Use of Parathyroid Function Index and Wisconsin Index to Differentiate Primary Hyperparathyroidism From Secondary Hyperparathyroidism: A Case-Control Study

Introduction: Patients with primary hyperparathyroidism (PHPT) can be asymptomatic or have a normal calcium level (NHPT). Patients with 25(OH) vitamin D insufficiency, on the other hand, may present with a similar presentation. In regions where 25(OH) vitamin D deficiency is common, patients are usually diagnosed with secondary hyperparathyroidism (SHPT). Therefore, it is necessary to separate PHPT and NHPT from SHPT. Parathormone and calcium values are used for differentiation in the clinic. The predictive value of the newly developed parathyroid function test (PFindex), which previously had a high diagnostic value, was evaluated in this patient population in our investigation.

Methods: The study comprised 163 PHPT and NHPT patients with pathological confirmation and 56 SHPT patients. The PHPT, NHPT, and SHPT properties were defined using PFindex. The diagnostic power of PFindex was investigated using a receiver operating characteristic (ROC) curve of the results assessed in three groups.

Results: The PHPT group had the highest PFindex (1365.4±784.6) compared to the other two groups (NHPT: 723.5±509.4; SHPT:227.2±49.9, all p < 0.001). A PFindex threshold of 327.8 yielded 91.9% and 90.9% sensitivity and specificity rates for distinguishing PHPT and NHPT from SHPT, respectively.

Conclusion: PFindex gave the outstanding diagnostic capacity to distinguish PHPT from SHPT due to our research. This straightforward tool can assist in making quick decisions about vitamin D therapy or surgery for PHPT.

Hungry bone syndrome following parathyroidectomy for primary hyperparathyroidism in a developed country in the Asia Pacific. A cohort study

Objectives

We sought to assess the incidence of hungry bone syndrome (HBS) following parathyroidectomy (PTX) for primary hyperparathyroidism (PHPT) in a cohort of multi-ethnic patients from a developed country in the Asia Pacific.

Methods

One hundred and sixty-four patients who underwent PTX for PHPT between 2012 and 2019 at the 2 largest public hospitals in Singapore were identified. HBS was defined as serum albumin-adjusted calcium ≤ 2.1 mmol/L with normal or raised serum intact parathyroid hormone (iPTH) levels, manifesting on or after the 3rd day, or persisting for more than 3 days post-operatively.

Results

Chinese constituted 73.8%, Malays 12.2%, Indians 9.8%, and other races 4.3%. HBS developed in 4 patients (2.4%) (95% CI, 0.8%–6.5%). HBS patients had significantly longer in-hospital stays; 20 days [IQR:15–22] vs 2 days [IQR:1–3]; P < 0.001in those who did not develop HBS. There was no difference in the incidence of HBS stratifying for age, sex, vitamin D status, or use of preoperative anti-resorptive medication use. For every 10 unit increase in iPTH and alkaline phosphatase (ALP) levels, the risk of HBS increased by 14% and 11%; RR (95% CI), 1.14 (1.05–1.21) and 1.11 (1.03–1.18), respectively.

Conclusions

The low incidence of HBS in multi-ethnic patients undergoing PTX by multiple surgeons for PHPT at the 2 largest public hospitals that see the most such patients in Singapore, a developed country, is consistent with the asymptomatic/milder form of presentation of PHPT in the developed world.

Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (PHPT) is the unregulated overproduction of parathyroid hormone (PTH) resulting in abnormal calcium homeostasis. The disease profile has evolved over the last century from symptomatic hyperparathyroidism to asymptomatic hyperparathyroidism. Primary hyperparathyroidism is a biochemical diagnosis. Parathyroidectomy is the only established cure for this disease. Every effort is made to localize the offending gland preoperaively with various imaging modalities. These localization studies along with intraoperative parathormone monitoring will direct the surgeon to either a focused parathyroidectomy or a four gland exploration. All symptomatic patients and asymptomatic patients who meet the criteria for surgery should undergo parathyroidectomy if no medical contraindications exist. Pharmacologic approaches are reserved for those patients unfit or unwilling to undergo surgery.

Hyperparathyroidism: Unusual location of brown tumors

Brown tumors (BTs) are due to a proliferation of multinucleated giant cells in osteolytic lesions. They complicate the course of hyperparathyroidism. Thanks to an early screening of bone metabolism disorders; BTs are nowadays rare bone manifestations. We demonstrate through these two cases reports unusual locations of BTs in hyperparathyroidism.

Changes in clinical patterns of Chinese patients with primary hyperparathyroidism in the past 12 years: a single-center experience

The clinical presentation of primary hyperparathyroidism (PHPT) differs between patients from developed and developing countries. In China, the clinical pattern has changed over the past few decades. Our aim was to elucidate general changes in the clinical characteristics of PHPT from 2010 to 2021. We enrolled 343 patients with PHPT at the Qilu Hospital of Shandong University, Jinan, China, from January 2010 to May 2021, including both surgical and non-surgical patients. Patients were divided into two subgroups, 2010-2016 (group A, n = 152) and 2017-2021 (group B, n = 191), based on the time span. We compared clinical manifestations and laboratory result data between these two groups. The mean patient age was 52.59 ± 13.55 years, and the male-to-female ratio was 1:2.54. Of the 343 patients, 183 (53.35%) had symptomatic PHPT; bone pain, urolithiasis, and fatigue were the most common symptoms. Post-operative pathology showed that 96.20% of the patients had parathyroid adenoma, whereas 2.41% had parathyroid carcinoma. Great changes occurred between 2010 and 2021; the percentage of patients with asymptomatic PHPT (aPHPT) increased from 36.18% in group A to 54.97% in group B. Moreover, patients in group B showed significantly lower serum calcium, alkaline phosphatase, parathyroid hormone, and urinary phosphate levels but higher serum 25-hydroxyvitamin D levels than those in group A. Clinical presentations in group B were also milder. In conclusion, the clinical characteristics of Chinese PHPT patients changed dramatically from 2010 to 2021, with asymptomatic PHPT (aPHPT becoming the predominant type over the last 3 years.

A Clinical Review of the Psychiatric Sequelae of Primary Hyperparathyroidism

Despite one-quarter of patients with primary hyperparathyroidism (PHPT) experiencing psychiatric symptoms, there remains a dearth of literature regarding the diagnosis and further management of psychiatric sequelae in PHPT. We aim to review the literature pertaining to the epidemiology, disease presentation, pathophysiology, diagnostics, and therapeutics regarding psychiatric sequelae of PHPT with an emphasis on clinical pearls for practicing psychiatrists. A literature search was conducted using the US National Library of Medicine’s PubMed resource using the following keywords in various combinations: primary hyperparathyroidism, neuropsychiatric, calcium, psychosis, mania, depression, catatonia, delirium, parathyroidectomy, and psychotropic medication. We discuss in depth all aspects of the diagnosis and management of psychiatric sequela in PHPT. We have also identified epidemiological trends, discussed the most common clinical presentations, and postulated possible mechanisms for psychiatric symptoms in PHPT. Psychiatrists should maintain diagnostic suspicion for PHPT in older adult female patients presenting with new-onset psychiatric illness. Several mechanisms involving the following may explain the variety of psychiatric symptoms in PHPT: tyrosine hydroxylase, parathyroid hormone, interleukin-6, monoamine oxidase, calcium, and the sodium-potassium adenosine triphosphatase transporter. We recommend psychiatrists take a symptom-oriented approach to management. Treating a patient’s psychosis, mania, depression, catatonia, delirium, or eating disorder pathology via conventional therapeutics seems like a rational approach despite the underlying medical etiology. Only parathyroidectomy has been proven to be definitive in the complete amelioration of psychiatric symptoms.