Indications for surgery still exist in asymptomatic primary hyperparathyroidism

Primary hyperparathyroidism (HPT) has recently proven more common than was anticipated only a few decades ago and an increasing number of patients are now diagnosed with mild hypercalcemia and less distinct symptoms. Although liberal indications for parathyroid surgery are generally adopted treatment is currently offered to only approximately 1/10 of patients with HPT in the population. Patients with really mild hypercalcemia appear to sustain little risk to develop classical complications such as hypercalcemic crisis, deteriorated renal function or pronounced loss of bone mineral, and it has been suggested that follow up without surgery may be a treatment option for patients with apparently asymptomatic HPT. However, a majority of also the asymptomatic patients and even those with only moderate elevations of serum calcium, will upon close examination reveal symptoms of neuromuscular weakness, fatigue, depression and especially in the elderly patients confusion or dementia-like disorders. It has to be appreciated also that the parathyroid disease seems to imply increased risk of death in cardiovascular disease, which appears to be reversed by parathyroid surgery. Thus, surgery should still constitute the principal treatment also of asymptomatic HPT. However, medical surveillance without operation may be chosen for selected, mainly elderly patients with mild hypercalcemia, but then the presence of symtoms, which could be favourably affected by surgery has to be carefully excluded. Surveillance should also assure that patients do not develop disability during long-term follow up.