Symptomatic PHPT 환자들이 parathyroid surgery를 받아야 할지라도 무증상 환자들의 광범위한 확인이 이 집단에서 수술적 조치가 필요성과 시기에 대한 문제를 제기했습니다. 무증상 일차성 부갑상샘기능항진증 환자의 일부에서는 수술이 필수적이지 않습니다. 대부분의 무증상 환자들은 질환이 진행하지 않습니다 (진행한다는 것은 hypercalcemia, hypercalciuria, bone disease, nephrolithiasis가 악화되는 것입니다). 그러나 일부에서는 질환이 진행하고 수술적 완치로 이득이 있습니다. 일차 목표는 질환 진행 위험이 있는 무증상 환자와 부갑상샘 절제술로 개선될 수 있는 질환의 특징이 있는 환자를 확인하는 것입니다. 이 두 그룹은 수술적 치료로 이득이 있을 수 있습니다.
1. The Fourth International Workshop on Asymptomatic Primary Hyperparathyroidism guidelines을 충족하는 무증상 환자들에서 경과관찰 대신 수술적 치료를 제안합니다. 다음 조건들 중의 하나만 만족해도 됩니다.
Guidelines for surgery in asymptomatic PHPT: A comparison of current guidelines with the previous one*
|
Measurement¶ |
2008 |
2014 |
|
Serum calcium (>upper limit of normal) |
1.0 mg/dL (0.25 mmol/L) |
1.0 mg/dL (0.25 mmol/L) |
|
Skeletal |
BMD by DXA: T-score <–2.5 at any site ¶ Previous fragility fractureΔ |
BMD by DXA: T-score <–2.5 at lumbar spine, total hip, femoral neck, or distal 1/3 radius ¶ Vertebral fracture by radiograph, CT, MRI, or VFA |
|
Renal |
eGFR <60 mL/min 24-hour urine for calcium not recommended |
Creatinine clearance <60 mL/min 24-hour urine for calcium >400 mg/day (>10 mmol/day) and increased stone risk by biochemical stone risk analysis◊ Presence of nephrolithiasis or nephrocalcinosis by radiograph, ultrasound, or CT |
|
Age (years) |
<50 |
<50 |
|
 |
||
Patients need to meet only one of these criteria to be advised to have parathyroid surgery. They do not have to meet more than one.
PHPT: primary hyperparathyroidism; BMD: bone mineral density; DXA: dual-energy x-ray absorptiometry; CT: computed tomography; MRI: magnetic resonance imaging; VFA: vertebral fracture assessment; eGFR: estimated glomerular filtration rate; ISCD: International Society for Clinical Densitometry.
* Surgery is also indicated in patients for whom medical surveillance is neither desired nor possible and in patients opting for surgery, in the absence of meeting any guidelines, as long as there are no medical contraindications.
¶ Consistent with the position established by the ISCD, the use of Z-scores instead of T-scores is recommended in evaluating BMD in premenopausal women and men younger than 50 years.
Δ The history of a fragility fracture at any site would define someone as having a complication of PHPT, and thus, the individual would be automatically considered to be a surgical candidate.
◊ Most clinicians will first obtain a 24-hour urine for calcium excretion. If marked hypercalciuria is present (>400 mg/day [>10 mmol/day]), further evidence of calcium-containing stone risk should be sought by a urinary biochemical stone risk profile, available through most commercial laboratories. In the presence of abnormal findings indicating increased calcium-containing stone risk and marked hypercalciuria, a guideline for surgery is met.
2. Surgical intervention criteria를 충족하지 않는 무증상 PHPT 환자들도 부갑상샘절제술이 유일한 치료법이기 때문에 이것을 여전히 선택하기도 합니다.
REF. UpToDate 2020.06.28
