Elsevier

Surgery

Volume 124, Issue 6, December 1998, Pages 993-999
Surgery

American Association of Endocrine Surgeons
Primary and reoperative parathyroid operations in hyperparathyroidism of multiple endocrine neoplasia type 1☆,☆☆

Presented at the 19th Annual Meeting of the American Association of Endocrine Surgeons, Orlando, Fla, Apr 26-28, 1998.
https://doi.org/10.1016/S0039-6060(98)70040-6Get rights and content

Abstract

Background: Operation and reoperation for hyperparathyroidism in multiple endocrine neoplasia type 1 (MEN 1) is controversial regarding surgical strategy, preoperative localization, and biochemical indexes of recurrence. Methods: Fifty patients with MEN 1 with hyperparathyroidism were followed up 2 to 27 years after subtotal (SPX; n = 35) or total parathyroidectomy with forearm autografiing (TPX; n = 15), including 24 who underwent 28 reoperations because of persistent or recurrent hyperparathyroidism. Results: Persistent or recurrent hyperparathyroidism was seen in 66% and 20% of patients after SPX involving extirpation of at least 3 glands and TPX, respectively, and 100% after single-gland excision as a primary procedure. After reoperation, hypercalcemia was reversed in 33% of patients by SPX and 61% by intended TPX procedures. All patients received vitamin D substitution after TPX, but restricted thyroid function allowed withdrawal in all but 10 patients (36%). Intact serum parathyroid hormone levels in nongrafted and grafted arms rose with time, but only exceptional ratios localized graft recurrence. Localization of recurrent hyperparathyroidism was achieved with 11C-labeled methionine positron emission tomography. Conclusion: MEN 1 hyperparathyroidism has a high risk of recurrence, and operation may include primarily SPX of at least 3 glands or TPX, although the latter includes a higher risk of long-term hypoparathyroidism. Reoperation should involve TPX with recognition of the enhanced recurrence rate in individuals with postoperative hyperparathyroidism. (Surgery 1998;124:993-9.)

Section snippets

Primary operations

Fifty patients (24 females and 26 males) of 19 families with MEN 1 underwent operation for primary hyperparathyroidism at a mean age of 44 ± 2 years (range 18 to 73 years; Table I).

. Clinical characteristics and duration of follow-up before and after subtotal resection with extirpation of fewer than 3 glands and 3 or more glands and TPX as a primary procedure

Empty CellSPX <3 glandsSPX ≥3 glandsTPXTotal
No.2691550
No. females/males15/113/66/924/26
Age at operation (y)45 ± 345 ± 641 ± 444 ± 2
Preoperative serum

Primary operation

Altogether, 11 patients (22%) had persistent hyperparathyroidism after the primary operation, and in 4 of them fewer than 4 glands were found at operation. Nine patients had undergone SPX with removal of fewer than 3 glands; the remaining 2 patients had been subjected to SPX with removal of 3 or more glands, with 4 identified parathyroid glands (Table II).

. Outcome of primary operation and duration of postoperative follow-up of SPX with extirpation of fewer than 3 glands and 3 or more glands and

Discussion

The recurrence rate after operation for MEN 1 hyperparathyroidism is high, especially after SPX.2, 3, 8 Extirpation of a single gland as a general primary procedure is inadequate, and even SPX with extirpation of fewer than 3 glands is associated with high rates of persistent or recurrent hyperparathyroidism. SPX with excision of at least 3 glands may be preferred if the patient harbors 1 or several normal-appearing glands together with the enlarged ones. It may be best to avoid transection to

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Supported by the Swedish Medical Research Council, Swedish Cancer Society, Swedish Medical Society, and Selander's Foundation.

☆☆

Reprint requests: Per Hellman, MD, PhD, Department of Surgery, University Hospital, S-751 85 Uppsala, Sweden.

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