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Review
. 2012;67 Suppl 1(Suppl 1):131-9.
doi: 10.6061/clinics/2012(sup01)22.

Total parathyroidectomy in a large cohort of cases with hyperparathyroidism associated with multiple endocrine neoplasia type 1: experience from a single academic center

Fabio Luiz de Menezes Montenegro  1 , Delmar Muniz Lourenço Jr, Marcos Roberto Tavares, Sergio Samir Arap, Climerio Pereira Nascimento Jr, Ledo Mazzei Massoni Neto, André D'Alessandro, Rodrigo Almeida Toledo, Flávia Lima Coutinho, Lenine Garcia Brandão, Gilberto de Britto e Silva Filho, Anói Castro Cordeiro, Sergio Pereira Almeida Toledo
Affiliations
Review

Total parathyroidectomy in a large cohort of cases with hyperparathyroidism associated with multiple endocrine neoplasia type 1: experience from a single academic center

Fabio Luiz de Menezes Montenegro et al. Clinics (Sao Paulo). 2012.

Abstract

Most cases of sporadic primary hyperparathyroidism present disturbances in a single parathyroid gland and the surgery of choice is adenomectomy. Conversely, hyperparathyroidism associated with multiple endocrine neoplasia type 1 (hyperparathyroidism/multiple endocrine neoplasia type 1) is an asynchronic, asymmetrical multiglandular disease and it is surgically approached by either subtotal parathyroidectomy or total parathyroidectomy followed by parathyroid auto-implant to the forearm. In skilful hands, the efficacy of both approaches is similar and both should be complemented by prophylactic thymectomy. In a single academic center, 83 cases of hyperparathyroidism/ multiple endocrine neoplasia type 1 were operated on from 1987 to 2010 and our first surgical choice was total parathyroidectomy followed by parathyroid auto-implant to the non-dominant forearm and, since 1997, associated transcervical thymectomy to prevent thymic carcinoid. Overall, 40% of patients were given calcium replacement (mean intake 1.6 g/day) during the first months after surgery, and this fell to 28% in patients with longer follow-up. These findings indicate that several months may be needed in order to achieve a proper secretion by the parathyroid auto-implant. Hyperparathyroidism recurrence was observed in up to 15% of cases several years after the initial surgery. Thus, long-term follow-up is recommended for such cases. We conclude that, despite a tendency to subtotal parathyroidectomy worldwide, total parathyroidectomy followed by parathyroid auto-implant is a valid surgical option to treat hyperparathyroidism/multiple endocrine neoplasia type 1. Larger comparative systematic studies are needed to define the best surgical approach to hyperparathyroidism/multiple endocrine neoplasia type 1.

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Conflict of interest statement

No potential conflict of interest was reported.

Figures

Figure 1
Figure 1
Age distribution according to gender in 83 cases of hyperparathyroidism/multiple endocrine neoplasia type 1.
Figure 2
Figure 2
Emerging recognition and surgical treatment of patients with hyperparathyroidism/multiple endocrine neoplasia type 1 at our institution.
Figure 3
Figure 3
Distribution of patients with hyperparathyroidism/multiple endocrine neoplasia type 1 who had not had a previous neck operation (1987 to 2011).
Figure 4
Figure 4
Distribution of patients with hyperparathyroidism/multiple endocrine neoplasia type 1 who had had a previous neck operation.
Figure 5
Figure 5
A marked decrease of intra-operative parathyroid hormone (ioPTH) after excision of the largest parathyroid gland only, in a case of hyperparathyroidism/multiple endocrine neoplasia type 1. Persistence or early hyperparathyroidism recurrence may occur if surgery is guided solely by ioPTH.
Figure 6
Figure 6
Sestamibi scintigraphy after two previous neck interventions in a patient with hyperparathyroidism/multiple endocrine neoplasia type 1 who had been treated initially at another hospital. There was a focal radiopharmacological concentration close to the left submandibular gland due to an undescended left inferior parathyroid.
Figure 7
Figure 7
Numbers (%) of patients with hyperparathyroidism/multiple endocrine neoplasia type 1 requiring calcium supplements according to time elapsed since the initial treatment (1998 to 2010).
See this image and copyright information in PMC

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