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Tertiary Hyperparathyroidism Histologic Patterns of Disease and Results of Parathyroidectomy

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Tertiary Hyperparathyroidism Histologic Patterns of Disease and Results of Parathyroidectomy PAPER Tertiary Hyperparathyroidism Histologic Patterns of Disease and Results of Parathyroidectomy Electron Kebebew, MD; Quan-Yang Duh, MD; Orlo H. Clark, MD Hypothesis: Patients with tertiary hyperparathyroid- (range, 95-1236 ng/L). The THPT was due to 4-gland hy- ism (THPT) commonly have parathyroid hyperplasia and perplasia in 33 patients and a single adenoma in only 1 should have a bilateral neck exploration with subtotal or patient. The parathyroid glands were in the normal po- total parathyroidectomy with autotransplantation to ob- sition in 23 patients and in ectopic locations in 11 pa- tain long-term cure. tients (8 intrathymic, 1 carotid sheath, 1 tracheoesoph- ageal groove, and 1 intramuscular). Preoperative localizing Design: A retrospective cohort study. studies did not identify ectopic or supernumerary glands in any of the patients (ultrasonography, 14 patients; tech- Setting: Tertiary referral medical center. netium Tc 99m sestamibi, 15; and magnetic resonance imaging, 7). Persistent (n=5) and recurrent (n=2) THPT Patients: Thirty-four consecutive patients (21 women was more common in patients who had an initial 1- or and 13 men; mean age, 48 years) who underwent neck 2-gland excision instead of subtotal or total parathy- exploration for THPT. roidectomy with autotransplantation (PϽ.001). Four pa- tients had transient hypocalcemia (Ͻ8.0 mg/dL [Ͻ2.0 Main Outcome Measures: Sites and histologic pat- mmol/L]), and no other permanent complications or tern of parathyroid disease, and postoperative normaliza- deaths occurred. Biochemical cure was achieved in 94% tion of serum calcium and parathyroid hormone levels. of patients with a mean follow-up of 4.8 years. Results: Twenty-seven patients underwent initial bilat- Conclusions: Tertiary hyperparathyroidism is usually eral neck exploration and 7 patients underwent repeat due to multiple hyperplastic parathyroid glands, and pa- neck exploration for persistent or recurrent THPT. The tients who have initial limited parathyroidectomy have mean serum total calcium level was 11.2 mg/dL (2.8 a higher risk of persistent or recurrent THPT. mmol/L) (range, 10.3-13.5 mg/dL [2.6-3.4 mmol/L]) and the mean intact parathyroid hormone level was 355 ng/L Arch Surg. 2004;139:974-977 ERTIARY HYPERPARATHY- volving 4 or more glands. Some investiga- roidism (THPT) is uncom- tors have reported that 2.6% to 32% of THPT mon and occurs in less than may be due to a single adenoma or double 8% of patients with second- adenomas.1,2,5,6,9-15 These variable findings ary hyperparathyroidism of single- or double-gland disease have im- after a successful kidney transplanta- portant implications for the surgical ap- T1-3 tion. In patients with secondary hyper- proach used to treat patients with THPT. parathyroidism due to chronic renal fail- There is a consensus that patients with sec- ure, THPT results from autonomous ondary or tertiary hyperparathyroidism proliferation of the parathyroid glands and should have a bilateral neck exploration with hypersecretion of parathyroid hormone subtotal or total parathyroidectomy and au- (PTH) after a successful kidney transplan- totransplantation. Many surgeons are now tation.4,5 The THPT results in significant using a focused surgical approach (eg, mini- metabolic complications and symptoms, mally invasive parathyroidectomy, video- especially in patients who have had kid- scopic parathyroidectomy, unilateral neck ney transplants and are taking immuno- exploration) in patients with sporadic pri- suppressive therapy, which can be treated mary hyperparathyroidism, who usually 6-8 From the Department of only by successful parathyroidectomy. (85%) have single adenomas, based on pre- Surgery, University of Tertiary hyperparathyroidism is com- operative localizing studies and intraopera- California, San Francisco. monly due to parathyroid hyperplasia in- tive PTH (IOPTH) measurement.16 Some (REPRINTED) ARCH SURG/ VOL 139, SEP 2004 WWW.ARCHSURG.COM 974 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 may, therefore, consider that up to one third of patients with THPT may also be candidates for a focused parathy- Clinical, Biochemical, and Pathological Characteristics roidectomy approach.9,14,15,17 of Patients With THPT The main objectives of this retrospective study were to determine the frequency of “true” single or double ad- Characteristic Finding enomas as a cause of THPT and to determine the accuracy Sex, No. F/M 21/13 of localizing studies in patients with THPT. Furthermore, Age, y Mean 47.8 ± 14.1 long-term follow-up results of parathyroidectomy in pa- Range 13-71 tients with THPT were used to determine risk factors as- Calcium level, mg/dL sociated with recurrent or persistent THPT. Mean 11.2 ± 1.2 Range 10.3-13.5 METHODS PTH level (intact), ng/L Mean 355 ± 590 Between September 1, 1982, and April 30, 2002, 34 patients Range 95-1236 underwent parathyroidectomy for THPT at the University of Creatinine, mg/dL 1.6 ± 0.6 California, San Francisco, hospitals. Tertiary hyperparathy- Alkaline phosphatase, U/L 208.7 ± 233.8 roidism was defined as the presence of hypercalcemia and el- Phosphorus, mg/dL 2.6 ± 0.5 evated PTH level in a patient with successful kidney trans- THPT plant who previously had secondary hyperparathyroidism due Initial 27 to chronic renal failure. Persistent 5 Pathology reports, operative notes, clinical medical records, Recurrent 2 laboratory data, and clinic follow-up notes were reviewed. In pa- Histopathologic finding tients undergoing initial parathyroidectomy, a bilateral neck ex- Hyperplasia 33 ploration was used with a subtotal parathyroidectomy leaving a Single adenoma 1 40- to 80-mg remnant and cryopreservation of the most normal Parathyroid gland size, cm parathyroid gland. In patients with persistent or recurrent THPT, Mean 1.66 ± 0.63 Median (range) 1.6 (0.5-3.6) a unilateral or focused approach based on preoperative localiz- Parathyroid gland location (per patient), No. ing studies was used. As part of routine care, before and after par- Normal anatomic distribution 23 athyroidectomy, serum calcium and PTH levels were collected Ectopic 11* prospectively. Intraoperative PTH measurement was used in some Sensitivity of localizing studies, No. (%) patients with THPT. Baseline IOPTH levels were checked twice Initial THPT before resection of any enlarged glands (once before dissection Ultrasonography (n = 9) 6 (67) and once right before parathyroid gland excision), and postop- Sestamibi scan (n = 9) 5 (9) erative PTH levels were measured, 10 minutes or longer after re- MR imaging (n = 1) 1 (100) section of an enlarged parathyroid gland. A decrease of more than Persistent/recurrent THPT 50% in the PTH level was used to define a successful neck ex- Ultrasonography (n = 5) 5 (100) ploration and parathyroidectomy.16 Tertiary hyperparathyroid- Technetium Tc99m sestamibi scan (n = 6) 6 (100) ism due to parathyroid hyperplasia was defined as hypercellular MR imaging (n = 6) 6 (100) parathyroid tissue present on permanent histologic examination Concurrent procedures during parathyroidectomy, No. 2† of all resected glands, operative findings of enlarged glands, and Complications (transient hypocalcemia), No. 4 normalization of postoperative calcium and PTH levels after sub- total parathyroidectomy. Tertiary hyperparathyroidism due to par- Abbreviations: MR, magnetic resonance; PTH, parathyroid hormone; athyroid adenoma was defined as hypercellular parathyroid tis- THPT, tertiary hyperparathyroidism. SI conversion factors: To convert calcium to millimoles per liter, multiply sue present on permanent histologic examination of a resected by 0.25; creatinine to micromoles per liter, multiply by 88.4; and phosphorus gland, operative findings of 1 enlarged gland in conjunction with to millimoles per liter, multiply by 0.323. at least 1 normal-appearing gland, and normalization of postop- *Eleven patients had 1 parathyroid gland each located in the thymus erative calcium and PTH levels after gland excision. (n = 8), tracheoesophageal groove (n = 1), carotid sheath (n = 1), and strap The accuracy of preoperative localizing studies was de- muscle (n = 1). termined by comparing the results of the imaging studies with †Total thyroidectomy for papillary thyroid cancer and near-total thyroidectomy for Graves disease. the operative finding, pathology report, and normalization of the postoperative serum calcium and PTH levels. Persistent THPT was defined as elevated calcium and PTH levels within rized in the Table. The mean age was 47.8±14.1 years. 6 months after parathyroidectomy. Recurrent THPT was de- The mean duration of THPT after successful kidney trans- fined as elevated calcium and PTH levels more than 6 months plantation was 3.6 years, ranging from 4 months to 15 after initial parathyroidectomy. A true-positive result of the lo- years. The mean total calcium level was 11.2±1.2 mg/dL calizing studies was based on the imaging study correctly iden- tifying all abnormal parathyroid glands. The ␹2 test and un- (2.8±0.3 mmol/L), and the mean intact PTH level was paired, 2-tailed t test were used for comparison of categorical 355±590 ng/L. data and continuous data, respectively. A difference was de- Twenty-seven patients underwent initial bilateral fined as statistically significant if the P value was less than .05. neck exploration, and 7 patients underwent repeat neck Unless stated, numerical values in the text and table represent exploration for persistent (n=5; 3 patients after 1-gland mean±SD.
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