Recurrence of secondary hyperparathyroidism in patients after total parathyroidectomy with autotransplantation: technical and therapeutic aspects

Abstract

Recurrence of secondary hyperparathyroidism (rSHPT) in patients after total parathyroidectomy (TPTX) with autotransplantation (AT) represents a major diagnostic and therapeutic challenge. The aim of this retrospective cohort study was to evaluate rSHPT in patients after TPTX with AT and the subsequent surgical treatment. 112 patients with secondary hyperparathyroidism (surgery 1998-2008) were evaluated. In 16 patients, rSHPT was detected, while all of them had been originally operated with TPTX, cervical thymectomy and AT. The recurrence rate of TPTX with AT in our patient cohort was 14.2% (16/112). All the 16 patients with rSHPT suffered from forearm-autotransplant(s) hyperparathyroidism (AT-HPT). AT-HPT was diagnosed after a median of 5.6 years (1.5-11 years). All "forearm" AT-HPT operations were performed using the method of intra-operative parathyroid-hormone measurement. The histopathologic result showed hyperplasia or an adenoma of the reimplanted parathyroid gland (PTG) particles. The parathyroid hormone measurement (PTH) showed normal values in all cases 2 weeks after surgery. In none of the patients persistent hypocalcemia was observed. Our data demonstrates that the high rate of rSHPT in patients after TPTX with AT with renal-insufficiency represents an unsolved problem, often leading to re-operation including possible morbidity. Although we are not showing direct data, we propose, that the alternative method of TPTX without AT, simultaneous cryopreservation and potential metachronous reimplantation could offer an excellent alternative. However, this therapy option needs to be validated in further clinical trials.

Intramuscular and subcutaneous forearm parathyroid autograft hyperplasia in renal dialysis patients: A retrospective cohort study

“…Previous studies reported the high incidence of intramuscular autograftectomy and repeated autograftectomy without comparison with subcutaneous autografts. [13][14][15] Chou et al 16 reported intramuscular autotransplantation had a greater incidence of autograftectomy than subcutaneous autotransplantation (9 of 75, 12% vs 1 of 110, 0.9%). The present study shows that intramuscular parathyroid autotransplantation led to a greater incidence of autograftectomy (15 of 65, 23% vs 14 of 823, 1.7%) and repeated autograftectomy (4 of 65, 6.4% vs 1 of 823, 0.1%) than subcutaneous parathyroid autotransplantation.…”

Total parathyroidectomy with trace amounts of parathyroid tissue autotransplantation as the treatment of choice for secondary hyperparathyroidism: a single-center experience

“…The extent of operative exploration for supernumerary glands may become less controversial with widespread utilization of the intraoperative PTH assay as an adjunct in guiding the completeness of resection. The utilization of intraoperative PTH monitoring may become a useful adjunct for assuring that the patient has undergone an adequate parathyroidectomy in sHPT [22-26]. Patients whose PTH level dropped under 400 ng/L by the removal of parathyroid gland, sHPT could be controlled by medical treatment after the operation.…”

Outcomes of Total Parathyroidectomy with Autotransplantation versus Subtotal Parathyroidectomy with Routine Addition of Thymectomy to both Groups: Single Center Experience of Secondary Hyperparathyroidism

“…This indicates that normalization should be expected within the first four weeks after the operation, although our data do not permit us to claim this with certainty. In the literature, the mean normalization time of PTH is reported as two weeks after the operation (19,20).…”