Less Than Subtotal Parathyroidectomy for Multiple Endocrine Neoplasia Type 1 Primary Hyperparathyroidism: A Systematic Review and Meta‐Analysis

Abstract

Background Multiple endocrine neoplasia type 1 (MEN1)‐associated primary hyperparathyroidism (pHPT) is classically associated with an asymmetric and asynchronous parathyroid involvement. Subtotal parathyroidectomy (STP), which is currently the recommended surgical treatment, carries a high risk of permanent hypoparathyroidism. The results of less than subtotal parathyroidectomy (LSTP) are conflicting, and its place in this setting is still a matter of debate. The aim of this study was to identify the place of LSTP in the surgical management of patients with MEN‐associated pHPT. Methods A systematic literature review was conducted in accordance with PRISMA and MOOSE guidelines, for studies comparing STP and LSTP for MEN1‐associated pHPT. The results of the two techniques, regarding permanent hypoparathyroidism, persistent hyperparathyroidism and recurrent hyperparathyroidism were computed using pairwise random‐effect meta‐analysis. Results Twenty‐five studies comparing STP and LSTP qualified for inclusion in the quantitative synthesis. In total, 947 patients with MEN1‐associated pHPT were allocated to STP (n = 569) or LSTP (n = 378). LSTP reduces the risk of permanent hypoparathyroidism [odds ratio (OR) 0.29, confidence interval (CI) 95% 0.17–0.49)], but exposes to higher rates of persistent hyperparathyroidism [OR 4.60, 95% CI 2.66–7.97]. Rates of recurrent hyperparathyroidism were not significantly different between the two groups [OR 1.26, CI 95% 0.83–1.91]. Conclusions LSTP should not be abandoned and should be considered as a suitable surgical option for selected patients with MEN1‐associated pHPT. The increased risk of persistent hyperparathyroidism could improve with the emergence of more efficient preoperative localization imaging techniques and a more adequate patients selection.

Recurrence After Surgery for Primary Hyperparathyroidism in 517 Patients With Multiple Endocrine Neoplasia Type 1

“…In our study, the comparison between STP and TP was not relevant, and patients with TP were excluded because there were too few cases (n = 18). A recent meta-analysis comparing STP and LTSP showed a lower risk of persistence of pHPT after STP, but recurrent hyperparathyroidism was not significantly different between the two groups, contrary to our results 9 . The authors acknowledged that the small number of patients included in most studies included and the heterogeneity of the follow-up has probably underrated the recurrence rate for pHPT.…”

“…In the literature, pHPT recurrence was observed in 5% to 66% of MEN1 patients after STP 6–9,11–22 . The recurrence rate observed after STP in our cohort (45%) is relatively high, the main reason being that the median follow-up (119 months) is longer than in most other studies on this subject.…”

“…From the *Department of Digestive and Endocrine Surgery, Dijon University Hospital; †INSERM, University de Bourgogne-Franche-Comté, UMR1231, EPICAD the rate of recurrent pHPT was not found to be significantly different between LTSP and STP. 9 Until now, no association between genotype and recurrence after STP has been found. Only one study reported the association between genotype and recurrence after LTSP in MEN1-related pHPT with a small number of patients.…”

Persistent and Recurrent Primary Hyperparathyroidism: Etiological Factors and Preoperative Evaluation

“…In the last meta-analysis, the perHPT rate was 4.4% in patients who underwent subtotal parathyroidectomy, while it increased to 23% in patients who underwent more limited resection than subtotal resection. [ 42 ] Despite all the developments in imaging methods, at least 30% of multiple gland diseases cannot be detected preoperatively. [ 43 ] The sensitivity of imaging methods is low in both double adenoma and multiglandular hyperplasia patients and misleading results were reported often.…”

Invited Commentary: Less than Subtotal Parathyroidectomy for Multiple Endocrine Neoplasia Type 1 Primary Hyperparathyroidism: A Systematic Review and Meta‐Analysis

“…This systematic review of the 2 currently most practiced parathyroidectomy strategies by Dr Bouriez and colleagues highlights the advantages and disadvantages of a LSTP and subtotal parathyroidectomy in MEN1 patients [ 3 ]. The LSTP usually consists in a unilateral operation where the pre-operatively identified presumed dominant parathyroid and the ipsilateral second parathyroid and thymus are removed.…”