Persistent and recurrent hyperparathyroidism

Abstract

More than 95% of patients with primary hyperparathyroidism (HPT) will be cured at initial operation by an experienced surgeon. Despite this success rate, persistent and recurrent HPT remain challenging clinical entities. The most cost effective and safest treatment for persistent and recurrent HPT is avoidance by successful first operation. The contributors to treatment failure can be categorized into factors related to the initial surgical procedure, anatomic variability, and the biology of disease. An understanding of the factors that commonly contribute to treatment failure can help prevent persistent and recurrent disease and plays an integral role in planning subsequent surgical approaches. Once a biochemical diagnosis of persistent or recurrent HPT is confirmed, a thorough evaluation of previous operative, pathology, and radiology reports is essential. Localization procedures supplement this information and help direct the reoperative approach. When complementary noninvasive studies, such as ultrasound, sestamibi, and magnetic resonance imaging are negative, equivocal, or discordant, invasive tests (eg, selective venous sampling for parathyroid hormone levels) are warranted. Intraoperative ultrasound and gamma-probe localization are of questionable value, but intraoperative parathyroid hormone assays help facilitate these challenging repeat dissections. Repeat parathyroid exploration is associated with more complications and fewer cures compared to the initial explorations and should only be undertaken by an experienced surgeon in a center that can provide expert preoperative localization, adjunctive intraoperative tools, and cryopreservation of parathyroid tissue when necessary. Although controversy exists regarding indications for reoperative treatment for persistent or recurrent HPT, parathyroidectomy remains the only curative treatment option. Surgery should be considered first-line treatment in most circumstances.

Current Concepts in the Presentation, Diagnosis and Management of Primary Hyperparathyroidism

“…Persistent or recurrent disease may be caused by surgeon inexperience, incomplete exploration, or supernumerary glands. Preoperative parathyroid surgery in these cases presents a challenge, as dense scar tissue and distorted tissue planes obscure intraoperative localization [78][79][80].…”

“…In persistent or recurrent cases, cure rates decrease as the number of previous neck operations increases [78][79][80]. Thus, numerous protocols have been suggested to improve surgical outcomes in patients who require reoperation.…”

“…Thus, numerous protocols have been suggested to improve surgical outcomes in patients who require reoperation. While one proposal includes mandatory 99mTc sestamibi scanning and cervical ultrasound before the operation [78], other protocols recommend a series of CTs, MRIs, and selective venous sampling until localization is achieved [79]. Many groups have reported appropriate, safe, and effective outcomes if both accurate preoperative imaging and IoPTH are used [78].…”

“…Many groups have reported appropriate, safe, and effective outcomes if both accurate preoperative imaging and IoPTH are used [78]. Medial cervical incision is the standard approach, as it allow bilateral cervical exploration, although some surgeons prefer to use the lateral approach to avoid scar tissues and achieve better posterior access to the thyroid bed [78,79]. In addition, several surgeons recommend radioguided parathyroidectomy in the reoperative setting [67][68][69].…”

“…Patients should be encouraged to maintain a normal intake of calcium. Medical management includes: 1) bisphosphonates and hormone replacement therapy to decrease bone turnover and improve BMD, although they do not decrease serum calcium or PTH levels; 2) cinacalcet to reduce serum calcium and PTH levels and raises serum phosphorus levels, although it does not reduce bone turnover or improve BMD [79]. Cinacalcet reduces PTH secretion by binding the calcium-sensing receptor (CaR) of parathyroid cells [86].…”