Patients with tertiary hyperparathyroidism (THPT) commonly have parathyroid hyperplasia and should have a bilateral neck exploration with subtotal or total parathyroidectomy with autotransplantation to obtain long-term cure.
A retrospective cohort study.
Tertiary referral medical center.
Thirty-four consecutive patients (21 women and 13 men; mean age, 48 years) who underwent neck exploration for THPT.
Main Outcome Measures
Sites and histologic pattern of parathyroid disease, and postoperative normalization of serum calcium and parathyroid hormone levels.
Twenty-seven patients underwent initial bilateral neck exploration and 7 patients underwent repeat neck exploration for persistent or recurrent THPT. The mean serum total calcium level was 11.2 mg/dL (2.8 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 (range, 95-1236 ng/L). The THPT was due to 4-gland hyperplasia in 33 patients and a single adenoma in only 1 patient. The parathyroid glands were in the normal position in 23 patients and in ectopic locations in 11 patients (8 intrathymic, 1 carotid sheath, 1 tracheoesophageal groove, and 1 intramuscular). Preoperative localizing studies did not identify ectopic or supernumerary glands in any of the patients (ultrasonography, 14 patients; technetium Tc 99m sestamibi, 15; and magnetic resonance imaging, 7). Persistent (n = 5) and recurrent (n = 2) THPT was more common in patients who had an initial 1- or 2-gland excision instead of subtotal or total parathyroidectomy with autotransplantation (P<.001). Four patients had transient hypocalcemia (<8.0 mg/dL [<2.0 mmol/L]), and no other permanent complications or deaths occurred. Biochemical cure was achieved in 94% of patients with a mean follow-up of 4.8 years.
Tertiary hyperparathyroidism is usually due to multiple hyperplastic parathyroid glands, and patients who have initial limited parathyroidectomy have a higher risk of persistent or recurrent THPT.