Focal proliferation in reactive hyperplastic parathyreoid tissue in end stage renal failure-implication for autotransplantation after total parathyroidectomy

Total parathyroidectomy with simultaneous autotransplantation may be associ ated with recurrence of graft-dependent hyperfunction due to excessive prol iferation. We performed macroscopic tissue selection with a stereomicroscop e prior to autotransplantation, which resulted in very low recurrence rates . As this technique greatly depends on experience, we investigated the poss ibility of additionally using proliferation staining (PCNA, MIB-1) for the detection of dysfunctional tissue. Selected tissue from 26 patients was inv estigated. Serial sections of freshly removed parathyroid tissue were corre lated with their macroscopic appearance, HE and immunohistochemically stain ed paraffin sections, and with semithin Epon sections. The asymptotic growt h mode of clonal proliferating regions was reflected by highest staining in tensity (1-5%) in small to medium sized foci (diffuse, up to 3 mm in diamet er) and very low staining in large areas (diffuse or nodular, 5-15 mm in di ameter, from 0.03 to 0.003% positive cells). Thus, very large dysfunctional regions with (almost) no proliferation could not be detected by this method. However, they were very evident on macrosc opic investigation. In conclusion, multiple fulminant recurrence after parathyroidectomy can be prevented by selecting tissue after proliferation staining. This may allow a delayed autotransplantation after total parathyoidectomy for those surge ons lacking experience in macroscopic tissue classification.