Secondary and tertiary hyperparathyroidism: Causes of recurrent disease after 446 parathyroidectomies

Objective To determine, in a series of patients with secondary and tertiary parathyro id hyperplasia, whether the type of parathyroidectomy (subtotal, total with autotransplantation, or total), the histologic pattern of the parathyroid tissue, or the proliferative index, as determined by Ki-67 analysis, could predispose patients to recurrent hyperparathyroidism. Summary Background Data Recurrent hyperparathyroidism appears in 10-70% of the patients undergoing surgery for secondary or tertiary hyperparathyroidism. The incidence could be related to the type of operation (Rothmund) but also depends on the hist ologic pattern of the glands removed (Niederle). Methods The retrospective investigation was performed on 446 patients undergoing pa rathyroid surgery. They were also studied in relation to the possibility of renal transplantation. In this population, two homogeneous groups were sub sequently identified (23 patients with clear signs of recurrence and 27 pat ients apparently cured); they were studied from the histologic and immunohi stochemical point of view using antibody to Ki-67 antigen. Results Subtotal parathyroidectomy, total parathyroidectomy with autotransplantatio n, and total parathyroidectomy produced similar results when considering th e regression of osteodystrophy, pruritus, and ectopic calcification. As one could anticipate, total parathyroidectomy increased the incidence of hypop arathyroidism. The percentage of recurrence was 5% to 8% after subtotal par athyroidectomy, total parathyroidectomy with autotransplantation, and total parathyroidectomy, and only after incomplete parathyroidectomy did this pe rcentage climb to 34.7%. In the recurrence group, the nodular form was more common and the proliferative fraction detected by Ki-67 was 1.9%; it was 0 .81% in the control group, Conclusions Because more radical procedures were not more effective, the authors favor a less radical procedure such as subtotal parathyroidectomy. Histologic pat terns and proliferative fraction could be useful indices of a recurrence, a nd these patients should be watched closely after surgery.