title: Surgical management of hyperparathyroidism in patients with multiple endocrine neoplasia type 2A.
abstract: BACKGROUND
  The surgical management of hyperparathyroidism in patients with multiple endocrine neoplasia type 2A (MEN 2A) is controversial. We report the long-term follow-up, mutational analysis, and surgical outcome in a large group of patients with MEN 2A and hyperparathyroidism.
  
  
  METHODS
  Clinical and genetic data for MEN 2A patients with biochemically and pathologically confirmed hyperparathyroidism and a minimum of 5 years of follow-up were analyzed retrospectively, and outcomes after surgical management were compared.
  
  
  RESULTS
  Thirty-five (29%) of 119 patients from 14 MEN 2A kindreds had biochemical and pathologic evidence of hyperparathyroidism, with a mean follow-up of 14.7 years. The phenotypic expression of hyperparathyroidism was associated with germline mutations of the RET protooncogene at codons 634 and 618. At initial operation, 21 (62%) patients had a selective resection, eight (24%) had a subtotal resection, five (14%) had total parathyroidectomy with autotransplantation, and one had an inadvertent total parathyroidectomy. Twenty-seven (77%) patients were cured by the first operation. Persistent hyperparathyroidism occurred in three (8.6%) patients, and recurrent hyperparathyroidism occurred in five (14.3%) patients; both occurred only in patients treated with selective or subtotal resection. Permanent postoperative hypoparathyroidism occurred in six (21%) of 29 patients after selective or subtotal resection, in the one patient with inadvertent total parathyroidectomy, and in one (20%) of 5 patients treated with total parathyroidectomy and autotransplantation.
  
  
  CONCLUSIONS
  Recurrent or persistent hyperparathyroidism occurs after selective or subtotal parathyroidectomy, as a result of either missed glands or interval development of neoplasia in previously normal parathyroid glands left in situ. Therefore we advocate total parathyroidectomy and heterotopic autotransplantation for patients with hyperparathyroidism and MEN 2A.
authors.affiliation: Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA.
authors.forename: K K
authors.initials: KK
authors.lastname: Herfarth
authors.forename: D
authors.initials: D
authors.lastname: Bartsch
authors.forename: G M
authors.initials: GM
authors.lastname: Doherty
authors.forename: S A
authors.initials: SA
authors.lastname: Wells
authors.forename: T C
authors.initials: TC
authors.lastname: Lairmore
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D029721:Drosophila Proteins; D005260:Female; D005500:Follow-Up Studies; D015870:Gene Expression; D006801:Humans; D006961:Hyperparathyroidism / Q000209:etiology* / Q000235:genetics / Q000601:surgery*; D006965:Hyperplasia; D008297:Male; D008875:Middle Aged; D018813:Multiple Endocrine Neoplasia Type 2a / Q000150:complications*; D009154:Mutation; D010280:Parathyroid Glands / Q000473:pathology; D010641:Phenotype; D011518:Proto-Oncogene Proteins / Q000235:genetics; D051096:Proto-Oncogene Proteins c-ret; D020794:Receptor Protein-Tyrosine Kinases / Q000235:genetics; D012008:Recurrence; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D029721:Drosophila Proteins; D011518:Proto-Oncogene Proteins; D051096:Proto-Oncogene Proteins c-ret; D020794:Receptor Protein-Tyrosine Kinases; C416649:Ret protein, Drosophila