title: Tertiary hyperparathyroidism: histologic patterns of disease and results of parathyroidectomy.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  A retrospective cohort study.
  
  
  METHODS
  Tertiary referral medical center.
  
  
  METHODS
  Thirty-four consecutive patients (21 women and 13 men; mean age, 48 years) who underwent neck exploration for THPT.
  
  
  METHODS
  Sites and histologic pattern of parathyroid disease, and postoperative normalization of serum calcium and parathyroid hormone levels.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, University of California, San Francisco 94143-1674, USA. kebebewe@surgery.ucsf.edu
authors.forename: Electron
authors.initials: E
authors.lastname: Kebebew
authors.forename: Quan-Yang
authors.initials: QY
authors.lastname: Duh
authors.forename: Orlo H
authors.initials: OH
authors.lastname: Clark
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D002118:Calcium / Q000097:blood; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D006961:Hyperparathyroidism / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010281:Parathyroid Hormone / Q000097:blood; D016105:Parathyroidectomy; D011183:Postoperative Complications; D012189:Retrospective Studies; D016896:Treatment Outcome
chemical_list: D010281:Parathyroid Hormone; D002118:Calcium