A 38-year-old patient with MEN1 syndrome is found to have hypercalcemia (calcium 11.8 mg/dL), PTH 180 pg/mL, and 4-gland hyperplasia on sestaMIBI scan. What is the surgical strategy of choice for MEN1-associated primary hyperparathyroidism?

• A Total parathyroidectomy with autotransplantation to forearm ✓
• B Minimally invasive parathyroidectomy of the single adenoma
• C 3.5-gland parathyroidectomy with cryopreservation of resected tissue
• D Medical management with cinacalcet; surgery deferred

Explanation

MEN1-associated hyperparathyroidism is almost always multiglandular (4-gland hyperplasia) with a very high recurrence rate after subtotal parathyroidectomy. Total parathyroidectomy with autotransplantation of parathyroid tissue into the non-dominant forearm muscle is the preferred approach, allowing easy access for re-excision if hypercalcemia recurs (which is far more accessible than the neck). Cryopreservation of parathyroid tissue is performed but does not replace autotransplantation. Minimally invasive parathyroidectomy is contraindicated in MEN1 due to multiglandular disease.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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