A 28-year-old woman with MEN1 presents with primary hyperparathyroidism. She is found to have multiglandular hyperplasia on imaging. Which surgical approach provides the best balance of cure and preservation of parathyroid function?

• A Single adenoma resection based on sestamibi localization
• B 3.5-gland resection (subtotal parathyroidectomy) or total parathyroidectomy with forearm autotransplantation ✓
• C Total parathyroidectomy without autotransplantation
• D Medical management with cinacalcet is preferred over surgery in MEN1

Explanation

In MEN1-associated hyperparathyroidism with multiglandular disease, surgical options are subtotal parathyroidectomy (removal of 3.5 glands, leaving a well-vascularized 40–60 mg remnant) or total parathyroidectomy with forearm autotransplantation. Both provide similar cure rates (~90%) while preserving parathyroid function. Single adenoma resection alone leads to unacceptably high recurrence rates because of multiglandular involvement. Total parathyroidectomy without autotransplantation causes permanent hypoparathyroidism. Cinacalcet may temporize but is not curative.

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

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Written and medically reviewed by the StethoPrep medical team.