A 40-year-old man presents with recurrent renal calculi, peptic ulceration, and a pituitary prolactinoma. Genetic testing reveals a MEN1 mutation. His serum calcium is 11.5 mg/dL. What is the recommended surgical approach for his primary hyperparathyroidism?

• A Minimally invasive parathyroidectomy of the single enlarged gland identified on sestamibi
• B Medical management with cinacalcet alone
• C Subtotal parathyroidectomy (3.5 gland resection) or total parathyroidectomy with autotransplantation ✓
• D Total parathyroidectomy without autotransplantation

Explanation

In MEN1-associated primary hyperparathyroidism, multigland disease is the rule rather than the exception, with all four glands being hyperplastic in >90% of cases. Therefore, minimally invasive parathyroidectomy targeting a single gland (as for sporadic adenoma) is inappropriate and has high recurrence rates. The recommended approach is either subtotal parathyroidectomy (resecting 3.5 glands, leaving a well-vascularized remnant) or total parathyroidectomy with autotransplantation to the forearm to allow easy access for recurrent disease. Concurrent thymectomy is also performed to remove supernumerary parathyroid tissue.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.