A 62-year-old man with MEN1 syndrome has a serum calcium of 11.8 mg/dL, PTH of 180 pg/mL (normal 15–65), and imaging showing four-gland hyperplasia. What is the most appropriate surgical strategy?
- A 3.5-gland parathyroidectomy (subtotal parathyroidectomy) ✓
- B Removal of the largest gland only
- C Total parathyroidectomy without autotransplantation
- D Medical management with cinacalcet
Correct answer: A. 3.5-gland parathyroidectomy (subtotal parathyroidectomy)
Explanation
In MEN1-associated hyperparathyroidism with four-gland hyperplasia, the standard surgical approach is subtotal (3.5-gland) parathyroidectomy, leaving approximately 50 mg of the most normal-appearing gland, or total parathyroidectomy with autotransplantation into the forearm. Subtotal parathyroidectomy preserves some endogenous parathyroid function while treating hypercalcemia. Removal of only one gland leads to high recurrence rates. Total parathyroidectomy without reimplantation causes permanent hypoparathyroidism.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
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