ETIOLOGY OF
PERSISTENT/RECURRENT PRIMARY HYPERPARATHYROIDISM
Persistent
primary hyperparathyroidism (PHPT) is defined as hyperparathyroidism appearing
within the first 6 months following parathyroidectomy. In contrast, recurrent
PHPT develops after 6 months following initial surgery. Persistent-recurrent (P-R)
PHPT is usually due to:
1.Inability
to accurately locate parathyroid adenoma during initial surgery
2.Presence
of double adenomas (a relatively rare occurrence, 3 – 5 % of patients with
PHPT), not recognized on preoperative localization studies or intraoperatively
(especially when parathyroidectomy is performed using the minimally invasive
approach)
3.Termination
of surgery despite that intraoperative parathormone levels measurement
indicates inadequate removal of the hyperfunctioning parathyroid parenchyma
4.Inadequate
resection of parathyroid parenchyma in multigland hyperplasia
5.Failure
to recognize underlying pathology in the remaining gland(-s) in patients with
familial types of PHPT, despite that the grossly pathologic gland(-s) are
removed initially. In these cases, P-R PHPT is due to the evolution of the
disease in the remaining gland(-s) which was (were) falsely evaluated as ‘normal’
at the time of initial surgery.
6.Residual
disease following not radical resection of parathyroid carcinoma (very rare,
< 1 % of cases of PHPT).
7.Development
of parathyromatosis, a very rare cause of PHPT occurring when the capsule of
the adenoma is ruptured during initial surgery, resulting in spillage of parts
of pathological parathyroid tissue within the tissues of the neck. Multiple
foci of hyperfunctioning parathyroid parenchyma may then develop
(parathyromatosis)
8.Presence
of undetected ectopic or supernumerary pathological parathyroid gland(-s)
(rare)
HOWEVER, THE
MAIN CAUSE OF P-R PHPT IS SURGEON’S INEXPERIENCE IN LOCATING AND APPROPRIATELY
RESECTING A SOLITARY PARATHYROID ADENOMA (THE MOST COMMON ETIOLOGY OF PHPT [~
85 %]).
This emphasizes
the importance of the experience of surgeon in endocrine surgery, in order to
achieve permanent cure during the initial surgery, thereby avoiding the risk of
P-R PHPT which will require further diagnostic and surgical intervention(-s).
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