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Kartini D, Dasawala F, Ham MF. Less than subtotal parathyroidectomy in multiple endocrine neoplasia type 1: A case report and review of the literature. Int J Surg Case Rep 2020; 77:337-340. [PMID: 33212306 PMCID: PMC7683229 DOI: 10.1016/j.ijscr.2020.10.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 10/31/2020] [Indexed: 11/16/2022] Open
Abstract
Traditionally, the surgical approach for primary hyperparathyroidism in MEN1 is either subtotal or total parathyroidectomy. Advances in medical imaging allows more accurate preoperative localization of abnormal parathyroid gland. Recent studies showed less than subtotal parathyroidectomy has comparable outcome compared to subtotal or total parathyroidectomy. Further studies are needed to determine whether there are subsets of MEN1 patients that can benefit from less than subtotal parathyroidectomy.
Introduction Multiple endocrine neoplasia type 1 (MEN1) is a rare syndrome with common presenting signs and symptoms secondary to primary hyperparathyroidism (PHPT), which is managed surgically. Traditionally, either subtotal parathyroidectomy (SPTX) or total parathyroidectomy with autologous transplantation (TPTX) is the approach of choice. However, recent studies showed comparable persistence and recurrence rate in a subset of MEN1 patients (two or more concordant preoperative imaging results) who underwent less than subtotal parathyroidectomy (LSPTX). Presentation of case We report a case of patient with PHPT and delayed diagnosis of MEN1, who underwent LSPTX without intraoperative parathyroid hormone (IOPTH) measurement. The approach was chosen based on the preoperative imaging studies. Unfortunately, the PHPT persisted and the patient was reoperated. To further elucidate the issue, a systematic search of the literature was conducted on Cochrane library, PubMed, and Scopus; articles relevant to the case were reviewed. Results are conflicting results with most of the studies showed LSPTX is inferior compared to the other two approaches. Discussion Therefore, given the current body of evidence, we consider that subtotal or total parathyroidectomy is still the preferred surgical approach for the treatment of PHPT in MEN1. Conclusion Further studies are still needed to see whether LSPTX is comparable to SPTX or TPTX in regards to persistent and recurrent hyperparathyroidism if the conditions are met.
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Affiliation(s)
- Diani Kartini
- Department of Surgery, Surgical Oncology Subdivision, Dr. Cipto Mangunkusumo General Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia.
| | - Filipus Dasawala
- Department of Surgery, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia.
| | - Maria Francisca Ham
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Indonesia, Jakarta, 10430, Indonesia.
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Nastos C, Papaconstantinou D, Kofopoulos-Lymperis E, Peppa M, Pikoulis A, Lykoudis P, Palazzo F, Patapis P, Pikoulis E. Optimal extent of initial parathyroid resection in patients with multiple endocrine neoplasia syndrome type 1: A meta-analysis. Surgery 2020; 169:302-310. [PMID: 33008613 DOI: 10.1016/j.surg.2020.08.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/03/2020] [Accepted: 08/07/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Hyperparathyroidism is an almost universal feature of multiple endocrine neoplasia type 1 syndrome. We present a systematic review and meta-analysis of the postoperative outcomes of patients undergoing initial operative treatment of primary hyperparathyroidism complicating multiple endocrine neoplasia 1. METHODS A comprehensive literature search was performed with a priori defined exclusion criteria for studies comparing total parathyroidectomy, subtotal parathyroidectomy, and less than subtotal parathyroidectomy. RESULTS Twenty-one studies incorporating 1,131 patients (272 undergoing total parathyroidectomy, 510 subtotal parathyroidectomy, and 349 less than subtotal parathyroidectomy) were identified. Pooled results revealed increased risk for long-term hypoparathyroidism in total parathyroidectomy patients (relative risk 1.61; 95% confidence interval, 1.12-2.31; P = .009) versus those undergoing subtotal parathyroidectomy. In the less than subtotal parathyroidectomy or subtotal parathyroidectomy comparison group, a greater risk for recurrence of hyperparathyroidism (relative risk 1.37; 95% confidence interval, 1.05-1.79; P = .02), persistence of hyperparathyroidism (relative risk 2.26; 95% confidence interval, 1.49-3.41; P = .0001), and reoperation for hyperparathyroidism (relative risk 2.48; 95% confidence interval, 1.65-3.73; P < .0001) was noted for less than subtotal parathyroidectomy patients, albeit with lesser risk for long-term for hypoparathyroidism (relative risk 0.47; 95% confidence interval, 0.29-0.75; P = .002). CONCLUSION Subtotal parathyroidectomy compares favorably to total parathyroidectomy, exhibiting similar recurrence and persistence rates with a decreased propensity for long-term postoperative hypoparathyroidism. The benefit of the decreased risk of hypoparathyroidism in less than subtotal parathyroidectomy is negated by the increase in the risk for recurrence, persistence, and reoperation. Future studies evaluating the performance of less than subtotal parathyroidectomy in specific multiple endocrine neoplasia 1 phenotypes should be pursued in an effort to delineate a patient-tailored, operative approach that optimizes long-term outcomes.
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Affiliation(s)
- Constantinos Nastos
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Dimitrios Papaconstantinou
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece.
| | - Efstratios Kofopoulos-Lymperis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Melpomeni Peppa
- Endocrine Unit, Second Department of Internal Medicine Propaedeutic, Research Institute and Diabetes Center, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas Pikoulis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Panagis Lykoudis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Fausto Palazzo
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Paul Patapis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
| | - Emmanouil Pikoulis
- Third Department of Surgery, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Chaidari, Greece
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Lorenz K, Schneider R, Elwerr M. [Intraoperative measurement of parathyroid hormone in hyperparathyroidism]. Chirurg 2020; 91:448-455. [PMID: 32052111 DOI: 10.1007/s00104-020-01123-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Intraoperative parathyroid hormone (IOPTH) determination is based on the short half-life of parathyroid hormone (PTH) and the rapid analytical technology. The IOPTH provides functional information regarding correction of the overproductive state in hyperparathyroidism (HPT) and is superior to macroscopic evaluation of the parathyroid gland (PG) as well as any (intraoperative frozen section) form of histology (so-called biochemical frozen section). In this article the relevance and evaluation of IOPTH is defined for the most important forms of HPT, for primary HPT, renal secondary and tertiary HPT, multiple endocrine neoplasia type 1 (MEN1) and parathyroid carcinoma and clinical scenarios based on the currently available data. It becomes apparent that the additional benefits of IOPTH depend on diverse prerequisites of the specific type of HPT, the diagnostics as well as individual patient factors and strategic considerations for resection. Overall, the costs for IOPTH are comparably low and seem to be justified with respect to the gain in quality. In the hands of specialized endocrine surgeons IOPTH is an essential tool for intraoperative decision-making and quality assurance.
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Affiliation(s)
- K Lorenz
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland.
| | - R Schneider
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland
| | - M Elwerr
- Klinik für Viszeral‑, Gefäß- und Endokrine Chirurgie, Universitätsklinikum Halle, Martin-Luther Universität Halle-Wittenberg, Ernst-Grube-Straße 40, 06120, Halle an der Saale, Deutschland
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Marini F, Giusti F, Tonelli F, Brandi ML. Multiple endocrine neoplasia type 1: a review of current diagnostic and treatment approaches. Expert Opin Orphan Drugs 2020. [DOI: 10.1080/21678707.2020.1811086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Francesca Marini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesca Giusti
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Francesco Tonelli
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Maria Luisa Brandi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
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Montenegro FLDM, Brescia MDG, Lourenço DM, Arap SS, d'Alessandro AF, de Britto e Silva Filho G, Toledo SPDA. Could the Less-Than Subtotal Parathyroidectomy Be an Option for Treating Young Patients With Multiple Endocrine Neoplasia Type 1-Related Hyperparathyroidism? Front Endocrinol (Lausanne) 2019; 10:123. [PMID: 30899245 PMCID: PMC6417394 DOI: 10.3389/fendo.2019.00123] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background: The surgical treatment of primary hyperparathyroidism (HPT) in patients with multiple endocrine neoplasia type 1 (MEN1) has evolved due the concern of permanent hypoparathyroidism. As the diagnosis has increased, the extent of operation has decreased. Most MEN1 patients requiring parathyroidectomy are younger than 50 years and they pose a difficult balance to achieve between persistent HPT and life-long hypoparathyroidism. The aim of the present study is to review our experience with a large series of patients with MEN1-related HPT (HPT/MEN1) treated at a single institution in order to find clues to a better treatment decision in these younger cases. Method: Retrospective analysis of consecutive HPT/MEN1 cases treated at a single institution with different operations: total parathyroidectomy and immediate forearm autograft (TPTX-AG), subtotal (STPTX), unintentional less than subtotal (U-LSTPTX) and intentional less than subtotal parathyroidectomy (I-LSTPTX). Results: Considering 84 initial cases operated on since 2011 (TPTX-AG, 39; STPTX, 22, U-LSTPTX, 13, and I-LSTPTX, 10), the rates of hypoparathyroidism were 30.8% (U-LSTPTX), 28.2% (TPTX-AG), 13.6% (STPTX), and 0% (I-LSTPTX). Two-thirds of them (68%; 57/84) were young (<50 years) or asdolescents. MIBI scan was more sensitive to show parathyroid glands and bilateral disease. Considering the concordance of MIBI and ultrasound for the possibility of unilateral clearance, it would be suitable to 22.6% of the cases. Intra-operative parathormone showed a significant decay even after unilateral exploration, but longer follow up is necessary. Overall, there were seven (4%) adolescents in 161 cases treated from 1987 to 2018, three underwent TPTX-AG and four had U-LSTPTX. Five are euparathyroid, one had mild recurrence, and one required a reoperation after 8 years due to the residual gland. Conclusions: Young patients are the most frequent candidates to parathyroidectomy. Less extensive procedures may be planned only if carefully reviewed preoperative imaging studies suggest a localized disease. Patients and their relatives should be fully informed of the risks and benefits during consent process. Future research with larger cohorts and long-term results are necessary to clarify if less than I-LSPTX or unilateral clearance are really adequate in selected groups of patients with HPT/MEN1 presenting lower volume of disease detected by preoperative imaging studies.
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Affiliation(s)
- Fabio Luiz de Menezes Montenegro
- Parathyroid Unit- LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Head and Neck Surgery, Department of Surgery, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- *Correspondence: Fabio Luiz de Menezes Montenegro
| | - Marilia D'Elboux Guimaraes Brescia
- Parathyroid Unit- LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Head and Neck Surgery, Department of Surgery, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Delmar Muniz Lourenço
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, Hospital das Clinicas, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Endocrine Oncology Division, Institute of Cancer of the State of Sao Paulo, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sergio Samir Arap
- Parathyroid Unit- LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Head and Neck Surgery, Department of Surgery, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Andre Fernandes d'Alessandro
- Parathyroid Unit- LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Head and Neck Surgery, Department of Surgery, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Gilberto de Britto e Silva Filho
- Parathyroid Unit- LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Head and Neck Surgery, Department of Surgery, Hospital das Clinicas HCFMUSP, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sergio Pereira de Almeida Toledo
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, Hospital das Clinicas, University of Sao Paulo School of Medicine, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
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Kamilaris CDC, Stratakis CA. Multiple Endocrine Neoplasia Type 1 (MEN1): An Update and the Significance of Early Genetic and Clinical Diagnosis. Front Endocrinol (Lausanne) 2019; 10:339. [PMID: 31263451 PMCID: PMC6584804 DOI: 10.3389/fendo.2019.00339] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 05/10/2019] [Indexed: 12/21/2022] Open
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is a rare hereditary tumor syndrome inherited in an autosomal dominant manner and characterized by a predisposition to a multitude of endocrine neoplasms primarily of parathyroid, enteropancreatic, and anterior pituitary origin, as well as nonendocrine neoplasms. Other endocrine tumors in MEN1 include foregut carcinoid tumors, adrenocortical tumors, and rarely pheochromocytoma. Nonendocrine manifestations include meningiomas and ependymomas, lipomas, angiofibromas, collagenomas, and leiomyomas. MEN1 is caused by inactivating mutations of the tumor suppressor gene MEN1 which encodes the protein menin. This syndrome can affect all age groups, with 17% of patients developing MEN1-associated tumors before 21 years of age. Despite advances in the diagnosis and treatment of MEN1-associated tumors, patients with MEN1 continue to have decreased life expectancy primarily due to malignant neuroendocrine tumors. The most recent clinical practice guidelines for MEN1, published in 2012, highlight the need for early genetic and clinical diagnosis of MEN1 and recommend an intensive surveillance approach for both patients with this syndrome and asymptomatic carriers starting at the age of 5 years with the goal of timely detection and management of MEN1-associated neoplasms and ultimately decreased disease-specific morbidity and mortality. Unfortunately, there is no clear genotype-phenotype correlation and individual mutation-dependent surveillance is not possible currently.
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Nobecourt PF, Zagzag J, Asare EA, Perrier ND. Intraoperative Decision-Making and Technical Aspects of Parathyroidectomy in Young Patients With MEN1 Related Hyperparathyroidism. Front Endocrinol (Lausanne) 2018; 9:618. [PMID: 30459713 PMCID: PMC6232704 DOI: 10.3389/fendo.2018.00618] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 09/27/2018] [Indexed: 01/13/2023] Open
Abstract
One in 5,000 to 1 in 50,000 births have multiple endocrine neoplasia type 1 (MEN1). MEN1 is a hereditary syndrome clinically defined by the presence of two of the following endocrine tumors in the same patient: parathyroid adenomas, entero-pancreatic endocrine tumors and pituitary tumors. Most commonly, patients with MEN1 manifest primarily with signs and symptoms linked to primary hyperparathyroidism. By age 50, it is estimated that 100% of patients with MEN1 will have been diagnosed with primary hyperparathyroidism. These patients will need to undergo resection of their hyperfunctioning glands, however there is no clear consensus on which procedure to perform and when to perform it in these patients. In this original study we describe and explain the rational of our peri-operative approach and management at MD Anderson Cancer Center of MEN1 patients with hyperparathyroidism. This protocol includes preoperative evaluation, intraoperative decision-making and detailed surgical technique adopted for these patients' care. Additionally we review follow-up and disease management in instances of recurrent primary hyperparathyroidism in patients with MEN1 syndrome.
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Affiliation(s)
- Priscilla F Nobecourt
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States
| | - Jonathan Zagzag
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Elliot A Asare
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nancy D Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Kluijfhout WP, Beninato T, Drake FT, Vriens MR, Gosnell J, Shen WT, Suh I, Liu C, Duh QY. Unilateral Clearance for Primary Hyperparathyroidism in Selected Patients with Multiple Endocrine Neoplasia Type 1. World J Surg 2017; 40:2964-2969. [PMID: 27402205 PMCID: PMC5104782 DOI: 10.1007/s00268-016-3624-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background Primary hyperparathyroidism is the most common manifestation of multiple endocrine neoplasia type 1 (MEN1). Guidelines advocate subtotal parathyroidectomy (STP) or total parathyroidectomy with autotransplantation due to high prevalence of multiglandular disease; however, both are associated with a significant risk of permanent hypoparathyroidism. More accurate imaging and use of intraoperative PTH levels may allow a less extensive initial parathyroidectomy (unilateral clearance, removing both parathyroids with cervical thymectomy) in selected MEN1 patients with primary hyperparathyroidism. Methods We performed a retrospective cohort study at a high-volume tertiary medical center including patients with MEN1 and primary hyperparathyroidism, who underwent STP or unilateral clearance as their initial surgery from 1995 to 2015. Unilateral clearance was offered to patients who had concordant sestamibi and ultrasound showing a single enlarged parathyroid gland. For both the groups, we compared rates of persistent/recurrent disease and permanent hypoparathyroidism. Results Eight patients had unilateral clearance and 16 had STP. Subtotal parathyroidectomy patients were younger (37 vs 52 years). One patient in each group had persistent disease. One (13 %) unilateral clearance and five (31 %) STP patients had recurrent hyperparathyroidism after a mean follow-up of 47 and 68 months (p = 0.62). No unilateral clearance patients and two of 16 SPT patients had permanent hypoparathyroidism (p = 0.54). Conclusions Some MEN1 patients with primary hyperparathyroidism who have concordant localizing studies may be selected for unilateral clearance as an alternative to STP. For appropriately selected MEN1 patients, unilateral clearance can achieve similar results as STP and has no risk of permanent hypoparathyroidism, and may facilitate possible future reoperations.
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Affiliation(s)
- Wouter P Kluijfhout
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA. .,Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Toni Beninato
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
| | - Frederick Thurston Drake
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
| | - Menno R Vriens
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jessica Gosnell
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
| | - Wen T Shen
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
| | - Insoo Suh
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
| | - Chienying Liu
- Division of Endocrinology, University of California, San Francisco, CA, USA
| | - Quan-Yang Duh
- Department of Surgery, University of California, Mt Zion, 1600 Divisadero Street, San Francisco, CA, 94115, USA
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Marini F, Giusti F, Tonelli F, Brandi ML. Management impact: effects on quality of life and prognosis in MEN1. Endocr Relat Cancer 2017; 24:T227-T242. [PMID: 28733468 DOI: 10.1530/erc-17-0203] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 07/21/2017] [Indexed: 12/25/2022]
Abstract
Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant endocrine tumor syndrome, caused by inactivating mutations of the MEN1 tumor suppressor gene at 11q13 locus, which predisposes to develop tumors in target neuroendocrine tissues. As the positional cloning and identification of the causative gene in 1997, genetic diagnosis, by the sequencing-based research of gene mutations, has become an important tool in the early and differential diagnosis of the disease. Application of the genetic test, in MEN1 index cases and in first-degree relatives of mutated patients, has been constantly increasing during the last two decades, also thanks to the establishment of multidisciplinary referral centers and specific genetic counseling, and thanks to the wide availability of high throughput instruments for gene sequencing and gene mutation identification. The MEN1 genetic test helps the specific diagnosis of probands, and allows the early identification of asymptomatic carriers, strongly contributing, together with progressions in tumor diagnostic techniques and in pharmacological and surgical therapeutic approaches, to the reduction of morbidity and mortality associated with the syndrome. International clinical guidelines for MEN1 have been drafted by panels of specialists in the field, with the main goal to improve the management of the disease and grant patients a better quality of life. Here, we review main recommendations and suggestions derived by the last published general guidelines in 2012, and by most recent published studies about MEN1 syndrome diagnosis, clinical management, therapeutic approaches and patients' quality of life.
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Affiliation(s)
- Francesca Marini
- Department of Surgery and Translational MedicineUniversity of Florence, Viale Pieraccini 6, Florence, Italy
| | - Francesca Giusti
- Department of Surgery and Translational MedicineUniversity of Florence, Largo Palagi 1, Florence, Italy
| | - Francesco Tonelli
- Department of Surgery and Translational MedicineUniversity of Florence, Largo Palagi 1, Florence, Italy
| | - Maria Luisa Brandi
- Department of Surgery and Translational MedicineUniversity of Florence, Largo Palagi 1, Florence, Italy
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10
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Brandi ML, Tonelli F. Genetic Syndromes Associated with Primary Hyperparathyroidism. Updates Surg 2016. [DOI: 10.1007/978-88-470-5758-6_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Nilubol N, Weinstein LS, Simonds WF, Jensen RT, Marx SJ, Kebebew E. Limited Parathyroidectomy in Multiple Endocrine Neoplasia Type 1-Associated Primary Hyperparathyroidism: A Setup for Failure. Ann Surg Oncol 2015; 23:416-23. [PMID: 26542588 DOI: 10.1245/s10434-015-4865-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Recently, some surgeons have suggested that minimally invasive parathyroidectomy guided by preoperative localizing studies of patients with multiple endocrine neoplasia type 1 (MEN1)-associated primary hyperparathyroidism (pHPT) provides an acceptable outcome while minimizing the risk of hypoparathyroidism. This study aimed to evaluate the outcome for MEN1 patients who underwent limited parathyroidectomy compared with subtotal parathyroidectomy. METHODS The authors performed a retrospective analysis of 99 patients with MEN1-associated pHPT who underwent at least one parathyroid operation at their institution. Preoperative imaging studies, intraoperative findings, and clinical outcomes for patients were compared. RESULTS A total of 99 patients underwent 146 operations. Persistent pHPT was significantly higher in patients whose initial operations involved removal of 1 or 2 glands (69 %) or 2.5 to 3 glands (20 %) compared with those who had 3.5 or more glands removed (6 %) (P < 0.01). Persistent pHPT occurred in 5 % of all operations that cumulatively removed 3.5 or more parathyroid glands compared with 40 % of operations that removed 3 or fewer glands (P < 0.01). The single largest parathyroid gland was correctly identified preoperatively in 69 % (22/32) of the patients. However, preoperative localizing studies missed enlarged contralateral parathyroid glands in 86 % (19/22) of these patients. Preoperative localizing studies missed the largest contralateral parathyroid gland in 16 % (5/32) of the patients. CONCLUSIONS Limited parathyroidectomy in MEN1 is associated with a high failure rate and should not be performed. Preoperative identification of a single enlarged parathyroid gland in MEN1 is not reliable enough to justify unilateral neck exploration because additional enlarged contralateral parathyroid glands are frequently missed.
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Affiliation(s)
- Naris Nilubol
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA.
| | - Lee S Weinstein
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - William F Simonds
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Robert T Jensen
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Stephen J Marx
- Metabolic Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Electron Kebebew
- Endocrine Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
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12
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Norton JA, Krampitz G, Jensen RT. Multiple Endocrine Neoplasia: Genetics and Clinical Management. Surg Oncol Clin N Am 2015; 24:795-832. [PMID: 26363542 DOI: 10.1016/j.soc.2015.06.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Early diagnosis of multiple endocrine neoplasia (MEN) syndromes is critical for optimal clinical outcomes; before the MEN syndromes can be diagnosed, they must be suspected. Genetic testing for germline alterations in both the MEN type 1 (MEN1) gene and RET proto-oncogene is crucial to identifying those at risk in affected kindreds and directing timely surveillance and surgical therapy to those at greatest risk of potentially life-threatening neoplasia. Pancreatic, thymic, and bronchial neuroendocrine tumors are the leading cause of death in patients with MEN1 and should be aggressively considered by at least biannual computed tomography imaging.
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Affiliation(s)
- Jeffrey A Norton
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.
| | - Geoffrey Krampitz
- Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Robert T Jensen
- Cell Biology Section, Digestive Diseases Branch, National Institute of Arthritis, Diabetes, Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD 20892-2560, USA
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Lairmore TC, Govednik CM, Quinn CE, Sigmond BR, Lee CY, Jupiter DC. A randomized, prospective trial of operative treatments for hyperparathyroidism in patients with multiple endocrine neoplasia type 1. Surgery 2014; 156:1326-34; discussion 1334-5. [PMID: 25262224 DOI: 10.1016/j.surg.2014.08.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 08/08/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hyperparathyroidism (HPT) in multiple endocrine neoplasia (MEN) type 1 is associated with multiglandular parathyroid disease. Previous retrospective studies comparing subtotal parathyroidectomy (SP) and total parathyroidectomy with autotransplantation (TP/AT) have not established clearly better outcomes with either procedure. METHODS Patients were assigned randomly to either SP or TP/AT and data were collected prospectively. The rates of persistent HPT, recurrent HPT, and postoperative hypoparathyroidism were compared. RESULTS The study cohort included 32 patients randomized to receive either SP or TP/AT (mean follow-up, 7.5 ± 5.7 years). The overall rate of recurrent HPT was 19% (6/32). Recurrent HPT occurred in 4 of 17 patients (24%) treated with SP and 2 of 15 patients (13%) treated with TP/AT (P = .66). Permanent hypoparathyroidism occurred in 3 of 32 patients (9%) overall. The rate of permanent hypoparathyroidism was 12% in the SP group (2/17) and 7% in the TP/AT group (1/15). A second operation was performed in 4 of 17 patients initially treated with SP (24%), compared with 1 of 15 patients undergoing TP/AT (7%; P = .34). CONCLUSION This randomized trial of SP and TP/AT in patients with MEN 1 failed to show any difference in outcomes when comparing results of SP versus TP/AT. Both procedures are associated with acceptable results, but SP may have advantages in that is involves only 1 surgical incision and avoids an obligate period of transient postoperative hypoparathyroidism.
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Affiliation(s)
- Terry C Lairmore
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX.
| | - Cara M Govednik
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX
| | - Courtney E Quinn
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX
| | - Benjamin R Sigmond
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX
| | - Cortney Y Lee
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX
| | - Daniel C Jupiter
- Baylor Scott and White Health Care and Texas A&M University System Health Science Center, College of Medicine, Temple, TX
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