Isolated adrenal mass in patients with a history of cancer: remember pheochromocytoma.

BACKGROUND: In a patient with a history of cancer, an isolated adrenal mass is usually thought to be a metastasis. Although a biochemical work-up to rule out pheochromocytoma is recommended, some question its practicality. This study was undertaken to determine the incidence of functional adrenal lesions in patients with a history of cancer and examine predictive factors for the type of lesion. METHODS: At a single institution, 33 patients with an isolated adrenal mass and a history of cancer underwent surgical treatment. Patients' records were retrospectively analyzed for type of adrenal lesion and other diagnostic parameters. RESULTS: There were 20 males and 13 females with a mean age of 58+/-2 years. Of these, 20 (61%) had adrenal metastases, 8 (24%) had pheochromocytomas, and 5 (15%) had adrenal adenomas. Usual diagnostic criteria, including presenting symptoms, primary tumor, and other demographic characteristics, did not consistently predict the pathology of the lesion. CONCLUSIONS: Nearly 1 in 4 resected adrenal masses in patients with a history of cancer were pheochromocytomas. The high incidence of pheochromocytoma in this series supports a thorough work-up, irrespective of previous cancer. Therefore, remember one thing in patients with an isolated adrenal mass and a history of cancer: pheochromocytoma.

Initial lymph node dissection increases cure rates in patients with medullary thyroid cancer.

OBJECTIVE: Medullary thyroid carcinoma (MTC) is the third most common type of thyroid cancer. MTC spreads early to local lymph nodes, and most endocrine surgeons recommend total thyroidectomy with central lymph node dissection (CLND) as the minimum initial operation. We reviewed our experience to determine if the initial operation influences clinical outcomes. METHODS: Twenty-two patients with sporadic or inherited MTC who received surgery at one academic centre between 1994 and 2004 were identified. Clinical, operative, and pathology findings were reviewed. RESULTS: Ten patients had prophylactic thyroidectomy for hereditary MTC, while 12 patients underwent therapeutic operations for sporadic MTC. The average age of the prophylactic group was 11 +/- 3, and 43 +/- 6 years for the therapeutic group. All patients in the prophylactic group received thyroidectomy without neck dissection. No patient in the prophylactic group had residual disease or required re-operation. In the therapeutic surgery group, three patients were treated with thyroidectomy plus CLND, and nine patients received thyroidectomy alone. The CLND group had a significantly higher cure rate as demonstrated by a lower incidence of residual disease (0% vs. 89%, p = 0.018), and re-operations (0% vs. 78%, p = 0.045). CONCLUSION: Initial CLND for MTC increases cure rates by reducing residual disease and re-operations.

Risks and consequences of incidental parathyroidectomy during thyroid resection.

BACKGROUND: Inadvertent removal of the parathyroid glands during elective thyroid surgery occurs more frequently in certain high-risk patients and can lead to symptomatic hypocalcaemia. METHODS: A case-control study was carried out at a tertiary referral, academic medical centre between May 1994 and August 2001. Five hundred and thirteen patients underwent thyroid resection. Pathology reports were reviewed to identify patients who had the inadvertent removal of a parathyroid gland during their thyroid surgery. Thirty-three (6.4%) patients had inadvertent resection of a parathyroid gland. The outcomes of these 33 patients (INCIDENTAL) were compared with the other 480 patients who did not have resection of parathyroid tissue (NO INCIDENTAL). RESULTS: Risk factors for inadvertent parathyroid resection included younger age (P = 0.003), bilateral thyroid resection (P = 0.001) and malignant pathology (P = 0.002). Factors that did not increase the risk of incidental parathyroidectomy included gland weight, sex, presence of a goitre, previous neck exploration and concurrent lymph node dissection. In the INCIDENTAL group 24% had a postoperative calcium levels less than 7.0 mg/dL (P = 0.001). Symptomatic hypocalcaemia developed in 12% of INCIDENTAL patients, compared to 4% in the NO INCIDENTAL group (P = 0.06). CONCLUSION: Incidental removal of parathyroid tissue occurred in 6.4% of thyroid resections. Younger patients undergoing a total or subtotal thyroidectomy for malignancy were at the highest risk. These patients had lower postoperative calcium levels, but the majority (88%) experienced no clinical consequences.

Equal oncologic results for laparoscopic and open resection of adrenal metastases.

BACKGROUND: While open adrenalectomy is often performed for malignant adrenal tumors, increasing numbers of surgeons have adopted the laparoscopic approach. The postoperative benefits of laparoscopic adrenalectomy are well established, but questions persist about long-term oncologic outcomes when used for malignant lesions. The current study was undertaken to compare laparoscopic with open adrenalectomy for isolated adrenal metastases. METHODS: From March 1993 to April 2006, 20 adults underwent adrenalectomy for isolated metastases to the adrenal gland. Three patients were excluded because of a concomitant nephrectomy (2) and an unresectable tumor (1). Patient demographics, tumor characteristics, and oncologic outcomes of the remaining patients were reviewed and analyzed. RESULTS: Of the 17 patients who received adrenalectomy for an isolated metastasis, there were 11 men and 6 women with a mean age of 58 +/- 3 y. Nine patients underwent laparoscopic adrenalectomy, and 8 patients had open adrenalectomy. Laparoscopic adrenalectomy was associated with less blood loss (63 +/- 8 mL versus 2207 +/- 1067 mL, P=0.05), a lower complication rate (0% versus 63%, P=0.009), and a shorter length of stay (2.4 +/- 0.6 d versus 5.4 +/- 0.7 d, P=0.02). With a follow-up of up to 97 mo, there were no port site metastases, no tumor recurrences, and no difference in survival between laparoscopic and open adrenalectomy (median 19 months versus 17 months, 5-year survival 34% versus 54%, P=0.96). CONCLUSIONS: When not limited by tumor size or invasion of surrounding tissue, laparoscopic adrenalectomy is a safe alternative to open adrenalectomy with equivalent oncologic outcomes and clear postoperative benefit for patients with isolated metastases to the adrenal gland.

Fine-needle aspiration optimizes surgical management in patients with thyroid cancer.

BACKGROUND: Fine-needle aspiration (FNA) is accurate in diagnosing papillary, medullary, and anaplastic thyroid cancer, as well as lymphoma. Although many surgeons routinely perform FNA before surgery, some question whether FNA influences operative management. Therefore, to determine whether FNA affects surgical management in patients with thyroid cancer, we reviewed our experience. METHODS: A total of 442 consecutive patients underwent thyroid surgery at 1 academic center. Of these, 411 had surgery for an index nodule in the absence of previous radiation or familial thyroid cancer. FNA, operative, and permanent histology findings were reviewed. RESULTS: The average patient age was 46 years, and 79% were female. A total of 211 patients (51%) had a preoperative FNA, and 71 (17%) had a final diagnosis of cancer. The sensitivity and specificity of FNA for thyroid cancer were 89% and 92%, respectively. In the FNA group, 1 (2.4%) of 41 patients with papillary thyroid cancer required completion thyroidectomy. In contrast, in the no-FNA group, 4 (40%) of 10 patients with papillary thyroid cancer required a second operation. No patient in the FNA group received thyroid resection for lymphoma, whereas three (100%) of three patients with lymphoma in the no-FNA group were treated surgically. A total of 98% of the FNA group, compared with 54% of the no-FNA group, received optimal surgical treatment for thyroid cancer. CONCLUSIONS: FNA is a sensitive and specific test for the diagnosis of thyroid cancer, allowing definitive initial surgery and avoiding unnecessary procedures. Therefore, we recommend routine use of preoperative thyroid FNA, even in those patients in whom a resection is already planned.

A prospective evaluation of novel methods to intraoperatively distinguish parathyroid tissue utilizing a parathyroid hormone assay.

BACKGROUND: Frozen section analysis has traditionally been used to confirm the identity of parathyroid tissue intraoperatively; however, it is time-consuming and costly and requires the excision of a significant portion of tissue. An intraoperative biopsy and analysis with a parathyroid hormone (PTH) assay is a possible alternative; however, this technique has not been perfected. METHODS: Two hundred twenty-three tissue specimens were collected prospectively from patients undergoing neck exploration. Each specimen was sampled intraoperatively using three different biopsy techniques: a fine-needle aspiration (FNA) with 10 passes of a needle (FNA10), a FNA with 20 passes of a needle (FNA20), and a tissue biopsy of approximately 1.0 mm3 (BIOPSY). The PTH concentration of each sample was determined via the Elecsys 1010 PTH immunoassay. The final tissue diagnosis was determined by histology or operative data. RESULTS: Parathyroid samples from all techniques had higher median PTH concentrations than nonparathyroid samples. However, the accuracies for the detection of parathyroid tissue varied markedly (PTH cutoff of 1000 pg/ml): the accuracies of the FNA10 and FNA20 were 71 and 80%, respectively, while the BIOPSY was 99% accurate. CONCLUSIONS: This is the first prospective study evaluating multiple methods to diagnose parathyroid tissue intraoperatively using a rapid PTH assay. We conclusively show that the BIOPSY technique is 99% accurate for the diagnosis of parathyroid tissue, and therefore, should be the method of choice when the intraoperative confirmation of parathyroid tissue is needed.

The role of intraoperative parathyroid hormone testing in patients with tertiary hyperparathyroidism after renal transplantation.

BACKGROUND: Intraoperative parathyroid hormone (PTH) testing has been shown to accurately define adequacy of parathyroid resection in patients with primary hyperparathyroidism (HPT) and alters the operative management in 10% to 15% of cases. However, the benefit of this technique in patients with tertiary HPT after renal transplantation undergoing parathyroidectomy is unclear. METHODS: Intraoperative PTH was measured in 32 consecutive patients undergoing parathyroidectomy for tertiary HPT after renal transplantation between March 2001 and November 2004 by using the Elecsys assay at baseline and, subsequently, 5, 10, and 15 minutes after curative resection. The outcomes of these patients were evaluated. RESULTS: All patients were cured after surgery. Of the 32 patients, 29 were found to have parathyroid hyperplasia, while 1 had a single adenoma and 2 had double adenomas. The average drop in intraoperative PTH levels after curative resection was 69 +/- 3.5% at 5 min., 77 +/- 2.3% at 10 minutes, and 83 +/- 3.4% at 15 minutes. PTH testing changed the intraoperative management in 5 (16%) patients. One patient with a single adenoma and 2 patients with double adenomas had a >50% drop at 10 minutes. after excision; therefore, the operation was terminated without further resection. Two patients did not have a >50% drop at 10 minutes after 3.5 gland resection. These patients were explored further, and additional supernumerary parathyroid glands were identified and resected. After resection of these additional glands, the PTH fell by >50%, indicating cure. CONCLUSIONS: In patients undergoing parathyroidectomy for tertiary HPT after renal transplantation, a decrease in intraoperative PTH levels >50% at 10 minutes after completion of the operation indicated adequate resection. Furthermore, intraoperative PTH testing altered the operative management in 16% of patients. Therefore, similar to its role in patients with primary HPT, intraoperative PTH testing appears to play an equally important role in the management of patients with tertiary HPT undergoing parathyroidectomy.

Intraoperative parathyroid hormone testing improves cure rates in patients undergoing minimally invasive parathyroidectomy.

BACKGROUND: Intraoperative parathyroid hormone (iPTH) testing often is used during minimally invasive parathyroidectomy for primary hyperparathyroidism (1 degrees HPT). However, several investigators report that these assays are not cost effective and do not improve outcomes significantly. METHODS: To determine the impact of iPTH testing on the outcomes of patients with 1 degrees HPT, we reviewed our experience. From January 1990 to June 2004, there were 345 consecutive patients with 1 degrees HPT and positive localization studies for a single parathyroid adenoma who were candidates for minimally invasive parathyroidectomy. Group 1 patients (n = 157) underwent parathyroid exploration without iPTH testing and group 2 patients (n = 188) had an operation with iPTH testing. RESULTS: Of the group 1 patients, 15 (10%) still were hypercalcemic postoperatively owing to additional unidentified hyperfunctioning parathyroid glands. In contrast, among 188 group 2 patients, 170 (90%) had resection of a single parathyroid adenoma, a greater than 50% decrease in iPTH levels, and were cured. The remaining 18 (10%) patients did not have an adequate reduction in iPTH levels and underwent bilateral neck exploration with resection of additional parathyroids. Of these 18 patients, 9 had double adenomas and 9 had 3- or 4-gland hyperplasia. Importantly, all patients in group 2 were cured. CONCLUSIONS: iPTH testing improves cure rates in patients undergoing minimally invasive parathyroidectomy. iPTH testing allowed intraoperative recognition and resection of additional hyperfunctioning parathyroids missed by preoperative imaging studies. Consequently, we strongly advocate the routine use of iPTH testing in patients who undergo minimally invasive parathyroidectomy for 1 degrees HPT.

A comprehensive evaluation of perioperative adjuncts during minimally invasive parathyroidectomy: which is most reliable?

OBJECTIVE: To determine the utility of several perioperative adjuncts for parathyroid localization during parathyroid surgery, we prospectively compared the accuracy of sestamibi-single photon emission computed tomography (SPECT) scanning, radioguided surgery, and intraoperative parathyroid hormone (ioPTH) testing. SUMMARY AND BACKGROUND DATA: Minimally invasive parathyroidectomy (MIP) is rapidly becoming the procedure of choice in patients with primary hyperparathyroidism (HPT). Several perioperative adjuncts can be used to localize parathyroid adenomas, including sestamibi-SPECT scanning, radioguided surgery, and ioPTH testing. However, the relative value of each of these technologies is unclear. METHODS: Between March 2001 through September 2004, 254 patients with primary HPT underwent parathyroidectomy. All patients had preoperative imaging studies and underwent radioguided surgery with a gamma probe and ioPTH testing. The use of each perioperative adjunct was determined based on the intraoperative findings. RESULTS: The mean age of patients was 61 +/- 1 year. The mean calcium and parathyroid hormone levels were 11.4 +/- 0.1 mg/dL and 136 +/- 6 pg/mL, respectively. Of the 254 patients, 206 (81%) had a single parathyroid adenoma, 28 (11%) had double adenomas, 19 (8%) had hyperplasia, and one had parathyroid cancer. All resected parathyroid glands were hypercellular (mean weight = 895 +/- 86 mg). The cure rate after parathyroidectomy was 98%. The positive predictive values for sestamibi scanning, radioguided surgery, and ioPTH testing were 81%, 88%, and 99.5%, respectively. CONCLUSIONS: This series is one of the largest to date that prospectively compares the use of sestamibi scanning, radioguided surgery, and ioPTH testing. Of all the perioperative adjuncts used during parathyroid surgery, ioPTH testing has the highest sensitivity, positive predictive value, and accuracy. Thus, the inherent variability of sestamibi scanning and radioguided techniques emphasizes the critical role of ioPTH testing during parathyroid surgery.

Changing trends for surgery in elderly patients with hyperparathyroidism at a single institution.

BACKGROUND: Many elderly patients with primary hyperparathyroidism (1HPT), which increases in incidence with age and is frequently asymptomatic, are often not referred for surgery. However, the development of minimally invasive techniques has facilitated complex operations even in the elderly. Therefore, we sought to delineate the changes in the trends for surgical referral at our institution for patients over 70 years of age with 1HPT. METHODS: From January 1990 to March 2004, 422 patients underwent surgery for 1HPT at our institution. Of these, 98 were 70 years or older. In 2001, we introduced minimally invasive radioguided parathyroidectomy (MIRP). Patients were then analyzed based upon the availability of this technology (pre-MIRP era 1990-2000, and MIRP era 2001-2004). RESULTS: In the MIRP era, more elderly patients were referred for surgery when compared to the pre-MIRP era (30% versus 18%, P = 0.001). On average, 18 elderly patients/year had parathyroid surgery in the MIRP era compared to only 4 elderly patients/year pre-MIRP, representing a 4.5-fold increase. Furthermore, there were significantly more patients undergoing parathyroidectomy who were asymptomatic from 1HPT during the MIRP era (14% versus 2%, P < 0.001). Importantly, patients who underwent surgery in the MIRP era had a higher cure rate, lower complication rate, and shorter hospital stay. CONCLUSIONS: Since the introduction of MIRP at our institution, there has been an increase in the number of elderly patients with 1HPT referred for surgery as well as the proportion with only mild disease. Furthermore, there have been improvements in elderly patient outcomes during this time. MIRP is one of several factors that have led to an increase in elderly patients undergoing surgery for 1HPT.

The utility of frozen section evaluation for follicular thyroid lesions.

BACKGROUND: Because fine-needle aspiration cannot reliably discriminate between benign and malignant follicular thyroid lesions, some surgeons use intraoperative frozen section (FS) to guide operative management. To determine the utility of FS for these lesions, we reviewed our institutional experience. METHODS: Between 1994 and 2001, 152 patients underwent surgical resection for follicular neoplasms. RESULTS: The mean age of the patients was 47 years, and 76% were female. Forty-one (32%) FSs were reported as benign, 5 (4%) as malignant, and 3 (2%) as indeterminate, and in 80 (62%), the diagnosis was "follicular lesion, deferred to permanent histology." On paraffin section, all patients with malignant FSs had thyroid cancer, and all 41 patients with benign FSs had benign lesions. Thus, FS for diagnosis of follicular thyroid cancer had a sensitivity, specificity, positive predictive value, and accuracy of 67%, 100%, 100%, and 96%, respectively. In most cases (64%), FS rendered no additional information at the time of operation. Therefore, the cost per useful FS was $7800, which is higher than the charge of a completion thyroidectomy (approximately $6000). CONCLUSIONS: FS analysis for follicular lesions seems to be highly specific and accurate. However, because of the low sensitivity, routine use of FS is not cost-effective in patients with follicular thyroid lesions.

Can thallium-pertechnetate subtraction scanning play a role in the preoperative imaging for minimally invasive parathyroidectomy?

PURPOSE: Preoperative Tc-99m sestamibi scanning can identify candidates for minimally invasive parathyroid surgery. However, a significant number of patients with single gland disease have negative scans and are not considered for the minimally invasive procedure. MATERIALS AND METHODS: To determine if T1-201/Tc-99m sodium pertechnetate subtraction scanning (TPSS) is a viable alternative imaging technique for patients with primary hyperparathyroidism (1 degrees HPTH), we reviewed our experience. The outcomes of 100 consecutive patients with 1 degrees HPTH who underwent preoperative TPSS and parathyroid exploration between 1995 and 2000 at our institution were retrospectively reviewed. RESULTS: The mean preoperative calcium and parathyroid hormone levels were 10.8 mg/dL and 220 pg/mL, respectively. The overall cure rate was 96%. Single gland disease was present in 88%. Of the 100 patients studied, 15 underwent both a Tc-99m sestamibi scan and TPSS, whereas the other 85 had only the TPSS. CONCLUSIONS: The sensitivity and positive predictive value of the TPSS were 73.3% and 90.4%, respectively. In the patients undergoing both TPSS and Tc-99m sestamibi scans, the results concurred in 60%. However, in 20% of the remaining patients, TPSS correctly localized the abnormal parathyroid(s) when Tc-99m sestamibi failed. TPSS has a comparable sensitivity and positive predictive value to Tc-99m sestamibi scanning. In patients with a negative Tc-99m sestamibi scan, TPSS can provide additional localizing information. As a result of the high positive predictive value of TPSS, a single parathyroid gland localized by TPSS alone can then be approached by minimally invasive parathyroidectomy.

Radioguided parathyroidectomy in patients with secondary and tertiary hyperparathyroidism.

BACKGROUND: To date there have been no reports on the feasibility of radioguided parathyroidectomy (RGP) in patients with secondary and tertiary hyperparathyroidism. METHODS: Twenty-three consecutive patients with secondary (n=5) or tertiary hyperparathyroidism (n=18) underwent RGP. Patients were injected with 10 mCi of technetium 99-sestamibi before surgery. All parathyroid glands were localized during operation with a neoprobe. RESULTS: The mean patient age was 50+/-3 years. The mean preoperative calcium and intact parathyroid hormone levels were 11.0+/-0.3 mg/dL and 400+/-107 pg/mL, respectively. Eighteen patients had 3- or 4-gland hyperplasia, 2 had double adenomas, 2 had forearm graft hyperplasia, 1 had 6-gland disease, and 3 had ectopic glands. All hyperplastic glands had ex vivo counts >20% of background (mean, 63%+/-6%), making frozen section unnecessary. When compared with 66 historical control subjects who underwent surgery without radioguidance for tertiary hyperparathyroidism, patients undergoing RGP had decreased operative times (96+/-8 minutes vs 151+/-15 minutes; P<.001) and lengths of stay (1.3+/-0.1 days vs 3.7+/-0.3 days; P<.001). CONCLUSIONS: RGP in patients with secondary and tertiary hyperparathyroidism is feasible, may reduce operative time, and permits omission of frozen section. Thus RGP appears to be a useful adjunct in the treatment of secondary and tertiary hyperparathyroidism.

Radioguided parathyroidectomy is equally effective for both adenomatous and hyperplastic glands.

OBJECTIVE: To determine the utility of radioguided parathyroidectomy for patients with hyperparathyroidism, we studied the properties of 180 resected, hyperfunctioning parathyroid glands. SUMMARY AND BACKGROUND DATA: Radioguided resection of hyperfunctioning parathyroid glands has been shown to be technically feasible in patients with parathyroid adenomas. Radioguided excision may obviate the need for intraoperative frozen section because excised parathyroid adenomas uniformly have radionuclide ex vivo counts >20% of background. The feasibility and applicability of radioguided techniques for patients with parathyroid hyperplasia are unclear. METHODS: Between March 2001 and September 2002, 102 patients underwent neck exploration for primary (n = 77) and secondary/tertiary (n = 25) hyperparathyroidism. All patients received an injection of 10 mCi of Tc-99m sestamibi the day of surgery. Using a gamma probe, intraoperative scanning was performed, looking for in vivo radionuclide counts > background to localize abnormal parathyroid glands. After excision, radionuclide counts of each ex vivo parathyroid gland were determined and expressed as a percentage of background counts.RESULTS Although patients with single adenomas had higher mean background radionuclide counts, the average in vivo counts of all enlarged glands were higher than background. Notably, in vivo counts did not differ between adenomatous and hyperplastic glands, suggesting equal sensitivity for intraoperative gamma detection. Ectopically located glands were identified in 22 cases and all were accurately localized using the gamma probe. Postresection, mean ex vivo radionuclide counts were highest in the single parathyroid adenomas and lowest in hyperplastic glands. Importantly, in all hyperplastic glands, the ex vivo counts were >20%. CONCLUSIONS: In patients with hyperparathyroidism, radioguided surgery is a sensitive adjunct for the intraoperative localization of both adenomatous and hyperplastic glands. In this series, all 180 enlarged parathyroids were located with the gamma probe. We have also shown that the ">20% rule" for ex vivo counts not only applies to parathyroid adenomas but also to hyperplastic glands. Therefore, radioguided resection is equally effective and informative for both adenomatous and hyperplastic glands.

Palliative thyroidectomy for malignant lymphoma of the thyroid.

BACKGROUND: Current treatment of malignant lymphoma of the thyroid consists of chemotherapy and external beam radiation. The diagnosis can routinely be made by fine-needle aspiration, obviating the need for surgery. However, a significant number of patients present with symptoms of obstruction, necessitating thyroidectomy for palliation. METHODS: To determine the outcomes of patients with malignant thyroid lymphoma after palliative thyroidectomy, we reviewed our experience. Between 1980 and 2001, 27 patients with thyroid lymphoma and symptoms or signs of airway and/or esophageal obstruction were evaluated at 1 of 3 academic institutions. RESULTS: The mean age of the patients was 66 +/- 3 years, and the majority was female. Patients presented with symptoms of dyspnea/stridor (30%), dysphagia/pain (30%), or impending airway obstruction (40%). All underwent palliative surgery. In addition to surgery, 10 patients had combined chemo- and radiotherapy, 10 had radiotherapy alone, and 4 had only chemotherapy. Symptom-free survival after palliative surgery was determined by Kaplan-Meier analysis. The mean actuarial symptom-free survival of patients with symptomatic, malignant thyroid lymphoma was 10 years (95% confidence interval, 7.67 to 12.33 years). CONCLUSIONS: Patients with malignant lymphoma of the thyroid can present with obstructive symptoms requiring palliative intervention. In this group of patients, thyroidectomy can be associated with good long-term palliation and low morbidity.

Long-term follow-up of patients with tertiary hyperparathyroidism treated by resection of a single or double adenoma.

OBJECTIVE: To determine whether patients with tertiary hyperparathyroidism due to single- or two-gland disease undergoing limited resection have similar long-term outcomes compared with patients with hyperplasia undergoing subtotal or total parathyroidectomy. SUMMARY BACKGROUND DATA: Tertiary hyperparathyroidism occurs in less than 2% of patients after renal transplantation. Approximately 30% of these cases are caused by one or two hyperfunctioning glands. Nevertheless, the standard operation for this disease has been subtotal or total parathyroidectomy with autotransplantation. METHODS: Seventy-one patients underwent surgery for tertiary hyperparathyroidism. At the time of surgery, 19 patients who had a single or double adenoma underwent limited resection of the enlarged glands only (adenoma group). The remaining 52 patients with three- or four-gland hyperplasia had subtotal or total parathyroidectomy with implantation (hyper group). Long-term cure rates between the two groups were compared. RESULTS: In the adenoma group, 7 patients had a single adenoma and 12 underwent resection of a double adenoma. In the hyper group, 49 patients had subtotal and 3 had total parathyroidectomies. After surgery, 70 of 71 patients (99%) were cured of their hypercalcemia. The incidence of postoperative transient hypocalcemia was significantly higher in the hyper group (27% vs. 5%). No patients in either group had permanent hypocalcemia requiring long-term supplementation. With up to 16 years of follow-up, there have been no recurrences in the adenoma group, whereas three patients (6%) in the hyper group have had recurrent or persistent hyperparathyroidism. CONCLUSIONS: Patients with tertiary hyperparathyroidism who underwent limited resection of a single or double adenoma only had equivalent long-term cure rates compared with patients undergoing more extensive resections. Therefore, the authors recommend in patients with tertiary hyperparathyroidism and enlargement of only one or two parathyroid glands that the resection be limited to these abnormal glands only.