HDCN Article Review/Hyperlink

Stehman-Breen C, Muirhead N, Thorning D, Sherrard D

Secondary hyperparathyroidism complicated by parathyromatosis

Am J Kidney Dis (Oct) 28:502-507 1996

The authors present 5 cases of parathyromatosis and discuss the difficulties encountered in their management. Parathyromatosis is the condition when multiple nodules or rests of parathyroid tissue hyperfunction resulting in refractory hyperparathyroidism. The cause is usually the result of seeding of parathyroid tissue following surgical manipulation of the parathyroid glands and can occur locally, within the neck or mediastinum, or distally, at the site of parathyroid implantation, usually the arm. The development of parathyromatosis may be explained by the recent observation that hyperplastic parathyroid tissue may undergo monoclonal transformation into adenomas as discussed by the authors.

All 5 cases were patients who had very severe hyperparathyroidism requiring multiple surgical interventions. Although, these patients presented prior to the routine use of calcitriol and calcium for the medical control of hyperparathyroidism, parathyroidectomy is still required in a subset of patients with refractory hyperparathyroidism. These cases exemplify both the controversy and difficulty associated with the surgical management of refractory hyperparathyroidism. The appropriate surgical procedure which should be preformed is unclear. As suggested by the authors, we also prefer a subtotal parathyroidectomy in which the three largest glands are removed and the smallest gland is left intact.

Comment: In summary, these cases illustrate the malignant nature of hyperparathyroidism and that it is not a disease curable by surgery. This manuscript underscores the importance of identifying and medically treating patients prior to the need for surgical intervention. (Stuart Sprague, M.D., Northwestern University, Chicago, IL)