Management of extracervical recurrence following total parathyroidectomy and autotransplantation for renal hyperparathyroidism

Background: In patients with renal hyperparathyroidism the choice of surgery varies between total parathyroidectomy with autotransplantation (TPTx + AT) and subtotal parathyroidectomy (SPT) with variable outcomes. The present study investigated the risk of extracervical recurrences in patients who underwent total parathyroidectomy with autotransplantation for dialysis patients with renal hyperparathyroidism. Methods: A retrospective cohort analysis of patients who underwent TPTx + AT for renal hyperparathyroidism between the years 2000 and 2023 at a tertiary referral hospital. Patient demographic profiles, biochemical and surgical data, incidence of recurrence and outcomes of intervention were collected. Results: Some 142 (71M:71 F) patients with a mean age of 58.6 ± 11.2 years underwent total parathyroidectomy and autotransplantation during the study period. The mean dialysis vintage was 6.3 ± 3.2 years. Extracervical recurrence was seen in 25 (17.6%) of 142 patients, after a mean follow-up of 9 (±4.2) years, with the common sites of recurrence being the deltoid autotransplant site (73.1%) and the mediastinum (11.5%), while 7.7% of recurrences were biochemical with no localized site. Of the recurrences, 19 of 25 (76%) underwent explant of the deltoid autotransplant, and two in the mediastinum underwent minimally invasive excision (one video assisted thoracic surgery and one robotic excision) of the parathyroid lesion. The median parathyroid hormone level at the time of recurrence was 109.4 pg/ml compared with 17.2 ng/L postexcision or explantation. The only factor predictive for recurrences in the cohort on multivariable analysis was postoperative serum PTH ( p = 0.001). Log-rank test showed no statistically significant difference in survival between the two groups ( p = 0.355). Conclusion: Extracervical recurrences in the autotransplant are not uncommon in the long-term following total parathyroidectomy and autotransplantation for patients with renal hyperparathyroidism. These recurrences need explantation or excision to reduce the PTH burden in patients who cannot avail a renal transplant.