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Management of the Parathyroid Glands in Preventative Thyroidectomy for Multiple Endocrine Neoplasia Type 2
Jeffrey F Moley, Kathryn A. Rowland*, Linda Jin*, Amber L. Traugott*, Michael Skinner*, Samuel A. Wells
Washington University School of Medicine, St. Louis, MO

Objectives: Multiple endocrine neoplasia type 2 is characterized by a near 100% risk of medullary thyroid carcinoma (MTC). Genetic testing identifies gene carriers in affected families and allows performance of preventative thyroidectomy. Management of the parathyroids in these operations is controversial, with some experts advocating total parathyroidectomy with autotransplantation, and others leaving the parathyroids in situ.
Methods: Between 1993 and 2003 we performed 50 preventative thyroidectomies. All patients had central neck dissection (CND), total parathyroidectomy and autotransplantation to the non-dominant forearm, regardless of preoperative calcitonin level (Group A). Between 2003 and the present, the lead author performed 95 preventative thyroidectomies, leaving the parathyroids in situ with an intact vascular pedicle (group B). Individual parathyroids were autotransplanted only if they appeared non-viable. CND was done only if calcitonin was greater than 40pg/ml.
Results: Permanent hypoparathyroidism occurred in 3/50 patients in group A, vs 1/95 in group B (p=0.1184). There were no permanent recurrent laryngeal nerve injuries in either group. No patient developed subsequent hyperparathyroidism. Recurrence/persistence of MTC requiring re-operation occurred in 2 patients in group A, and in 1 patient in group B (though follow-up is longer in group A, and several group B patients currently have elevated calcitonin). No patients have died.
Conclusions: Routine total parathyroidectomy with autotransplantation and CND during preventative thyroidectomy has excellent long-term results. Preservation of the parathyroids in situ during preventative thyroidectomy, and selective central neck dissection based upon calcitonin level in MEN 2 gene carriers is an effective and safe alternative.


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