Dear Sir,

We read with interest the article titled “Unilateral Clearance for Primary Hyperparathyroidism in Selected Patients with Multiple Endocrine Neoplasia Type 1” by Kluijfhout et al. [1]. The article deals with interesting concept of existence of spectrum of aggressiveness of hyperparathyroidism (HPT) in MEN1 patient and bats for less aggressive parathyroidectomy in select group of patients with MEN1-related HPT as against the current recommended guidelines of subtotal parathyroidectomy (STP) or total parathyroidectomy (TPT) with autotransplantation in all patients [2]. Even though genotype–phenotype correlation is not well described in patients with MEN1 syndrome, it is reported that patients with nonsense or frame-shift mutations in exons 2, 9 and 10 in MEN1 gene are less likely to have persistent or recurrent disease [3]. The concept of utilizing genetic information in deciding surgical approach for HPT in MEN1 is very interesting and thought-provoking. We congratulate the authors for their work and have few queries and comments to make [1].

  1. 1.

    Did all patients undergoing selective clearance have a preoperative diagnosis of MEN1?

    Patients undergoing STP were younger (37 vs. 52 years) than those undergoing unilateral clearance. How many of these were symptomatic for HPT? Is it possible that difference in age of presentation is a manifestation of genetic heterogeneity?

  2. 2.

    How many patients undergoing selective clearance had more than two parathyroid or supernumerary glands removed?

  3. 3.

    The fact that the only recurrence in selective clearance was noted 8 years after surgery as compared to five recurrences in STP group which occurred at 2, 8, 8, 12 and 15 years after surgery is also interesting and perhaps a reflection of low virulence of HPT in selective clearance group.