World Journal of Surgery

, Volume 37, Issue 1, pp 102–106

Incidence and Localization of Ectopic Parathyroid Adenomas in Previously Unexplored Patients

  • Madhuchhanda Roy
  • Haggi Mazeh
  • Herbert Chen
  • Rebecca S. Sippel



Parathyroidectomy has a success rate of >95 % for cure of primary hyperparathyroidism. In about 6–16 % of cases, one or more hyperfunctioning parathyroid gland(s) are found in an ectopic location. Accurate preoperative imaging can aid in detecting these ectopically located glands and allow a focused surgical approach with an even higher success rate. The objective of this study was to assess the utility of ultrasonography (US) and technetium-99m-sestamibi (MIBI) scans in locating ectopic parathyroid glands in previously unexplored patients who presented with primary hyperparathyroidism.


We analyzed a total of 1,562 patients who underwent surgery for hyperparathyroidism at our institution from 2000 to 2010. Ectopic parathyroid adenomas were identified in 346 of the patients (22 %). Of the 346 patients, we excluded 144 who underwent reoperations, had four-gland hyperplasia or were missing imaging details. We carefully reviewed the data, including demographics, laboratory values, preoperative localizing imaging details, and operative findings. Preoperative US and MIBI results were compared to the intraoperative findings.


We analyzed 202 patients with ectopic glands for accuracy of preoperative localization. Of these 202 patients, a single adenoma was the most common (89 %) followed by double adenoma (11 %). The ectopic parathyroid glands were predominantly located in the thymus (38 %) followed by 31 % in the retroesophageal region; 18 % were intrathyroidal. Preoperative MIBI scans had a sensitivity of 89 % (161/197), whereas US had a sensitivity of 59 % (35/63) for detecting ectopic glands. Overall, both imaging modalities had a positive predictive value of 90 %, with MIBI correctly predicting ectopic glands best in the thymus, mediastinum, or the retroesophageal space, and US was most accurate at detecting intrathyroidal glands.


Based on the data available at our institution, MIBI has a higher sensitivity than US in correctly localizing ectopic parathyroid adenomas, but the accuracy of detection varies based on location. Both imaging techniques have a high PPV for detecting an ectopic gland. Therefore, imaging with MIBI and US can be complementary, and positive localization of an ectopic gland with either modality is highly accurate and can facilitate a more focused surgical approach.


  1. 1.
    Kaplan EL, Yashiro T, Salti G (1992) Primary hyperparathyroidism in the 1990s: choice of surgical procedures for this disease. Ann Surg 215:300–317PubMedCrossRefGoogle Scholar
  2. 2.
    Wang C (1976) The anatomic basis of parathyroid surgery. Ann Surg 183:271–275PubMedCrossRefGoogle Scholar
  3. 3.
    Phitayakorn R, McHenry CR (2006) Incidence and location of ectopic abnormal parathyroid glands. Am J Surg 191:418–423PubMedCrossRefGoogle Scholar
  4. 4.
    Carter WB, Carter DL, Cohn HE (1993) Cause and current management of reoperative hyperparathyroidism. Am Surg 59:120–124PubMedGoogle Scholar
  5. 5.
    Akerström G, Malmaeus J, Bergström R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21PubMedGoogle Scholar
  6. 6.
    Carty SE, Worsey J, Virji MA et al (1997) Concise parathyroidectomy: the impact of preoperative SPECT 99mTc sestamibi scanning and intraoperative quick parathormone assay. Surgery 122:1107–1114 (discussion 1114–1116)PubMedCrossRefGoogle Scholar
  7. 7.
    Arici C, Cheah WK, Ituarte PH et al (2001) Can localization studies be used to direct focused parathyroid operations? Surgery 129:720–729PubMedCrossRefGoogle Scholar
  8. 8.
    Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235:665–670 (discussion 670–672)PubMedCrossRefGoogle Scholar
  9. 9.
    Wild JL, Weigel T, Chen H (2006) The need for intraoperative parathyroid hormone monitoring during radioguided parathyroidectomy by video-assisted thoracoscopy (VATS). Clin Nucl Med 31:9–12PubMedCrossRefGoogle Scholar
  10. 10.
    Cook MR, Pitt SC, Schaefer S et al (2010) A rising ioPTH level immediately after parathyroid resection: are additional hyperfunctioning glands always present? An application of the Wisconsin criteria. Ann Surg 251:1127–1130PubMedCrossRefGoogle Scholar
  11. 11.
    Yip L, Pryma DA, Yim JH et al (2008) Can a lightbulb sestamibi SPECT accurately predict single-gland disease in sporadic primary hyperparathyroidism? World J Surg 32:784–792. doi:10.1007/s00268-008-9532-x (discussion 793–794)PubMedCrossRefGoogle Scholar
  12. 12.
    Shen W, Düren M, Morita E et al (1996) Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 131:861–867 (discussion 867–869)PubMedCrossRefGoogle Scholar
  13. 13.
    Loftus KA, Anderson S, Mulloy AL et al (2007) Value of sestamibi scans in tertiary hyperparathyroidism. Laryngoscope 117:2135–2138PubMedCrossRefGoogle Scholar
  14. 14.
    Gough I (2006) Reoperative parathyroid surgery: the importance of ectopic location and multigland disease. ANZ J Surg 76:1048–1050PubMedCrossRefGoogle Scholar
  15. 15.
    Yen TW, Wang TS, Doffek KM et al (2008) Reoperative parathyroidectomy: an algorithm for imaging and monitoring of intraoperative parathyroid hormone levels that results in a successful focused approach. Surgery 144:611–619 (discussion 619–621)PubMedCrossRefGoogle Scholar
  16. 16.
    Perrier ND, Edeiken B, Nunez R et al (2009) A novel nomenclature to classify parathyroid adenomas. World J Surg 33:412–416. doi:10.1007/s00268-008-9894-0 PubMedCrossRefGoogle Scholar
  17. 17.
    Mazeh H, Stoll SJ, Robbins JB et al (2012) Validation of the “Perrier” parathyroid adenoma location nomenclature. World J Surg 36:612–616. doi:10.1007/s00268-011-1412-0 PubMedCrossRefGoogle Scholar
  18. 18.
    Ryan JA, Eisenberg B, Pado KM et al (1997) Efficacy of selective unilateral exploration in hyperparathyroidism based on localization tests. Arch Surg 132:886–890 (discussion 890–891)PubMedCrossRefGoogle Scholar
  19. 19.
    Hindié E, Mellière D, Perlemuter L et al (1997) Primary hyperparathyroidism: higher success rate of first surgery after preoperative Tc-99m sestamibi-I-123 subtraction scanning. Radiology 204:221–228PubMedGoogle Scholar
  20. 20.
    Martin RC, Greenwell D, Flynn MB (2000) Initial neck exploration for untreated hyperparathyroidism. Am Surg 66:269–272PubMedGoogle Scholar
  21. 21.
    Jaskowiak N, Norton JA, Alexander HR et al (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224:308–320 (discussion 320–321)PubMedCrossRefGoogle Scholar
  22. 22.
    Lal A, Chen H (2007) The negative sestamibi scan: is a minimally invasive parathyroidectomy still possible? Ann Surg Oncol 14:2363–2366PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2012

Authors and Affiliations

  • Madhuchhanda Roy
    • 1
  • Haggi Mazeh
    • 2
  • Herbert Chen
    • 3
  • Rebecca S. Sippel
    • 2
  1. 1.Section of Plastic and Reconstructive Surgery, Department of SurgeryUniversity of WisconsinMadisonUSA
  2. 2.Section of Endocrine Surgery, Department of SurgeryUniversity of WisconsinMadisonUSA
  3. 3.Section of Endocrine Surgery, Department of SurgeryUniversity of WisconsinMadisonUSA

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