World Journal of Surgery

, Volume 38, Issue 6, pp 1274–1281 | Cite as

The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity

  • Kelly L. McCoy
  • Naomi H. Chen
  • Michaele J. Armstrong
  • Gina M. Howell
  • Michael T. Stang
  • Linwah Yip
  • Sally E. Carty
Article

Abstract

Background

Over decades, improvements in presymptomatic screening and awareness of surgical benefits have changed the presentation and management of primary hyperparathyroidism (PHPT). Unrecognized multiglandular disease (MGD) remains a major cause of operative failure. We hypothesized that during parathyroid surgery the initial finding of a mildly enlarged gland is now frequent and predicts both MGD and failure.

Methods

A prospective database was queried to examine the outcomes of initial exploration for sporadic PHPT using intraoperative PTH monitoring (IOPTH) over 15 years. All patients had follow-up ≥6 months (mean = 1.8 years). Cure was defined by normocalcemia at 6 months and microadenoma by resected weight of <200 mg.

Results

Of the 1,150 patients, 98.9 % were cured and 15 % had MGD. The highest preoperative calcium level decreased over time (p < 0.001) and varied directly with adenoma weight (p < 0.001). Over time, single adenoma weight dropped by half (p = 0.002) and microadenoma was increasingly common (p < 0.01). MGD risk varied inversely with weight of first resected abnormal gland. Microadenoma required bilateral exploration more often than macroadenoma (48 vs. 18 %, p < 0.01). When at exploration the first resected gland was <200 mg, the rates of MGD (40 vs. 11 %, p = 0.001), inadequate initial IOPTH drop (67 vs. 79 %, p = 0.002), operative failure (6.6 vs. 0.7 %, p < 0.001), and long-term recurrence (1.6 vs. 0.3 %, p = 0.007) were higher.

Conclusions

Single parathyroid adenomas are smaller than in the past and require more complex pre- and intraoperative management. During exploration for sporadic PHPT, a first abnormal gland <200 mg should heighten suspicion of MGD and presages a tenfold higher failure rate.

References

  1. 1.
    Pasieka JL, Parsons L, Jones J (1998) Prospective surgical outcome study of relief of symptoms following surgery in patients with primary hyperparathyroidism. World J Surg 122:513–518. doi:10.1007/s002689900428 CrossRefGoogle Scholar
  2. 2.
    Mazzaglia PJ, Berber E, Kovach A et al (2008) The changing presentation of hyperparathyroidism over 3 decades. Arch Surg 143:260–266PubMedCrossRefGoogle Scholar
  3. 3.
    Perrier ND, Balachandran D, Wefel JS et al (2009) Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with “asymptomatic” primary hyperparathyroidism. Surgery 146:1116–1122PubMedCrossRefGoogle Scholar
  4. 4.
    Silverberg SJ, Bilezikian JP, Bone HG et al (1999) Therapeutic controversies in primary hyperparathyroidism. J Clin Endocrinol Metab 84:2275–2285PubMedCrossRefGoogle Scholar
  5. 5.
    Lo CY, Chan WF, Kung AW et al (2004) Surgical treatment of primary hyperparathyroidism: changes in clinical pattern over 3 decades. Arch Surg 139:77–82PubMedCrossRefGoogle Scholar
  6. 6.
    Bindlish V, Freeman JL, Witterick IJ et al (2002) Correlation of biochemical parameters with single parathyroid adenoma weight and volume. Head Neck 24:1000–1003PubMedCrossRefGoogle Scholar
  7. 7.
    Moretz WH, Watts TL, Virgin FW et al (2007) Correlation of intraoperative parathyroid hormone levels with parathyroid gland size. Laryngoscope 117:1957–1960PubMedCrossRefGoogle Scholar
  8. 8.
    Mozes G, Curlee KJ, Rowland CM et al (2002) The predictive value of laboratory findings in patients with primary hyperparathyroidism. J Am Coll Surg 194:126–130PubMedCrossRefGoogle Scholar
  9. 9.
    Mazeh H, Chen H, Leverson G et al (2012) Creation of a “Wisconsin Index” nomogram to predict the likelihood of additional hyperfunctioning parathyroid glands during parathyroidectomy. Ann Surg 257:138–141CrossRefGoogle Scholar
  10. 10.
    Hamidi S, Aslani A, Nakhjavani M et al (2006) Are biochemical values predictive of adenoma’s weight in primary hyperparathyroidism? ANZ J Surg 76:882–885PubMedCrossRefGoogle Scholar
  11. 11.
    Randhawa PS, Mace AD, Houraei SAR et al (2007) Primary hyperparathyroidism: do perioperative biochemical variables correlate with parathyroid adenoma weight or volume? Clin Otolaryngol 32:179–184PubMedCrossRefGoogle Scholar
  12. 12.
    Calva-Cerqueira D, Smith BJ, Hostetler ML et al (2007) Minimally invasive parathyroidectomy and preoperative MIBI scan: correlation of gland weight and preoperative PTH. J Am Coll Surg 205:S38–S44PubMedCrossRefGoogle Scholar
  13. 13.
    Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235:665–672PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Irvin GL, Carneiro DM, Solorzano CC (2004) Progress in the operative management of sporadic primary hyperparathyroidism over 34 years. Ann Surg 239:704–711PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Westerdahl J, Bergenfelz A (2007) Unilateral vs bilateral neck exploration for primary hyperparathyroidism: five year follow-up of a randomized controlled trial. Ann Surg 246:976–981PubMedCrossRefGoogle Scholar
  16. 16.
    Russell CF, Dolan SJ, Laird JD (2006) Randomized clinical trial comparing scan directed unilateral vs bilateral cervical exploration for primary hyperparathyroidism due to solitary adenoma. Br J Surg 93:418–421PubMedCrossRefGoogle Scholar
  17. 17.
    Carty SE, Worsey J, Virji MA et al (1997) Concise parathyroidectomy: the impact of preoperative SPECT 99 mTc sestamibi scanning and intraoperative quick parathormone assay. Surgery 122:1107–1114PubMedCrossRefGoogle Scholar
  18. 18.
    Melck AL, Armstrong MJ, Yip L et al (2012) Case-controlled comparison of video-assisted and conventional minimally invasive parathyroidectomy. Am Surg 78:125–132PubMedGoogle Scholar
  19. 19.
    Mitchell J, Milas M, Barbosa G et al (2008) Avoidable operations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 144:899–907PubMedCrossRefGoogle Scholar
  20. 20.
    Lew JI, Rivera M, Irvin GL et al (2010) Operative failure in the era of focused parathyroidectomy. Arch Surg 145:628–633PubMedCrossRefGoogle Scholar
  21. 21.
    Merlino JI, Ko K, Minotti A et al (2003) The false negative technetium-99 m-sestamibi scan in patients with primary hyperparathyroidism: correlation with clinical factors and operative findings. Am Surg 69:225–230PubMedGoogle Scholar
  22. 22.
    Chiu B, Sturgeon C, Angelos P (2006) What is the link between nonlocalizing sestamibi scans, multigland disease and persistent hypercalcemia? A study of 401 consecutive patients undergoing parathyroidectomy. Surgery 140:418–422PubMedCrossRefGoogle Scholar
  23. 23.
    Kebebew E, Hwang J, Reiff E et al (2006) Predictors of single-gland vs multigland parathyroid disease in primary hyperparathyroidism: a simple and accurate scoring model. Arch Surg 141:777–782PubMedCrossRefGoogle Scholar
  24. 24.
    Dy BM, Richards ML, Vazquez BJ et al (2012) Primary hyperparathyroidism and negative Tc99 sestamibi imaging: to operate or not? Ann Surg Oncol 19:2272–2278PubMedCrossRefGoogle Scholar
  25. 25.
    Yip L, Pryma DA, Yim JH et al (2009) Sestamibi SPECT intensity scoring system in sporadic primary hyperparathyroidism. World J Surg 33:426–433. doi:10.1007/s00268-008-9841-0 PubMedCrossRefGoogle Scholar
  26. 26.
    Miccoli P, Bendinelli C, Berti P et al (1999) Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery 126:1117–1122PubMedCrossRefGoogle Scholar
  27. 27.
    Sosa JA, Udelsman R (2003) Minimally invasive parathyroidectomy. Surg Oncol 12:125–134PubMedCrossRefGoogle Scholar
  28. 28.
    Johnson LR, Doherty G, Lairmore T et al (2001) Evaluation of the performance and clinical impact of a rapid intraoperative parathyroid hormone assay in conjunction with preoperative imaging and concise parathyroidectomy. Clin Chem 47:919–925PubMedGoogle Scholar
  29. 29.
    Irvin GL, Prudhomme DL, Deriso GT et al (1994) A new approach to parathyroidectomy. Ann Surg 219:574–581PubMedCentralPubMedCrossRefGoogle Scholar
  30. 30.
    Wang TS, Paieka JL, Carty SE (2014) Techniques of parathyroid exploration at North American endocrine surgery fellowship programs: what the next generation is being taught. Am J Surg [Epub ahead of print]Google Scholar
  31. 31.
    Rasbach DA, Monchik JM, Geelhoed GW et al (1984) Solitary parathyroid microadenoma. Surgery 96:1092–1098PubMedGoogle Scholar
  32. 32.
    Leichty RD, Teter A, Suba EJ (1986) The tiny parathyroid adenoma. Surgery 100:1048–1052Google Scholar
  33. 33.
    Goasguen N, Chirica M, Roger N et al (2010) Primary hyperparathyroidism from parathyroid microadenoma: specific features and implications for a surgical strategy in the era of minimally invasive parathyroidectomy. J Am Coll Surg 210:456–462PubMedCrossRefGoogle Scholar
  34. 34.
    Almquist M, Bergenfelz A, Martensson H et al (2010) Changing biochemical presentation of primary hyperparathyroidism. Langenbecks Arch Surg 395:925–928PubMedCrossRefGoogle Scholar
  35. 35.
    Gilat H, Cohen M, Feinmesser R et al (2005) Minimally invasive parathyroidectomy for resection of a parathyroid adenoma: the role of preoperative high-resolution ultrasonography. J Clin Ultrasound 33:283–287PubMedCrossRefGoogle Scholar
  36. 36.
    Cheung K, Wang TS, Farrokhyar F et al (2012) A meta-analysis of preoperative localization techniques for patients with primary hyperparathyroidism. Ann Surg Oncol 19:577–583PubMedCrossRefGoogle Scholar
  37. 37.
    Berber E, Parikh RT, Ballem N et al (2008) Factors contributing to negative parathyroid localization: an analysis of 1000 patients. Surgery 144:74–79PubMedCrossRefGoogle Scholar
  38. 38.
    Barczynski M, Golkowski F, Konturek A et al (2006) Technetium-99m-sestamibi subtraction scintigraphy vs. ultrasonography combined with rapid parathyroid hormone assay in parathyroid aspirates in preoperative localization of parathyroid adenomas and in directing surgical approach. Clin Endocrinol 65:106–113CrossRefGoogle Scholar
  39. 39.
    Masatsugu T, Yamashita H, Noguchi S et al (2005) Significant clinical differences in primary hyperparathyroidism between patients with and those without concomitant thyroid disease. Surg Today 35:351–356PubMedCrossRefGoogle Scholar
  40. 40.
    Doherty GM, Weber B, Norton JA (1994) Cost of unsuccessful surgery for primary hyperparathyroidism. Surgery 116:954–957PubMedGoogle Scholar
  41. 41.
    Jaskoiak N, Norton JA, Alexander HR et al (1996) A prospective trial evaluating a standard approach to reoperation for missed parathyroid adenoma. Ann Surg 224:308–320CrossRefGoogle Scholar
  42. 42.
    Zarebczan B, Chen H (2011) Influence of surgical volume on operative failures for hyperparathyroidism. Adv Surg 45:237–248PubMedCentralPubMedCrossRefGoogle Scholar
  43. 43.
    Wang TS, Roman SA, Sosa JA (2009) Predictors of outcomes following pediatric thyroid and parathyroid surgery. Curr Opin Oncol 21:23–28PubMedCrossRefGoogle Scholar
  44. 44.
    Stavrakis AI, Ituarte PHG, Ko CY et al (2007) Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery 142:887–899PubMedCrossRefGoogle Scholar
  45. 45.
    Hodin R, Angelos P, Carty S et al (2012) No need to abandon unilateral parathyroid surgery. J Am Coll Surg 215:297PubMedCrossRefGoogle Scholar
  46. 46.
    Chiu B, Sturgeon C, Angelos P (2006) Which intraoperative parathyroid hormone assay criterion best predicts operative success? A study of 352 consecutive patients. Arch Surg 141:483–488PubMedCrossRefGoogle Scholar
  47. 47.
    Carneiro DM, Solorzano CC, Nader MC et al (2003) Comparison of intraoperative iPTH assay (QPTH) criteria in guiding parathyroidectomy: which criterion is the most accurate? Surgery 134:973–981PubMedCrossRefGoogle Scholar
  48. 48.
    Reiher AE, Schafer S, Chen H et al (2012) Does the final intraoperative PTH really have to fall into the normal range to signify cure? Ann Surg Oncol 19:1862–1867PubMedCrossRefGoogle Scholar
  49. 49.
    Richards ML, Thompson GB, Farley DR et al (2011) An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg 146:280–285PubMedCrossRefGoogle Scholar
  50. 50.
    McGill J, Sturgeon C, Kaplan SP et al (2008) How does the operative strategy for primary hyperparathyroidism impact the findings and cure rate? J Am Coll Surg 207:246–249PubMedCrossRefGoogle Scholar
  51. 51.
    Milas M, Wagner K, Easley KA et al (2003) Double adenomas revisited: nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). Surgery 134:995–1004PubMedCrossRefGoogle Scholar
  52. 52.
    Miccoli P, Berti P, Materazzi G et al (2008) Endoscopic bilateral neck exploration versus quick intraoperative parathormone assay (qPTHa) during endoscopic parathyroidectomy: a prospective randomized trial. Surg Endosc 22:398–400PubMedCrossRefGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2014

Authors and Affiliations

  • Kelly L. McCoy
    • 1
  • Naomi H. Chen
    • 1
  • Michaele J. Armstrong
    • 1
  • Gina M. Howell
    • 1
  • Michael T. Stang
    • 1
  • Linwah Yip
    • 1
  • Sally E. Carty
    • 1
  1. 1.Division of Endocrine SurgeryUniversity of PittsburghPittsburghUSA

Personalised recommendations