Skip to main content
SpringerLink
Log in

Frequency of Ectopic and Supernumerary Intrathymic Parathyroid Glands in Patients with Renal Hyperparathyroidism: Analysis of 461 Patients Undergoing Initial Parathyroidectomy with Bilateral Cervical Thymectomy

  • Published:
World Journal of Surgery Aims and scope Submit manuscript

Abstract

Background

The frequency of intrathymic parathyroid glands (IPGs) in patients undergoing parathyroidectomy for renal hyperparathyroidism (rHPT) varies considerably between 14.8% and 45.3%. Total parathyroidectomy with autotransplantation and subtotal parathyroidectomy are the most accepted surgical procedures to treat patients with rHPT. However, routine bilateral cervical thymectomy (BCT) is still discussed, although controversially.

Methods

From a prospective database of patients who underwent parathyroid surgery for rHPT between 1975 and 2009, patients with routine BCT at initial PTX were further analyzed regarding the frequency of ectopic and supernumerary IPGs. Duration of hemodialysis and stage of chronic kidney disease were correlated with the frequency of supernumerary IPGs to elucidate a potential role of long-standing proliferation stimuli to any surplus parathyroid tissue.

Results

Initial parathyroidectomy with BCT was performed in 461 patients. IPGs were resected in 205 of them (44.5%). They were ectopic in 181 (39.3%) and supernumerary in 30 patients (6.5%). The frequency of supernumerary IPGs in patients on permanent hemodialysis was 7.4% (29/392), 3.9% (1/26) in predialysis patients, and 0% (0/43) in patients after successful kidney transplantation. This differences reached no statistical significance.

Conclusions

BCT is essential in patients with fewer than four parathyroid glands identified at typical positions. Because of the low frequency of supernumerary IPGs and a suspected low proliferation stimulus, the relevance of BCT after resection of four glands in predialysis patients and those after successful kidney transplantation must be questioned. Nevertheless, routine BCT seems to be acceptable and can be recommended in patients on permanent hemodialysis not awaiting kidney transplantation until proven otherwise by prospective trials.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6

Similar content being viewed by others

References

  1. Fujisaki T, Hida M, Hiraga S et al (1997) Cellular proliferation and secretion in secondary hyperparathyroidism during renal failure. Nephron 77:68–75

    Article  PubMed  CAS  Google Scholar 

  2. Tominaga Y, Kohara S, Namii Y et al (1996) Clonal analysis of nodular parathyroid hyperplasia in renal hyperparathyroidism. World J Surg 20(7):744–750

    Article  PubMed  CAS  Google Scholar 

  3. Slatopolsky E (1998) The role of calcium, phosphorus and vitamin D metabolism in the development of secondary hyperparathyroidism. Nephrol Dial Transplant 13(Suppl 3):3–8

    Article  PubMed  Google Scholar 

  4. Edis AJ, Levitt MD (1987) Supernumerary parathyroid glands: implications for the surgical treatment of secondary hyperparathyroidism. World J Surg 11:398–401

    Article  PubMed  CAS  Google Scholar 

  5. Udelsmann R (1999) Secondary hyperparathyroidism. Oper Tech Gen Surg 1:62–70

    Article  Google Scholar 

  6. Felsenfeld AJ (1997) Considerations for the treatment of secondary hyperparathyroidism in renal failure. J Am Soc Nephrol 8:993–1004

    PubMed  CAS  Google Scholar 

  7. Aly A, Douglas M (2003) Embryonic parathyroid rests occur commonly and have implications in the management of secondary hyperparathyroidism. ANZ J Surg 73:284–288

    Article  PubMed  Google Scholar 

  8. Shih ML, Duh QY, Hsieh CB et al (2009) Total parathyroidectomy without autotransplantation for secondary hyperparathyroidism. World J Surg 33:248–254

    Article  PubMed  Google Scholar 

  9. Richards ML, Wormuth J, Bingener J et al (2006) Parathyroidectomy in secondary hyperparathyroidism: is there an optimal operative management? Surgery 139:174–180

    Article  PubMed  Google Scholar 

  10. Uno N, Tominaga Y, Matsuoka S et al (2008) Incidence of parathyroid glands located in thymus in patients with renal hyperparathyroidism. World J Surg 32:2516–2519

    Article  PubMed  Google Scholar 

  11. Shen WT, Kebebew E, Suh I et al (2009) Two hundred and two consecutive operations for secondary hyperparathyroidism: has medical management changed the profiles of patients requiring parathyroidectomy? Surgery 146:296–299

    Article  PubMed  Google Scholar 

  12. British Association of Endocrine Surgeons (BAETS) (1999) Guidelines for the surgical management of endocrine disease and training requirements for endocrine surgery. http://www.baes.info/Pages/guidelines.php

  13. AWMF Leitlinien-Register Nr 003/004 (1999) Therapie des Hyperparathyreoidismus. Mitteilungen der Dt Ges f Chirurgie 28(4)

  14. Low TH, Clark J, Gao K et al (2009) Outcome of parathyroidectomy for patients with renal disease and hyperparathyroidism: predictors for recurrent hyperparathyroidism. ANZ J Surg 79:378–382

    Article  PubMed  Google Scholar 

  15. Butterworth PC, Nicholson ML (1998) Surgical anatomy of the parathyroid glands in secondary hyperparathyroidism. J R Coll Surg Edinb 43:271–273

    PubMed  CAS  Google Scholar 

  16. Gomes EM, Nunes RC, Lacativa PG et al (2007) Ectopic and extranumerary parathyroid glands location in patients with hyperparathyroidism secondary to end stage renal disease. Acta Cir Bras 22:105–109

    Article  PubMed  Google Scholar 

  17. Verdonck J, Geuens G, Delaere P et al (2009) Surgical findings and post-operative parathormone levels in patients with secondary hyperparathyroidism. B-ENT 5:143–148

    PubMed  CAS  Google Scholar 

  18. Drakopoulos S, Koukoulaki M, Apostolou T et al (2009) Total parathyroidectomy without autotransplantation in dialysis patients and renal transplant recipients, long-term follow-up evaluation. Am J Surg 198:178–183

    Article  PubMed  Google Scholar 

  19. Stracke S, Keller F, Steinbach G et al (2009) Long-term outcome after total parathyroidectomy for the management of secondary hyperparathyroidism. Nephron Clin Pract 111:c102–c109

    Article  PubMed  CAS  Google Scholar 

  20. Norris EH (1973) The parathyroid glands and lateral thyroid in man: their morphogenesis, histogenesis, topographic anatomy and prenatal growth. Contrib Embryol Carnegic Inst Wash 26:247–294

    Google Scholar 

  21. Alveryd A (1968) Parathyroid glands in thyroid surgery. I. Anatomy of parathyroid glands. II. Postoperative hypoparathyroidism: identification and autotransplantation of parathyroid glands. Acta Chir Scand 389:1–120

    PubMed  CAS  Google Scholar 

  22. Akerstrom G, Malmaeus J, Bergstrom R (1984) Surgical anatomy of human parathyroid glands. Surgery 95:14–21

    PubMed  CAS  Google Scholar 

  23. Naves-Diaz M, Passlick-Deetjen J, Guinsburg A et al (2010) Calcium, phosphorus, PTH and death rates in a large sample of dialysis patients from Latin America: the CORES Study. Nephrol Dial Transplant May 31 [Epub ahead of print]

  24. Coen G, Pierantozzi A, Spizzichino D et al (2010) Risk factors of one year increment of coronary calcifications and survival in hemodialysis patients. BMC Nephrol 11:10

    Article  PubMed  Google Scholar 

  25. Pilz S, Tomaschitz A, Drechsler C et al (2010) Parathyroid hormone level is associated with mortality and cardiovascular events in patients undergoing coronary angiography. Eur Heart J 31:1591–1598

    Article  PubMed  CAS  Google Scholar 

  26. Gilmour JR (1938) The gross anatomy of parathyroid glands. J Pathol 46:133–149

    Article  Google Scholar 

  27. Wang C (1976) The anatomic basis of parathyroid surgery. Ann Surg 183:271–275

    Article  PubMed  CAS  Google Scholar 

  28. Nobori M, Saiki S, Tanaka N et al (1994) Blood supply of the parathyroid gland from the superior thyroid artery. Surgery 115:417–423

    PubMed  CAS  Google Scholar 

  29. 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

    Article  PubMed  CAS  Google Scholar 

  30. Shen W, Duren M, Morita E et al (1996) Reoperation for persistent or recurrent primary hyperparathyroidism. Arch Surg 131:861–867

    PubMed  CAS  Google Scholar 

  31. Nobori M, Koyama H, Shirakawa M et al (1986) Parathyroid gland location in Japanese autopsy cases. Asahichuoiho 191:6

    Google Scholar 

  32. Pattou FN, Pellissier LC, Noel C et al (2000) Supernumerary parathyroid glands: frequency and surgical significance in treatment of renal hyperparathyroidism. World J Surg 24:1330–1334

    Article  PubMed  CAS  Google Scholar 

  33. Tominaga Y, Katayama A, Sato T, et al (2003) Re-operation is frequently required when parathyroid glands remain after initial parathyroidectomy for advanced secondary hyperparathyroidism in uraemic patients. Nephrol Dial Transplant 18(Suppl 3):iii65–iii70

    Google Scholar 

  34. Numano M, Tominaga Y, Uchida K et al (1998) Surgical significance of supernumerary parathyroid glands in renal hyperparathyroidism. World J Surg 22:1098–1102

    Article  PubMed  CAS  Google Scholar 

  35. Rothmund M, Wagner PK (1988) Reoperations for persistent and recurrent secondary hyperparathyroidism. Ann Surg 207:310–314

    Article  PubMed  CAS  Google Scholar 

  36. Dotzenrath C, Cupisti K, Goretzki E et al (2003) Operative treatment of renal autonomous hyperparathyroidism: cause of persistent or recurrent disease in 304 patients. Langenbecks Arch Surg 387:348–354

    PubMed  CAS  Google Scholar 

  37. Abe K, Adachi I, Miyakawa S et al (1977) Production of calcitonin, adrenocorticotropic hormone, and beta-melanocyte-stimulating hormone in tumors derived from amine precursor uptake and decarboxylation cells. Cancer Res 37:4190–4194

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Visceral, Thoracic and Vascular Surgery, Philipps University Marburg, Baldingerstrasse, 35043, Marburg, Germany

    Ralph Schneider, Jens Waldmann, Detlef K. Bartsch & Katja Schlosser

  2. Department of General, Visceral, and Vascular Surgery, Clinical Center Nordstadt, Hannover, Germany

    Emilio Domínguez Fernández

  3. Department of Pathology, Philipps University Marburg, Marburg, Germany

    Annette Ramaswamy

Authors
  1. Ralph Schneider
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jens Waldmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Annette Ramaswamy
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Emilio Domínguez Fernández
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Detlef K. Bartsch
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Katja Schlosser
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Ralph Schneider.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schneider, R., Waldmann, J., Ramaswamy, A. et al. Frequency of Ectopic and Supernumerary Intrathymic Parathyroid Glands in Patients with Renal Hyperparathyroidism: Analysis of 461 Patients Undergoing Initial Parathyroidectomy with Bilateral Cervical Thymectomy. World J Surg 35, 1260–1265 (2011). https://doi.org/10.1007/s00268-011-1079-6

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-011-1079-6

Keywords

Search

Navigation