Skip to main content
SpringerLink
Log in

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

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

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.

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

Similar content being viewed by others

References

  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

    Article  Google Scholar 

  2. Mazzaglia PJ, Berber E, Kovach A et al (2008) The changing presentation of hyperparathyroidism over 3 decades. Arch Surg 143:260–266

    Article  PubMed  Google Scholar 

  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 146:1116–1122

    Article  PubMed  Google Scholar 

  4. Silverberg SJ, Bilezikian JP, Bone HG et al (1999) Therapeutic controversies in primary hyperparathyroidism. J Clin Endocrinol Metab 84:2275–2285

    Article  CAS  PubMed  Google Scholar 

  5. Lo CY, Chan WF, Kung AW et al (2004) Surgical treatment of primary hyperparathyroidism: changes in clinical pattern over 3 decades. Arch Surg 139:77–82

    Article  PubMed  Google Scholar 

  6. Bindlish V, Freeman JL, Witterick IJ et al (2002) Correlation of biochemical parameters with single parathyroid adenoma weight and volume. Head Neck 24:1000–1003

    Article  PubMed  Google Scholar 

  7. Moretz WH, Watts TL, Virgin FW et al (2007) Correlation of intraoperative parathyroid hormone levels with parathyroid gland size. Laryngoscope 117:1957–1960

    Article  CAS  PubMed  Google Scholar 

  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 194:126–130

    Article  PubMed  Google Scholar 

  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 257:138–141

    Article  Google Scholar 

  10. Hamidi S, Aslani A, Nakhjavani M et al (2006) Are biochemical values predictive of adenoma’s weight in primary hyperparathyroidism? ANZ J Surg 76:882–885

    Article  PubMed  Google Scholar 

  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 32:179–184

    Article  CAS  PubMed  Google Scholar 

  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–S44

    Article  PubMed  Google Scholar 

  13. Udelsman R (2002) Six hundred fifty-six consecutive explorations for primary hyperparathyroidism. Ann Surg 235:665–672

    Article  PubMed Central  PubMed  Google Scholar 

  14. Irvin GL, Carneiro DM, Solorzano CC (2004) Progress in the operative management of sporadic primary hyperparathyroidism over 34 years. Ann Surg 239:704–711

    Article  PubMed Central  PubMed  Google Scholar 

  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 246:976–981

    Article  PubMed  Google Scholar 

  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 93:418–421

    Article  CAS  PubMed  Google Scholar 

  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 122:1107–1114

    Article  CAS  PubMed  Google Scholar 

  18. Melck AL, Armstrong MJ, Yip L et al (2012) Case-controlled comparison of video-assisted and conventional minimally invasive parathyroidectomy. Am Surg 78:125–132

    PubMed  Google Scholar 

  19. Mitchell J, Milas M, Barbosa G et al (2008) Avoidable operations for thyroid and parathyroid surgery: effect of hospital volume. Surgery 144:899–907

    Article  PubMed  Google Scholar 

  20. Lew JI, Rivera M, Irvin GL et al (2010) Operative failure in the era of focused parathyroidectomy. Arch Surg 145:628–633

    Article  CAS  PubMed  Google Scholar 

  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 69:225–230

    PubMed  Google Scholar 

  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 140:418–422

    Article  PubMed  Google Scholar 

  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 141:777–782

    Article  PubMed  Google Scholar 

  24. Dy BM, Richards ML, Vazquez BJ et al (2012) Primary hyperparathyroidism and negative Tc99 sestamibi imaging: to operate or not? Ann Surg Oncol 19:2272–2278

    Article  PubMed  Google Scholar 

  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

    Article  PubMed  Google Scholar 

  26. Miccoli P, Bendinelli C, Berti P et al (1999) Video-assisted versus conventional parathyroidectomy in primary hyperparathyroidism: a prospective randomized study. Surgery 126:1117–1122

    Article  CAS  PubMed  Google Scholar 

  27. Sosa JA, Udelsman R (2003) Minimally invasive parathyroidectomy. Surg Oncol 12:125–134

    Article  PubMed  Google Scholar 

  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 47:919–925

    CAS  PubMed  Google Scholar 

  29. Irvin GL, Prudhomme DL, Deriso GT et al (1994) A new approach to parathyroidectomy. Ann Surg 219:574–581

    Article  PubMed Central  PubMed  Google Scholar 

  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]

  31. Rasbach DA, Monchik JM, Geelhoed GW et al (1984) Solitary parathyroid microadenoma. Surgery 96:1092–1098

    CAS  PubMed  Google Scholar 

  32. Leichty RD, Teter A, Suba EJ (1986) The tiny parathyroid adenoma. Surgery 100:1048–1052

    Google Scholar 

  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 210:456–462

    Article  PubMed  Google Scholar 

  34. Almquist M, Bergenfelz A, Martensson H et al (2010) Changing biochemical presentation of primary hyperparathyroidism. Langenbecks Arch Surg 395:925–928

    Article  PubMed  Google Scholar 

  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 33:283–287

    Article  PubMed  Google Scholar 

  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 19:577–583

    Article  PubMed  Google Scholar 

  37. Berber E, Parikh RT, Ballem N et al (2008) Factors contributing to negative parathyroid localization: an analysis of 1000 patients. Surgery 144:74–79

    Article  PubMed  Google Scholar 

  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 65:106–113

    Article  Google Scholar 

  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 35:351–356

    Article  PubMed  Google Scholar 

  40. Doherty GM, Weber B, Norton JA (1994) Cost of unsuccessful surgery for primary hyperparathyroidism. Surgery 116:954–957

    CAS  PubMed  Google Scholar 

  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 224:308–320

    Article  Google Scholar 

  42. Zarebczan B, Chen H (2011) Influence of surgical volume on operative failures for hyperparathyroidism. Adv Surg 45:237–248

    Article  PubMed Central  PubMed  Google Scholar 

  43. Wang TS, Roman SA, Sosa JA (2009) Predictors of outcomes following pediatric thyroid and parathyroid surgery. Curr Opin Oncol 21:23–28

    Article  PubMed  Google Scholar 

  44. Stavrakis AI, Ituarte PHG, Ko CY et al (2007) Surgeon volume as a predictor of outcomes in inpatient and outpatient endocrine surgery. Surgery 142:887–899

    Article  PubMed  Google Scholar 

  45. Hodin R, Angelos P, Carty S et al (2012) No need to abandon unilateral parathyroid surgery. J Am Coll Surg 215:297

    Article  PubMed  Google Scholar 

  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 141:483–488

    Article  PubMed  Google Scholar 

  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 134:973–981

    Article  PubMed  Google Scholar 

  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 19:1862–1867

    Article  PubMed  Google Scholar 

  49. Richards ML, Thompson GB, Farley DR et al (2011) An optimal algorithm for intraoperative parathyroid hormone monitoring. Arch Surg 146:280–285

    Article  PubMed  Google Scholar 

  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 207:246–249

    Article  PubMed  Google Scholar 

  51. Milas M, Wagner K, Easley KA et al (2003) Double adenomas revisited: nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). Surgery 134:995–1004

    Article  PubMed  Google Scholar 

  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 22:398–400

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

The authors gratefully acknowledge the adept assistance and continued expertise of Mohamed A. Virji, MD, with regard to the development, interpretation, and understanding of IOPTH use at our institution.

Conflict of interest

None.

Author information

Authors and Affiliations

  1. Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, Pittsburgh, PA, 15213, USA

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

Authors
  1. Kelly L. McCoy
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Naomi H. Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michaele J. Armstrong
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gina M. Howell
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Michael T. Stang
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Linwah Yip
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Sally E. Carty
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kelly L. McCoy.

Rights and permissions

Reprints and permissions

About this article

Cite this article

McCoy, K.L., Chen, N.H., Armstrong, M.J. et al. The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity. World J Surg 38, 1274–1281 (2014). https://doi.org/10.1007/s00268-014-2450-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00268-014-2450-1

Keywords

Search

Navigation