The small abnormal parathyroid gland is increasingly common and heralds operative complexity.

Published

Journal Article

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.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.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.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.

Full Text

Duke Authors

Cited Authors

  • McCoy, KL; Chen, NH; Armstrong, MJ; Howell, GM; Stang, MT; Yip, L; Carty, SE

Published Date

  • June 2014

Published In

Volume / Issue

  • 38 / 6

Start / End Page

  • 1274 - 1281

PubMed ID

  • 24510243

Pubmed Central ID

  • 24510243

Electronic International Standard Serial Number (EISSN)

  • 1432-2323

International Standard Serial Number (ISSN)

  • 0364-2313

Digital Object Identifier (DOI)

  • 10.1007/s00268-014-2450-1

Language

  • eng