Elsevier

Surgery

Volume 134, Issue 6, December 2003, Pages 995-1003
Surgery

Original communication
Double adenomas revisited: Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease)

https://doi.org/10.1016/j.surg.2003.07.009Get rights and content

Abstract

Background

A double adenoma (DA) is a recognized clinical entity of primary hyperparathyroidism (HPT) and is presumed to have uniform location distribution. We reviewed our experience with 2-gland parathyroid disease to identify anatomic patterns and implications for surgical management.

Methods

Clinical characteristics were reviewed for 828 consecutive patients with HPT at 2 endocrine referral centers that practice bilateral neck exploration with intraoperative parathyroid hormone (IOPTH) measurement.

Results

Fifteen percent (127 of 828) of HPT patients demonstrated 2 enlarged glands; 13% (107 of 828), 3- or 4-gland hyperplasia; and 71% (592 of 828), single adenomas. DAs in superior parathyroids affected 57 of 127 (45%) patients, an observed frequency 3-fold higher than expected (P<.001, chi-square test). DAs were larger than normal glands (240±575 mg vs 28±23 mg, P<.001), and superior parathyroid adenomas were larger than adenomas at other sites (421±983 mg vs 202±353 mg, P = .002). Technetium 99 metastable (Tc99m)-sestamibi imaging and IOPTH identified DAs correctly in only 5 of 84 (6%) and 19 of 75 (25%) of patients tested, respectively.

Conclusions

DAs have nonuniform anatomic distribution with predilection for abnormal growth in bilateral superior parathyroids—embryologic remnants of the fourth branchial pouch. Since additional abnormal glands were detected by observation with technetium 99 metastable (Tc99m)-sestamibi imaging and IOPTH rarely aiding detection, unilateral neck exploration may predispose to persistent or recurrent HPT.

Section snippets

Methods

This retrospective, 2-institution study covers 828 unselected patients with HPT treated at Emory University Hospital (1993–2002) and The Cleveland Clinic (1999–2002). Parathyroidectomy was performed by a single endocrine surgeon at each institution (C.J.W. at Emory; A.S. at The Cleveland Clinic). During this time period, the surgical approach in both institutions consisted of bilateral open neck exploration. Preoperative technetium 99 metastable (Tc99m)-sestamibi imaging, ultrasonography, and

Overview of clinical features

Of 828 consecutive cases of HPT, DAs were found in 127 patients (15%), SAs in 592 patients (71%), MGH in 107 patients (13%); 2 patients had negative explorations (1%). Patients with DA were predominantly women (110 of 127, 87%) aged 59±13 years. The female gender distribution and age of DA patients were not statistically different than those observed in patients with SA (77% women, 60±14 years) and MGH (76% women, 62.7±13 years).

Diagnostic elevations of serum calcium and PTH for DA patients

Discussion

In this large cohort of patients with HPT, the distinct entity of 2 abnormal parathyroid glands was encountered in 15% of cases. DAs were most likely to be found involving both superior parathyroid glands and were more likely to harbor larger glands at these locations. This pattern of distribution indicates that double parathyroid adenomas do not follow uniform allocation as previously assumed.

Upon closer inspection of reported series of DAs (Table II), our findings are not necessarily

Conclusion

DAs are a distinct entity of multigland hyperparathyroidism that can potentially exist in 1 out of every 7 neck explorations. DAs have a nonuniform distribution that shows increased probability of involving both sides of the neck, with the most prevalent location affecting both superior parathyroid glands. These observations confirm the need for a meticulous search and identification of all parathyroid glands at initial operation. Unilateral neck exploration guided by Tc99m-sestamibi and

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