The Small Abnormal Parathyroid Gland is Increasingly Common and Heralds Operative Complexity
Corresponding Author
Kelly L. McCoy
- [email protected]
- +412-647-0467 | Fax: +412-648-9551
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Tel.: +412-647-0467, Fax: +412-648-9551, [email protected]Search for more papers by this authorNaomi H. Chen
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorMichaele J. Armstrong
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorGina M. Howell
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorMichael T. Stang
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorLinwah Yip
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorSally E. Carty
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorCorresponding Author
Kelly L. McCoy
- [email protected]
- +412-647-0467 | Fax: +412-648-9551
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Tel.: +412-647-0467, Fax: +412-648-9551, [email protected]Search for more papers by this authorNaomi H. Chen
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorMichaele J. Armstrong
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorGina M. Howell
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorMichael T. Stang
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorLinwah Yip
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorSally E. Carty
Division of Endocrine Surgery, University of Pittsburgh, 3471 Fifth Avenue, Kaufmann Building, Suite 101, 15213 Pittsburgh, PA, USA
Search for more papers by this authorPresented at International Surgical Week—ISW 2013, Helsinki, Finland, 25–29 August 2013.
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.
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