The complex and heterogeneous entity of double adenomas in primary hyperparathyroidism

Abstract Context Preoperative imaging is performed routinely to guide surgical management in primary hyperparathyroidism, but the optimal imaging modalities are debated. Objective Our objectives were to evaluate which imaging modalities are associated with improved cure rate and higher concordance rates with intraoperative findings. A secondary aim was to determine whether additive imaging is associated with higher cure rate. Design, Setting, and Patients This is a retrospective cohort review of 1485 adult patients during a 14-year period (2004-2017) at an academic tertiary referral center that presented for initial parathyroidectomy for de novo primary hyperparathyroidism. Main Outcome Measures Surgical cure rate, concordance of imaging with operative findings, and imaging performance. Results The overall cure rate was 94.1% (95% confidence interval, 0.93-0.95). Cure rate was significantly improved if sestamibi/single-photon emission computed tomography (SPECT) was concordant with operative findings (95.9% vs. 92.5%, P = 0.010). Adding a third imaging modality did not improve cure rate (1 imaging type 91.8% vs. 2 imaging types 94.4% vs. 3 imaging types 87.2%, P = 0.59). Despite having a low number of cases (n = 28), 4-dimensional (4D) CT scan outperformed (higher sensitivity, specificity, positive predictive value, negative predictive value) all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas. Conclusions Preoperative ultrasound combined with sestamibi/SPECT were associated with the highest cure and concordance rates. If pathology was not found on ultrasound and sestamibi/SPECT, additional imaging did not improve the cure rate or concordance. 4D CT scan outperformed all imaging modalities in multiglandular disease and double adenomas, and sestamibi/SPECT in single adenomas, but these findings were underpowered.

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Recurrent Primary Hyperparathyroidism Occurs More Frequently in Patients with Double Adenomas

Journal of Surgical Research ◽

10.1016/j.jss.2013.11.794 ◽

2014 ◽

Vol 186 (2) ◽

pp. 673

Author(s):

A. Alhefdhi ◽

D. Schneider ◽

R. Sippel ◽

H. Chen

Keyword(s):

Primary Hyperparathyroidism ◽

Double Adenomas

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Recurrent and persistence primary hyperparathyroidism occurs more frequently in patients with double adenomas

Journal of Surgical Research ◽

10.1016/j.jss.2014.02.024 ◽

2014 ◽

Vol 190 (1) ◽

pp. 198-202 ◽

Cited By ~ 24

Author(s):

Amal Alhefdhi ◽

David F. Schneider ◽

Rebecca Sippel ◽

Herbert Chen

Keyword(s):

Primary Hyperparathyroidism ◽

Double Adenomas

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One hundred double adenomas in primary hyperparathyroidism

European Surgery ◽

10.1007/s10353-013-0233-9 ◽

2013 ◽

Vol 45 (6) ◽

pp. 295-300

Author(s):

N. Lehwald ◽

M. Krausch ◽

K. Cupisti ◽

S. Geisler ◽

P. Gerlach ◽

...

Keyword(s):

Primary Hyperparathyroidism ◽

Double Adenomas

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A systematic review of the diagnosis and treatment of primary hyperparathyroidism from 1995 to 2003

Otolaryngology ◽

10.1016/j.otohns.2004.10.005 ◽

2005 ◽

Vol 132 (3) ◽

pp. 359-372 ◽

Cited By ~ 427

Author(s):

James M. Ruda ◽

Christopher S. Hollenbeak ◽

Brendan C. Stack

Keyword(s):

Primary Hyperparathyroidism ◽

Bilateral Neck Exploration ◽

Neck Exploration ◽

Preoperative Imaging ◽

Intraoperative Pth ◽

Multiple Gland Disease ◽

Preoperative Diagnostic ◽

Diagnostic Modalities ◽

Surgical Treatments ◽

Double Adenomas

OBJECTIVE: To systematically review the current preoperative diagnostic modalities, surgical treatments, and glandular pathologies associated with primary hyperparathyroidism. STUDY DESIGN: A systematic literature review. RESULTS: Of the 20,225 cases of primary hyperpara-thyroidism reported, solitary adenomas (SA), multiple gland hyperplasia disease (MGHD), double adenomas (DA), and parathyroid carcinomas (CAR) occurred in 88.90%, 5.74%, 4.14%, and 0.74% of cases respectively. Tc99m-sestamibi and ultrasound were 88.44% and 78.55% sensitive, respectively, for SA, 44.46% and 34.86% for MGHD, and 29.95% and 16.20% for DA, respectively. Postoperative normocalcemia was achieved in 96.66%, 95.25%, and 97.69% of patients offered minimally invasive radio-guided parathyroidectomy (MIRP), unilateral, and bilateral neck exploration (BNE). Intraoperative PTH assays (IOPTH) were helpful in approximately 60% of bilateral neck exploration conversion (BNEC) surgeries. CONCLUSION: The overall prevalence of multiple gland disease (MGD and DA) was lower than often suggested by conventional wisdom. Furthermore, preoperative imaging was less accurate than it is often perceived for accurately imaging MGD. MIRP and UNE were more successful in achieving normo-calcemia than is typically quoted. IOPTH was a helpful but not “fool-proof” adjunct in parathyroid exploration surgery. SIGNIFICANCE: These results support a greater role for the treatment of primary hyperparathyroidism using less invasive approaches. EMB rating: B-3.

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Prospective comparison of high resolution ultrasonography with technetium sestamibi scintigraphy and operative findings in detection of abnormally hyper functioning parathyroid gland/glands in primary hyperparathyroidism

International Surgery Journal ◽

10.18203/2349-2902.isj20164461 ◽

2016 ◽

Vol 4 (1) ◽

pp. 313

Author(s):

Parvez Mohi Ud Din Dar ◽

Munir Ahmad Wani ◽

Khureed Alam Wani ◽

Shariq Rashid Masoodi ◽

Riaz Ahmad Misgar ◽

...

Keyword(s):

High Resolution ◽

Primary Hyperparathyroidism ◽

Parathyroid Gland ◽

Prospective Comparison ◽

Parathyroid Adenomas ◽

99Mtc Mibi ◽

Operative Findings ◽

High Resolution Ultrasonography ◽

Positive Results ◽

Double Adenomas

Background:Ultrasonography is cheap, easily available and convenient modality of diagnosis.Methods: We prospectively studied 61 patients with PHPT. Patients preoperatively underwent USG neck and MIBI scan, results were interpreted independently and compaired with intra operative findings.Results:61 patients who underwent parathyroidectomy for PHPT were studied. Ultrasonography neck showed correct side in 46/51 (90%) and correct site in 32/51 (63%) patients with single parathyroid adenomas. MIBI scan showed correct side and site of parathyroid adenoma in 46/50 (92%) and 43/50 (86%) patients respectively. Patients with double adenomas USG neck showed positive results in all 5 patient with 100% sensitivity where as MIBI scan showed positive results in four out of five patients (80%). 1 patient with four gland hyperplasia USG picked three out of four enlarged glands while as MIBI scan not picked any of the enlarged glands. Operative findings revealed that right lower parathyroid gland was the most common gland involved (54%) followed by left lower (29%), right upper (6.6%), left upper (0%) and multiple / bilateral (9.6%).Conclusions:USG is an affordable, conventional and useful tool in detecting enlarged parathyroid glands in most of the patients with PHPT, but operator dependant. However, when USG can’t detect enlarged parathyroid gland 99mTc-MIBI Scan is complimentary to it.

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