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

Mira Milas, Kristin Wagner, Kirk A. Easley, Allan Siperstein, Collin J. Weber, Gary B. Talpos, R. Lawrence A. Danto, Edwin L. Kaplan, Peter Angelos

Research output: Contribution to journalArticlepeer-review

70 Scopus citations


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 peirent (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.

Original languageEnglish (US)
Pages (from-to)995-1003
Number of pages9
Issue number6
StatePublished - Dec 2003

ASJC Scopus subject areas

  • Surgery


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