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

Kresimira 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 journalArticle

59 Citations (Scopus)

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 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)995-1004
Number of pages10
JournalSurgery
Volume134
Issue number6
DOIs
StatePublished - Dec 2003
Externally publishedYes

Fingerprint

Adenoma
Parathyroid Hormone
Hyperparathyroidism
Technetium
Neck
Parathyroid Diseases
Parathyroid Neoplasms
Primary Hyperparathyroidism
Chi-Square Distribution
Hyperplasia
Referral and Consultation
Observation
Growth

ASJC Scopus subject areas

  • Surgery

Cite this

Milas, K., Wagner, K., Easley, K. A., Siperstein, A., Weber, C. J., Talpos, G. B., ... Angelos, P. (2003). Double adenomas revisited: Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). Surgery, 134(6), 995-1004. https://doi.org/10.1016/j.surg.2003.07.009

Double adenomas revisited : Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). / Milas, Kresimira; Wagner, Kristin; Easley, Kirk A.; Siperstein, Allan; Weber, Collin J.; Talpos, Gary B.; Danto, R. Lawrence A; Kaplan, Edwin L.; Angelos, Peter.

In: Surgery, Vol. 134, No. 6, 12.2003, p. 995-1004.

Research output: Contribution to journalArticle

Milas, K, Wagner, K, Easley, KA, Siperstein, A, Weber, CJ, Talpos, GB, Danto, RLA, Kaplan, EL & Angelos, P 2003, 'Double adenomas revisited: Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease)', Surgery, vol. 134, no. 6, pp. 995-1004. https://doi.org/10.1016/j.surg.2003.07.009
Milas, Kresimira ; Wagner, Kristin ; Easley, Kirk A. ; Siperstein, Allan ; Weber, Collin J. ; Talpos, Gary B. ; Danto, R. Lawrence A ; Kaplan, Edwin L. ; Angelos, Peter. / Double adenomas revisited : Nonuniform distribution favors enlarged superior parathyroids (fourth pouch disease). In: Surgery. 2003 ; Vol. 134, No. 6. pp. 995-1004.
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AU - Milas, Kresimira

AU - Wagner, Kristin

AU - Easley, Kirk A.

AU - Siperstein, Allan

AU - Weber, Collin J.

AU - Talpos, Gary B.

AU - Danto, R. Lawrence A

AU - Kaplan, Edwin L.

AU - Angelos, Peter

PY - 2003/12

Y1 - 2003/12

N2 - 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.

AB - 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.

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