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The truth about double adenomas: incidence, localization, and IOPTH
*Lucia De Gregorio, *Carrie C Lubitz, Richard A Hodin, *Randall D Gaz, *Sareh Parangi, *Roy Phitayakorn, *Antonia E Stephen
Massachusetts General Hospital, Boston, MA
Objective: Determine the incidence of double parathyroid adenoma and analyze the utility of localization studies and intra-operative parathyroid hormone (IOPTH) assay in this setting.
Design: Retrospective review of a series of 1076 consecutive parathyroid surgical operations, from 2010 to 2013.
Setting: Academic medical center.
Patients: 1039 consecutive patients underwent surgical exploration for primary hyperparathyroidism. Inclusion criteria were: first-time operation and 6 month minimum post-operative follow-up. MEN syndrome patients were excluded. 504 patients met the inclusion criteria.
Interventions: Neck exploration and parathyroidectomy of identified abnormal parathyroid glands.
Main Outcome Measures: According to the surgical findings, the series was divided into single gland disease (SGD), double gland disease (DGD) and multiple gland disease (MGD, more than two glands). The sensitivity of ultrasound (US), 99mTechnethium-sestamibi (MIBI) and 4-dimensional computerized tomography (4DCT) to correctly lateralize each gland in the DGD group was calculated. The results of the IOPTH assay, and how this impacted the extent of surgery, were analyzed.
Results: 347 patients had SGD (69%), 68 patients had DGD (13.5%) and 86 had MGD (17%). In the DGD group, sensitivity of US, MIBI and 4DCT to lateralize each adenoma was 42%, 34.5% and 64%, respectively. Initially, 27 patients (40%) with DGD had been planned for a focal exploration. 22 planned focal explorations were extended to BNE. The conversion to BNE was due to the IOPTH assay in 18 cases (two thirds of the initially planned focal explorations). At 6 month follow up, all DGD patients were normocalcemic.
Conclusions: Localization studies in DGD can be misleading by reporting SGD. 4DCT seems to have the highest sensitivity. In focal explorations, biochemical cure should be verified by IOPTH measurement.
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