Parathyroid "double adenomas": fact of fiction?

It has been suggested that primary hyperparathyroidism (HPT) may occasionally be caused by "multiple adenomas." If this is true, then selective excision of the enlarged glands should be curative in such cases. To examine this proposition, we reviewed the records of 1,962 patients with surgically proved HPT and culled all those who met the following criteria: (1) identification and excision of two enlarged and histologically hypercellular parathyroid glands, each weighing more than 70 mg, and (2) identification and preservation of two other normal-sized parathyroid glands. There were 38 such patients (1.9% of the total group). Thirty-seven patients were euparathyroid at follow-up (an average of 4.6 years postoperatively). Only one individual, a member of a kindred with multiple endocrine neoplasia (MEN), type 1, had persistent HPT; but four other patients with MEN syndromes were among the group cured by surgery. The findings of this study support the notion that more than one adenoma may occasionally be found in primary HPT, and that selective excision of the enlarged glands with preservation of the normal parathyroid glands constitutes adequate treatment. One possible exception to this rule is the patient with either familial HPT or one of the MEN syndromes; subtotal parathyroidectomy is preferred in this situation.