Abstract
Two-hundred seventy-four patients with primary hyperparathyroidism had selective removal of enlarged parathyroid glands. Biopsies were taken from all parathyroid glands. Normal-size glands were not resected irrespective of their histological appearance. After a mean follow-up of 13.5 years the rates of persistent and recurrent hyperparathyroidism were, respectively, 3.6% and 0.7%. Transient and permanent hypoparathyroidism occurred in 24% and 2.5% of the patients. The microscopic appearance of enlarged glands and of biopsies taken from normal-size glands were reviewed by two pathologists. Normal parathyroid glands were distinguished from abnormal glands fairly accurately (sensitivity 93%, specificity 80%). Microscopic classification of abnormal parathyroid glands as adenomas or hyperplastic glands correlated poorly with the gross classification as single or multigland disease. Flow cytometric DNA analysis of paraffin embedded parathyroid tissue showed significant differences for DNA index, % S-phase and % G2M (p<0.001). Differentiating single from multigland disease by means of DNA analysis was not possible. In conclusion, removal of only enlarged parathyroid glands results in acceptable rates of persistent and recurrent hyperparathyroidism. Biopsies should only be taken sparingly to prevent transient and permanent hypoparathyroidism. Microscopic examination and flow cytometric DNA analysis can differentiate normal from abnormal parathyroid glands but are unable to differentiate abnormal glands into single or multigland disease.
Résumé
Deux cent soixante quatorze patients ayant une hyperparathyroïdie primaire ont eu une exérèse élective des glandes parathyroïdes hypertrophiques. Des biopsies ont été prélevées au niveau de toutes les glandes parathyroïdiennes. Les glandes de taille normale ont été laissées en place quel que soit leur aspect histologique. Après un suivi moyen de 13.5 ans, les taux d'hyperparathyroïdie persistante et de récidive étaient observés chez 3.6% et 2.5% des patients. Une hypoparathyroïdie transitoire est survenue dans 24% des cas et elle était permanente chez 2.5% des patients. Les lames provenant des glandes hypertrophiques et des biopsies réalisées au niveau des glandes de taille normale ont été revues par deux anatomopathologistes. On a pu distinguer les glandes parathyroïdes normales des glandes anormales avec une assez bonne précision (sensibilité 93%, spécificité 80%). La classification histologique des anomalies parathyroïdiennes en adénome et en hyperplasie était mal correlée à la classification selon le caractère unique ou multiple de l'atteinte glandulaire. Une analyse de l'ADN par cytométrie de flux sur les coupes de issu parathyroïdien inclus dans la paraffine a montré des différences significatives en ce qui concerne l'index ADN, le pourcentage de phase S et de G2M (p<0.001). Il n'était pas possible, d'après l'analyse de l'ADN, de faire la différence entre atteinte uni ou pluriglandulaire. En conclusion, l'éxérèse des seules glandes hypertrophiques donne des résultats acceptables en ce qui concerne le taux de persistance ou de récidive de l'hyperparathyroïdie. Des biopsies ne devraient être prélevées que dans des cas sélectionnés pour prévenir l'hypoparathyroïdie permanente ou transitoire. L'examen histologique et l'analyse par cytométrie de flux peuvent différencier les glandes normales des parathyroïdes pathologiques mais ne sont pas capables de distinguer atteintes uni et multiglandulaires.
Resumen
Doscientos setenta y cuatro pacientes con hiperparatiroidismo primario fueron sometidos a resección selectiva de las glándulas paratiroides aumentadas de tamaño. Se tomaron biopsias de la totalidad de las glándulas paratiroides; las paratiroides de tamaño normal fueron dejadas, sin tener en cuenta la apariencia microscópica. En un seguimiento promedio de 13.5 años las tasas de hiperparatiroidismo persistente o recurrente fueron 3.6% y 2.5%, respectivamente. Se observó hipoparatiroidismo transitorio en 24% y permanente en 2.5% de los pacientes. Los cortes microscópicos de las glándulas aumentadas de tamaño y de las biopsias de las glandulas de tamaño normal fueron revisadas por dos patólogos. La diferencia entre glándulas normales y glándulas anormales fue establecida con bastante certeza (sensibilidad=93%, especificidad=80%). La clasificación microscópica de las glándulas anormales entre adenomas e hiperplasia se correlacionó pobremente con la clasificación macroscópica entre enfermedad uniglandular o enfermedad multiglandular. El análisis de DNA por citometría de flujo del tejido paratiroideo incluido en parafina demostró difereneias significativas en cuanto al índice de DNA, el % de formas S y el % de G2M (p<0.001). La diferenciación entre enfermedad uniglandular y enfermedad multiglandular no fue posible mediante el análisis de DNA. En conclusión, la resección de sólo las paratiroides aumentadas de tamano resulta en tasas aceptables de hiperparatiroidismo persistente o recurrente. Sólo ocasionalmente se deben tomar biopsias, para así evitar el hipoparatiroidismo transitorio o permanente. El examen microscópico y el análisis de DNA por citometria de flujo pueden diferenciar entre glándulas paratiroides normales y glándulas anormales, pero no entre enfermedad uniglandular y enfermedad multiglandular.
Article PDF
Similar content being viewed by others
Avoid common mistakes on your manuscript.
References
Rudberg, C., Akerstrom, G., Palmer, M., Ljunghall, S., Adami, H. O., Johansson, H., Grimelius, L., Thoren, L., Berstrom, R.: Late results of operation for primary hyperparathyroidism. Surgery99:643, 1986
McGarity, W.C., McKeown, P.P., Sewell, C.W.: The role of routine biopsy of all parathyroid glands in primary hyperparathyroidism. Am. Surg.51:8, 1985
Cooke, T.J.C., Boey, J.H., Sweeney, C.W.: Parathyroidectomy: Extent of resection and late results. Br. J. Surg.64:153, 1977
Black, W.C., Utley, J.R.: The differential diagnosis of parathyroid adenomas and chief cell hyperplasia. Am. J. Clin. Pathol.49:761, 1967
Saxe, A.W., Baier, R., Tesluk, H., Toerson, W.: The role of the pathologist in the surgical treatment of hyperparathyroidism. Surg. Gynecol. Obstet.161:101, 1985
Clark, O.H., Way, L.W., Hunt, T.K.: Recurrent hyperparathyroidism. Ann. Surg.179:729, 1974
Wells, S.A., Leight, G.S., Hensley, M., Dilley, W.G.: Hyperparathyroidism associated with the enlargement of two or three parathyroid glands. Ann. Surg.202:533, 1985
Paloyan, E., Paloyan, D., Pickleman, J.R.: Hyperparathyroidism today. Surg. Clin. North Am.53:211, 1973
Haff, R.C., Amstrong, R.G.: Trends in the current management of primary hyperparathyroidism. Surgery75:715, 1974
Irvin, G.L., Bagwell, C.B.: Identification of histologically undetectable parathyroid hyperplasia by flow cytometry. Am. J. Surg.138:567, 1979
Irvin, G.L., Taupier, M.A., Block, N.L., Reiss, E.: DNA patterns in parathyroid disease predict postoperative parathyroid hormone secretion. Surgery104:115, 1988
Bowlby, L.S., DeBault, L.E., Abraham, S.R.: Flow cytometric DNA analysis and parathyroid surgery. Am. J. Pathol.128:338, 1987
Rosen, I.B., Musclow, C.E.: DNA histograms of parathyroid tissue in determining extent of parathyroidectomy. Surgery98:1024, 1985
Lamers, C.B.H.W., Froeling, P.G.A.M.: Clinical significance of hyperparathyroidism in familial multiple endocrine adenomatosis type I (MEA I). Am. J. Med.66:422, 1979
Ghandur-Mnaymneh, L., Kimura, N.: The parathyroid adenoma: A histologic definition with a study of 172 cases of primary hyperparathyroidism. Am. J. Pathol.115:70, 1984
Van de Geer, J.P.: Introduction to Multivariate Analysis for the Social Sciences, W.H. Freeman and Company, San Francisco, 1982, pp. 201–254
Bruining, H.A., Van Houten, H., Juttmann, J.R., Lamberts, S.W.J., Birkenhager, J.C.: Results of operative treatment of 615 patients with primary hyperparathyroidism. World J. Surg.5:85, 1981
Thompson, N.W.: The techniques of initial parathyroid exploration and reoperative parathyroidectomy. In Endocrine Surgery Update, N.W. Thompson, A.I. Vinik, editors, Grune and Stratton, New York, 1985, pp. 365–374
Edis, A.J.: Surgical anatomy and technique of neck exploration for primary hyperparathyroidism. Surg. Clin. North Am.57:495, 1977
Rothmund, M.: Therapie des primären hyperparathyreodismus. In Hyperparathyreodismus, M. Rothmund, editor, Georg Thieme Verlag, Stuttgart-New York, 1980, pp. 160–165
Tibblin, S., Bondeson, A.G., Ljungberg, O.: Unilateral parathyroidectomy for solitary parathyroid adenoma. In Fortschritte der Endokrinologischen Chirurgie, M. Rothmund, F. Kummerle, editors, Georg Thieme Verlag, Stuttgart-New York, 1981, pp. 114–119
Wang, C.A.: Surgical management of primary hyperparathyroidism. Curr. Probl. Surg.12:11, 1985
Edis, A.J., Beahrs, O.H., Van Heerden, J.A., Akwari, O.E.: “Conservative” versus “liberal” approach to parathyroid neck exploration. Surgery92:827, 1977
Kaplan, E.L., Bartlett, S., Sugimoto, J., Fredland, A.: Relation of postoperative hypocalcemia to operative techniques: Deleterious effects of excessive use of parathyroid biopsy. Surgery92:827, 1982
Bondeson, A.G., Bondeson, L., Ljungberg, O., Tibblin, S.: Fat staining in parathyroid disease: Diagnostic value and impact on surgical strategy: Clinicopathologic analysis of 191 cases. Hum. Pathol.16:1255, 1985
Dufour, D.R., Wilkerson, S.Y.: The normal parathyroid revisited: Percentage of stromal fat. Hum. Pathol.13:717, 1982
Dekker, A., Dunsford, H.A., Geyer, S.J.: The normal parathyroid gland at autopsy: The significance of stromal fat in adult patients. J. Pathol.128:127, 1979
Paloyan, E., Lawrence, A.M., Baker, W.H., Straus, F.H.: Near-total parathyroidectomy. Surg. Clin. North Am.49:43, 1969
Myers, R.T.: Follow-up study of surgically treated primary hyperparathyroidism. Ann. Surg.179:729, 1974
Harlow, S., Roth, S.I., Marshall, R.B.: Flow cytometric DNA analysis of normal and pathologic parathyroid glands. Mod. Pathol.4:310, 1991
Joensuu, H., Klemi, P.J.: DNA analysis in adenomas of endocrine organs. Am. J. Pathol.132:145, 1988
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Bonjer, H.J., Bruining, H.A., Birkenhager, J.C. et al. Single and multigland disease in primary hyperparathyroidism: Clinical follow-up, histopathology, and flow cytometric DNA analysis. World J. Surg. 16, 737–743 (1992). https://doi.org/10.1007/BF02067373
Issue Date:
DOI: https://doi.org/10.1007/BF02067373