Do parathyroid glands without adenoma need to be removed?

From the Guidelines

No, parathyroid glands without adenomas do not need to be removed, as the primary goal of parathyroid surgery is to remove abnormal glands, such as those with adenomas, while preserving normal functioning parathyroid tissue. This approach is supported by the American College of Radiology's appropriateness criteria for parathyroid adenoma, which emphasizes the importance of targeted surgery to remove only the diseased gland(s) 1. The decision to remove parathyroid glands should be based on intraoperative findings, guided by frozen section pathology and intraoperative parathyroid hormone monitoring to confirm successful removal of all abnormal tissue while preserving normal function.

Key Considerations

• Parathyroid surgery aims to remove abnormal glands, such as those with adenomas, while preserving normal functioning parathyroid tissue 1.
• Removing normal parathyroid glands unnecessarily could lead to hypoparathyroidism, requiring lifelong calcium and vitamin D supplementation.
• In cases of multiple gland disease or hyperplasia, surgeons may perform a subtotal parathyroidectomy or a total parathyroidectomy with autotransplantation of some parathyroid tissue to maintain calcium homeostasis.

Surgical Approaches

• Bilateral neck exploration (BNE) and minimally invasive parathyroidectomy (MIP) are two accepted curative operative strategies for primary hyperparathyroidism (PHPT) 1.
• MIP is often performed for patients with a single adenoma, as it conveys the benefits of shorter operating times, faster recovery, and decreased perioperative costs 1.
• BNE is necessary in cases of discordant or nonlocalizing preoperative imaging or when there is high suspicion for multigland disease (MGD) 1.

From the Research

Parathyroid Gland Removal without Adenoma

• The decision to remove a parathyroid gland without adenoma depends on various factors, including the presence of hyperparathyroidism, gland weight, and pathology 2.
• In cases of primary hyperparathyroidism, a subtotal parathyroidectomy may be performed, which can lead to postoperative hypocalcemia 2.
• The use of preoperative localization studies, such as 18F-Fluorocholine PET/CT, can help identify single adenoma and guide a focused parathyroidectomy without intraoperative parathormone testing 3.
• Minimally invasive parathyroidectomy (MIP) is a targeted approach that can be used to remove the offending parathyroid gland, and it has many advantages over traditional bilateral four-gland exploration, including less operative time, fewer complications, and improved cosmetic results 4.

Indications for Parathyroid Gland Removal

• Patients with primary hyperparathyroidism who have a single adenoma on preoperative localization studies can safely undergo a focused parathyroidectomy without intraoperative parathormone testing 3.
• Patients with renal hyperparathyroidism may require a more extensive surgical approach, including subtotal parathyroidectomy, due to the higher risk of postoperative hypocalcemia 2.
• The management of post-thyroidectomy hypoparathyroidism is not well established, and further research is needed to examine the effects of current treatments, including calcium, vitamin D, and recombinant parathyroid hormone 5.

Surgical Approaches

• Endoscopic parathyroidectomy is a safe and feasible surgical procedure that can be used to remove the parathyroid gland, especially in cases of solitary gland affliction 6.
• The use of intraoperative parathyroid hormone monitoring and preoperative imaging studies can help guide the surgical approach and ensure complete removal of the diseased gland 6.