Surgical treatment of double parathyroid adenomas in primary hyperparathyroidism: A clinical case

INTRODUCTION: The frequency of occurrence of double parathyroid adenomas in patients with primary hyperparathyroidism is from 2 to 11% of cases. Nowadays, double adenomas remain a difficult diagnostic and therapeutic task. PRESENTATION OF CASE: A 64-year-old woman was referred to an endocrine surgeon to evaluate a persistently elevating level of calcium. In the biochemical analysis the serum level of total calcium was increased - 2.79 mmol/l, ionized calcium - 1.64 mmol/l, parathyroid hormone - 191.4 pg/mL. Ultrasound and MSCT scan of the neck showed an increase of the parathyroid glands under the lower poles of both lobes of the thyroid gland. No functionally active parathyroid glands were found on scintigraphy. The patient underwent bilateral neck exploration with identification of all four parathyroid glands and a double parathyroid adenomectomy. According to a histological study, the removed parathyroid glands are represented by adenomas from the dark main cells. Remission of primary hyperparathyroidism was achieved. DISCUSSION: This clinical report confirms the literature on a decrease in the sensitivity of imaging methods in the diagnosis of double adenomas. A decrease in the effectiveness of intraoperative monitoring of parathyroid hormone with double adenomas was confirmed. In this patient, a double parathyroid adenomectomy was sufficient to achieve remission of hyperparathyroidism. CONCLUSION: With double adenomas, a comprehensive assessment of all imaging methods is required. A positive test during intraoperative monitoring of IPTG does not exclude a double adenoma in a patient. It is necessary to perform a bilateral neck exploration with identification of all parathyroid glands.