title: Localization and operative management of undescended parathyroid adenomas in patients with persistent primary hyperparathyroidism.
abstract: BACKGROUND
  Between 5% and 10% of patients who undergo cervical exploration for primary hyperparathyroidism will have persistent or recurrent hyperparathyroidism. Many of these patients have parathyroid tumors in unusual locations. One such site of ectopic parathyroid tissue is an undescended parathyroid adenoma at or superior to the carotid bifurcation. We describe our experience with the preoperative localization and surgical management of undescended parathyroid adenomas.
  
  
  METHODS
  From 1982 to 1993 a consecutive series of 255 patients have undergone localization studies and surgical exploration for persistent or recurrent hyperparathyroidism at the Clinical Center of the National Institutes of Health. Operative strategy was determined by review of the patient's surgical history, disease reports, and data from localizing studies. Patients with an undescended parathyroid adenoma identified before the operation were examined with a direct approach high in the neck. Patients who did not have definitive preoperative localization were explored with the previous transverse cervical incision.
  
  
  RESULTS
  Seventeen undescended parathyroid adenomas were identified in 255 patients. Thirteen (76%) of 17 patients had an undescended parathyroid adenoma precisely localized before the operation and were examined via a limited, oblique incision high in the neck anterior to the sternocleidomastoid muscle. In the 13 patients who had undergone accurate localization before the operation, the median operative time was 75 minutes compared with 235 minutes for four patients who did not have an undescended parathyroid adenoma identified before the operation and were examined via a previous transverse cervical incision. All patients were cured of their hyperparathyroidism.
  
  
  CONCLUSIONS
  Undescended parathyroid adenomas were the cause of failed cervical exploration in 17 (7%) of 255 patients. Accurate preoperative localization of these lesions is possible in most cases with a combination of noninvasive and invasive modalities. Successful preoperative localization can convert a prolonged exploration of the neck and mediastinum into a brief, curative procedure with minimal morbidity.
authors.affiliation: Surgical Metabolism Section, National Cancer Institute, National Institutes of Health, Bethesda, Md 20892.
authors.forename: K G
authors.initials: KG
authors.lastname: Billingsley
authors.forename: D L
authors.initials: DL
authors.lastname: Fraker
authors.forename: J L
authors.initials: JL
authors.lastname: Doppman
authors.forename: J A
authors.initials: JA
authors.lastname: Norton
authors.forename: T H
authors.initials: TH
authors.lastname: Shawker
authors.forename: M C
authors.initials: MC
authors.lastname: Skarulis
authors.forename: S J
authors.initials: SJ
authors.lastname: Marx
authors.forename: A M
authors.initials: AM
authors.lastname: Spiegel
authors.forename: H R
authors.initials: HR
authors.lastname: Alexander
mesh_terms: D000236:Adenoma / Q000175:diagnosis / Q000601:surgery*; D000328:Adult; D000368:Aged; D002118:Calcium / Q000097:blood; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006961:Hyperparathyroidism / Q000175:diagnosis / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D010282:Parathyroid Neoplasms / Q000175:diagnosis / Q000601:surgery*
chemical_list: D002118:Calcium