Evolution of parathyroid pathology identification during concomitant thyroid surgery
Tucker Bettis#
, Logan D. Glosser#, Neil Saunders, Thomas Yamashita, Loreski Collado, Quynh Tran, Anee Jackson, Collin Weber, Jyotirmay Sharma, Snehal G. Patel
Contributions: (I) Conception and design: T Bettis, LD Glosser, SG Patel; (II) Administrative support: None; (III) Provision of study materials or patients: N Saunders, T Yamashita, A Jackson, J Sharma, SG Patel; (IV) Collection and assembly of data: T Bettis, LD Glosser, L Collado, Q Tran, C Weber; (V) Data analysis and interpretation: T Bettis, LD Glosser, SG Patel; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
#These authors contributed equally to this work as co-first authors.
Background: Concomitant thyroid and parathyroid disease is well described, but published series usually report a single combined prevalence and do not separate the mode by which parathyroid pathology is detected at thyroid surgery. We describe the evolution of these patterns at a single academic center.
Methods: We conducted a retrospective cohort study of patients undergoing thyroid surgery at Emory University from January 1999 to December 2025 (parent cohort, n=10,871). Patients with parathyroid pathology found at the same operation were identified by manual chart review (n=128) and reconciled against the institutional research dataset, yielding 125 patients after exclusions. Each patient was classified into a surgical-intent pathway: planned preoperative diagnosis, intraoperative discovery, or incidental pathology finding. Differences in pathway distribution across eras were evaluated descriptively and with Pearson chi-square testing. Exploratory analyses are reported in the supplement.
Results: Among 125 patients (76% female; median age 60 years), the surgical-intent pathway was planned in 96 (76.8%), intraoperative discovery in 22 (17.6%), and incidental pathology finding in 7 (5.6%). The planned pathway rose from 29 of 45 cases (64%) in 1999–2009 to 31 of 32 (97%) in 2020–2025, while intraoperative or incidental findings decreased from 16 of 45 (36%) to 1 of 32 (3%). Coexisting thyroid malignancy was present in 35 of 125 patients (28%); of these, 31 (89% of thyroid neoplasms) were papillary thyroid carcinoma, median tumor size was 0.8 [interquartile range (IQR), 0.4–1.1] cm, and 19 (54%) were T1a.
Conclusions: At this institution, parathyroid pathology detected during concomitant thyroid surgery shifted from intraoperative or incidental discovery toward planned preoperative identification over a 27-year period. Most coexisting malignancies were small, low-stage papillary carcinomas. The 28% rate reflects a selected combined-operation cohort and should not be generalized to all primary hyperparathyroidism patients.
Keywords: Parathyroid adenoma; concomitant thyroidectomy; primary hyperparathyroidism (PHPT); papillary thyroid carcinoma; era trends
Submitted Jun 05, 2026. Accepted for publication Jul 20, 2026. Published online Jul 30, 2026.
doi: 10.21037/gs-2026-0326
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Key findings
• Over a 27-year period, concomitant parathyroid pathology detected during thyroid surgery shifted from intraoperative or incidental discovery toward planned preoperative identification.
• By 2020–2025, nearly all concomitant parathyroid pathology in this cohort was recognized before surgery.
• Coexisting thyroid malignancy was most commonly low-stage papillary thyroid carcinoma.
What is known and what is new?
• Concomitant thyroid and parathyroid disease has been previously described, but most published series report only a combined prevalence without distinguishing how parathyroid pathology is detected during thyroid surgery.
• This study introduces a classification framework with three pathways—planned preoperative diagnosis, intraoperative discovery, and incidental pathology finding—and demonstrates a substantial temporal shift toward planned identification.
What is the implication, and what should change now?
• Contemporary endocrine surgical practice increasingly identifies concomitant parathyroid disease before surgery, likely reflecting advances in imaging, referral patterns, and standardized preoperative endocrine evaluation.
• Future studies evaluating concomitant thyroid and parathyroid disease should distinguish operative-intent pathways rather than reporting pooled prevalence alone.
Introduction
Coexisting thyroid and parathyroid disease has been recognized for decades, beginning with early reports of thyroid carcinoma found in patients undergoing surgery for primary hyperparathyroidism (PHPT) (1). Reported thyroid carcinoma rates in PHPT series vary widely—approximately 2% to 18%—reflecting differences in denominator, geography, ultrasound use, and operative selection (2-7). In principle, the thyroid and parathyroid glands should always be evaluated together in the preoperative period; however, in classical series this has not consistently been the case, contributing to considerable heterogeneity and a lack of standardization across studies and patient cohorts. The American Association of Endocrine Surgeons (AAES) recommends that clinically relevant thyroid disease be assessed preoperatively and managed during parathyroidectomy (8), a position echoed by the Fifth International Workshop on Primary Hyperparathyroidism (9); the 2015 American Thyroid Association (ATA) guidelines provide ultrasound-based thresholds for nodule evaluation (10). Institutional experience has continued to emphasize the value of concurrent thyroid–parathyroid evaluation and the impact of routine preoperative biochemical screening (11), as well as the frequency with which parathyroid tissue is encountered during thyroid surgery (12,13).
Most published series do not separate the different clinical pathways by which parathyroid pathology is detected at thyroid surgery. In practice, parathyroid disease may be diagnosed preoperatively and addressed as part of a planned operation; recognized intraoperatively during a thyroid-focused operation; or identified only at final histopathology. How these pathways have changed across a long observation period has not been described.
We assembled a 27-year thyroid-operative cohort to describe (I) the relative frequency of planned, intraoperative-discovery, and incidental-pathology pathways; (II) how those pathways changed over time; and (III) the spectrum of coexisting thyroid malignancy in this selected combined-operation population. We present this article in accordance with the STROBE reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0326/rc).
Methods
Setting and cohort
A retrospective cohort study was conducted, a tertiary academic referral center. The parent operative cohort comprised 10,871 patients who underwent thyroid surgery between January 1999 and December 2025 (27-year span). Patients with parathyroid pathology found at the same operation were detected by manual chart review of the institutional surgical-pathology dataset (n=128) and reconciled against the institutional research dataset.
Inclusion criteria: adult patients (≥18 years) who underwent thyroid surgery at Emory University between 1999 and 2025 and in whom parathyroid pathology (adenoma, hyperplasia, or pathology text describing both) was documented in the surgical-pathology report from the same operation.
Exclusion criteria: secondary or tertiary hyperparathyroidism, multiple endocrine neoplasia syndromes, parathyroid carcinoma, re-operation for previously diagnosed parathyroid disease, and patients younger than 18 years. Three additional patients were excluded after reconciliation (two without a research-dataset record and one with a specimen label that did not match specimen content). The final analytic cohort comprised 125 patients.
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Emory University (No. #2026P000179) and individual consent for this retrospective analysis was waived.
Definitions
Each patient was classified into a surgical-intent pathway based on structured review of preoperative clinic notes, referral records, and operative reports. Planned preoperative diagnosis required both: (I) explicit documentation of PHPT (or suspected parathyroid pathology) in the preoperative consultation or clinic note; and (II) inclusion of parathyroidectomy as a stated component of the operative plan in the operative note or consent. Intraoperative discovery meant that parathyroid pathology was recognized during an operation undertaken primarily for thyroid disease and resected during the same operation, without preoperative documentation of parathyroid disease. Incidental pathology finding meant that parathyroid pathology was identified only at final histopathologic review, without preoperative or intraoperative recognition. Classification was performed by two independent reviewers, with senior-author adjudication of discordant cases.
Variables
Extracted variables included demographics (age, sex, race), surgical era (1999–2009, 2010–2014, 2015–2019, 2020–2025), surgical-intent pathway, pathology subgroup (adenoma; hyperplasia; pathology text describing both), and malignant thyroid histopathology [histology subtype, tumor size, multifocality, invasion, extrathyroidal extension, and pT distribution per American Joint Committee on Cancer (AJCC) 8th edition, worst per patient]. Postoperative morbidity variables included transient hypocalcemia, permanent hypoparathyroidism, and permanent recurrent-laryngeal-nerve injury.
Statistical analysis
Categorical variables are reported as counts and percentages; continuous variables as medians with interquartile ranges (IQRs). The primary analysis was descriptive. Differences in pathway distribution across eras were evaluated with a Pearson Chi-squared test (era × pathway); two-sided P values are reported. Pre-specified exploratory sensitivity analyses (post-2009 electronic-medical-record-mature subset; cohort excluding incidental-pathology cases) were performed and are reported in the supplement. Missing data were not imputed; incompleteness of legacy-era preoperative imaging documentation is noted where relevant and is addressed by the sensitivity analyses. Analyses were performed in Python 3.13 (SciPy 1.15.3).
Results
Cohort characteristics
Of 10,871 thyroid-operative patients between 1999 and 2025, 125 (1.1%) had parathyroid pathology identified at the same operation and constituted the analytic cohort (Figure 1). Ninety-five (76.0%) were female, and median age was 60 (IQR, 51–67) years (Table 1). Operative morbidity was low: postoperative hypocalcemia occurred in 2 patients (1.6%), and no permanent hypoparathyroidism or permanent recurrent-laryngeal-nerve injury was observed.
Table 1
| Variable | Planned (n=96) | Intraoperative discovery (n=22) | Incidental pathology finding (n=7) | All (n=125) |
|---|---|---|---|---|
| Age (years) | 61 [51–69] | 56 [49–63] | 51 [35–64] | 60 [51–67] |
| Female | 73 (76.0) | 17 (77.3) | 5 (71.4) | 95 (76.0) |
| Race—White | 52 (54.2) | 13 (59.1) | 3 (42.9) | 68 (54.4) |
| Race—Black | 35 (36.5) | 6 (27.3) | 4 (57.1) | 45 (36.0) |
| Race—Asian | 1 (1.0) | 0 (0.0) | 0 (0.0) | 1 (0.8) |
| Race—other/unknown | 8 (8.3) | 3 (13.6) | 0 (0.0) | 11 (8.8) |
| Pathology—adenoma | 56 (58.3) | 13 (59.1) | 2 (28.6) | 71 (56.8) |
| Pathology—mixed adenoma/hyperplasia wording | 35 (36.5) | 7 (31.8) | 2 (28.6) | 44 (35.2) |
| Pathology—hyperplasia | 5 (5.2) | 2 (9.1) | 3 (42.9) | 10 (8.0) |
| Coexisting thyroid malignancy | 27 (28.1) | 6 (27.3) | 2 (28.6) | 35 (28.0) |
| Papillary thyroid carcinoma† | 25 (92.6) | 4 (66.7) | 2 (100.0) | 31 (88.6) |
| Follicular carcinoma† | 2 (7.4) | 0 (0.0) | 0 (0.0) | 2 (5.7) |
| Medullary thyroid carcinoma† | 0 (0.0) | 2 (33.3) | 0 (0.0) | 2 (5.7) |
| Postoperative hypocalcemia | 2 (2.1) | 0 (0.0) | 0 (0.0) | 2 (1.6) |
| Permanent hypoparathyroidism | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
| Permanent recurrent-laryngeal-nerve injury | 0 (0.0) | 0 (0.0) | 0 (0.0) | 0 (0.0) |
Data are presented as n (%) or median [interquartile range]. †, percentages for thyroid carcinoma subtypes are calculated as a proportion of coexisting thyroid malignancies within each pathway (denominator equals the coexisting-malignancy count in the row above), not of the total cohort. “Mixed adenoma/hyperplasia wording” denotes pathology text containing both descriptors.
The surgical-intent pathway was planned preoperative diagnosis in 96 patients (76.8%), intraoperative discovery in 22 (17.6%), and incidental pathology finding in 7 (5.6%). Parathyroid pathology was adenoma in 71 (56.8%), hyperplasia in 10 (8.0%), and pathology text describing both adenoma and hyperplasia in 44 (35.2%). Coexisting thyroid malignancy rates were similar across pathways: 27 of 96 planned patients (28.1%), 6 of 22 intraoperative-discovery patients (27.3%), and 2 of 7 incidental-pathology patients (28.6%).
Era shift
The relative frequency of the three modes of identification changed across the 27-year observation period (Table 2, Figure 2). The planned pathway accounted for 29 of 45 operations (64%) in 1999–2009, 19 of 30 (63%) in 2010–2014, 17 of 18 (94%) in 2015–2019, and 31 of 32 (97%) in 2020–2025. Intraoperative-discovery and incidental-pathology findings together fell from 16 of 45 cases (36%) in 1999–2009 to 1 of 32 (3%) in 2020–2025. Detailed pathology-subgroup distributions by era and surgical-intent pathway are provided in Table S1.
Table 2
| Era | Planned, n [%] | Intraoperative, n [%] | Incidental, n [%] | Total, n |
|---|---|---|---|---|
| 1999–2009 | 29 [64] | 10 [22] | 6 [14] | 45 |
| 2010–2014 | 19 [63] | 10 [34] | 1 [3] | 30 |
| 2015–2019 | 17 [94] | 1 [6] | 0 [0] | 18 |
| 2020–2025 | 31 [97] | 1 [3] | 0 [0] | 32 |
| All eras | 96 [77] | 22 [18] | 7 [5] | 125 |
Percentages are calculated within each era row and may not sum to exactly 100 owing to rounding; the raw numerators/denominators are shown in the manuscript text. Pearson Chi-squared P<0.001 for the era × pathway association.
Coexisting thyroid malignancy
Coexisting thyroid malignancy was identified in 35 of 125 patients (28.0%) (Table 3). Papillary thyroid carcinoma accounted for 31 of 35 (89% of all thyroid neoplasms), follicular carcinoma for 2 of 35 (6%), and medullary thyroid carcinoma for 2 of 35 (6%). The median greatest tumor dimension was 0.8 (IQR, 0.4–1.1; range, 0.08–6.3) cm; 19 of 35 (54%) were T1a, and no pT4 disease was identified. Any extrathyroidal extension was identified in 8 of 35 patients (23%), and multifocality in 5 of 35 (14%). Detailed nodal (pN) and invasion features are reported in Table S2. Preoperative imaging utilization by surgical-intent pathway is summarized in Table S3, and pre-specified sensitivity analyses for the era trend are reported in Table S4.
Table 3
| Variable | Value |
|---|---|
| Papillary thyroid carcinoma | 31 [89] |
| Follicular carcinoma | 2 [6] |
| Medullary thyroid carcinoma | 2 [6] |
| Greatest tumor dimension (cm) | 0.8 (0.4–1.1) |
| Multifocality | 5 [14] |
| Any extrathyroidal extension | 8 [23] |
| pT—T1a | 19 [54] |
| pT—T1b | 7 [20] |
| pT—T2 | 4 [11] |
| pT—T3a | 1 [3] |
| pT—T3b | 4 [11] |
| Total lymph nodes involved/examined | 15/97 |
Data are presented as n [%], median (interquartile range), or n. T-stage uses the American Joint Committee on Cancer 8th edition, worst per patient. Percentages are calculated over 35 patients with coexisting thyroid malignancy; pT percentages may not sum to exactly 100 owing to rounding. Detailed nodal (pN) and invasion features are reported in Table S2. N, node; T, tumor.
Discussion
Over this 27-year period, concomitant parathyroid disease was increasingly detected preoperatively rather than intraoperatively. Early-era cases were often discovered during operations undertaken primarily for thyroid disease; by 2020–2025, nearly all parathyroid pathology came to the operating room as a known preoperative diagnosis. In short: at this institution, incidental and intraoperative parathyroid findings during thyroid surgery have become uncommon.
Several concurrent developments plausibly underlie this shift. First, wider adoption of routine preoperative biochemical screening—including serum calcium and, more recently, parathyroid hormone (PTH)—before thyroid surgery has increased detection of previously silent PHPT (11). Second, the introduction and standardization of high-resolution cervical ultrasound and the American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) framework provided a consistent means of characterizing thyroid nodules and prompted earlier recognition of coexistent parathyroid enlargement (10). Third, institutional practice evolved toward multidisciplinary endocrine-tumor evaluation with earlier involvement of endocrinology, endocrine surgery, and radiology, consistent with contemporary AAES and international-workshop recommendations (8,9).
A notable inflection is evident between 2010–2014 (63% planned) and 2015–2019 (94% planned). At our institution, this coincided with the adoption of the 2015 ATA thyroid nodule guidelines (10), broader clinical uptake of TI-RADS reporting, and the transition to a dedicated endocrine-surgery service model with routine preoperative endocrinology co-evaluation. Although causation cannot be established from a descriptive cohort, the temporal alignment between practice-guideline updates and the observed shift in identification pathway is striking.
Context within the literature
The 28% coexisting thyroid malignancy rate is best understood through the denominator (Table 4). Ordered chronologically to match Table 4, PHPT-denominator series report lower rates: approximately 2% in Bentrem et al. (7), 10.6% in Ogawa et al. (6), 6% thyroid cancer in the 200-patient parathyroidectomy series by Morita et al. (3), 2.8% in Lehwald et al. (5), and 8.1% incidental thyroid carcinoma in Riss et al. (4). The Gland Surgery report by Wright et al. is the closest journal-specific comparator (2). Our cohort most closely reflects a selected combined-operative population, and this rate reflects that selection rather than the broader PHPT population.
Table 4
| Study | Denominator | Coexisting thyroid malignancy |
|---|---|---|
| Bentrem et al., Thyroid 2002 (7) | PHPT surgical 25-year series (n=580) | ~2% |
| Ogawa et al., Thyroid 2007 (6) | PHPT with systematic US/FNAB (n=85) | 10.6% |
| Morita et al., Surgery 2008 (3) | Parathyroidectomy patients (n=200) | 6% |
| Murray et al., J Surg Res 2012 (11) | Thyroidectomy patients with concomitant PHPT (n=56) | 39% (malignancy as thyroid operative indication) |
| Lehwald et al., Horm Metab Res 2013 (5) | Unselected PHPT surgical (n=1,464) | 2.8% |
| Riss et al., Ann Surg Oncol 2015 (4) | PHPT surgical series (n=1,065) | 8.1% |
| Wright et al., Gland Surg 2017 (2) | Combined thyroid/parathyroid referrals (n=621) | 10.75%/24.27% concomitant diagnosis |
| Current cohort | Selected thyroid-operative with parathyroid pathology (n=125) | 28.0% |
Studies are ordered chronologically from oldest to most recent. Rates for the current cohort should not be interpreted as the prevalence of thyroid malignancy in all PHPT patients; see “Discussion”—“Context within the literature” section. Ca, serum calcium; FNAB, fine-needle aspiration biopsy; PHPT, primary hyperparathyroidism; PTH, parathyroid hormone; US, ultrasound.
The relatively low overall rate of concomitant parathyroid pathology in the parent thyroid-surgery cohort (125 of 10,871; 1.1%) also merits comment. Contemporary high-volume endocrine surgery centers increasingly perform routine preoperative measurement of both serum calcium and PTH before thyroid surgery, a practice that can increase detection of coexistent parathyroid disease (11). Our observed 1.1% rate may in part reflect evolving biochemical evaluation practices over the study period rather than a stable biological prevalence.
A shift in pathology subgroup distribution is also apparent across eras (Table S1). Adenoma predominated in earlier eras (23 of 45, 51% in 1999–2009), while cases with pathology text describing both adenoma and hyperplasia (“mixed”) accounted for a larger proportion in more recent periods (17 of 32, 53% in 2020–2025). Possible explanations include evolution in histopathologic reporting conventions, improved preoperative localization allowing recognition of multiglandular disease, and greater awareness of parathyroid hyperplasia as a co-occurring finding. This shift may also reflect the transition from bilateral neck exploration toward focused, image-guided parathyroidectomy in the modern era.
Practice implications and outcome considerations
The clinical implication is that modern surgeons evaluating concomitant thyroid and parathyroid disease should expect most parathyroid pathology in this setting to be recognized before surgery rather than discovered intraoperatively. Whether this trend is generalizable beyond a high-volume academic endocrine surgery program is uncertain; other high-volume centers with routine preoperative biochemical screening and multidisciplinary evaluation may plausibly observe similar shifts, but low-volume centers with less standardized preoperative workflows may not. External validation from other institutional cohorts would be valuable.
Operative morbidity in this selected cohort was low (postoperative hypocalcemia 2 of 125, 1.6%; no permanent hypoparathyroidism or permanent recurrent-laryngeal-nerve injury). We did not systematically capture operative time, length of stay, biochemical cure rates, disease recurrence, or long-term complications; these outcomes were unavailable in the current dataset and represent an important direction for future work.
Strengths and limitations
Strengths include the 27-year observation window, manual chart-review cohort assembly with reconciliation against an institutional research dataset, and a three-category classification of how parathyroid pathology was detected. Several limitations should be considered. This is a single-institution, selected thyroid-operative cohort, and prevalence estimates are not generalizable to all PHPT patients. Preoperative imaging documentation is incomplete in the legacy era; sensitivity analyses are provided in Table S4. Identification of incidental parathyroid pathology on histopathology depends on the pathologist actively evaluating for parathyroid tissue; without a standardized instruction to do so, both normal and pathologically altered parathyroid tissue may be overlooked, and the true rate of incidental findings may exceed the 5.6% reported here. Series that specifically audit parathyroid tissue in thyroidectomy specimens report substantially higher rates of incidental parathyroidectomy (12,13). In the most recent period [2020–2025], only 1 of 32 cases followed a non-planned pathway, so estimates for contemporary practice rest on a small denominator. The exploratory malignant-versus-benign comparison is underpowered. Beyond transient hypocalcemia, we did not test operative time, length of stay, biochemical cure, or recurrence.
Conclusions
At this institution, parathyroid pathology detected during concomitant thyroid surgery shifted from intraoperative or incidental discovery toward planned preoperative identification over a 27-year period. Most coexisting malignancies were small, low-stage papillary carcinomas.
Acknowledgments
The authors thank Diya Patel for assistance with figure design and visual preparation for this manuscript.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0326/rc
Data Sharing Statement: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0326/dss
Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0326/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2026-0326/coif). The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Emory University (No. #2026P000179) and individual consent for this retrospective analysis was waived.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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