The results of surgery for mediastinal parathyroid tumors: a comparative study of 63 patients

Robotic transthoracic approach to ectopic mediastinal parathyroid adenoma: A case report

INTRODUCTION

Ectopic parathyroid adenomas represent an important cause of refractory hyperparathyroidism. While most ectopic mediastinal parathyroid adenomas can be accessed through a transcervical approach, this is not always feasible, posing a significant challenge.

CASE PRESENTATION

We report the case of a 60-year-old female patient who presented with symptomatic hyperparathyroidism. Sestamibi scan was performed and failed to identify a parathyroid adenoma. Bilateral neck exploration was performed on twice, with normal parathyroid glands excised on both occasions. At this stage, a repeat sestamibi and CT scan revealed a suspected parathyroid adenoma in the mediastinum. A transthoracic robotic parathyroidectomy was performed, and the adenoma successfully excised. A full serological and symptomatic recovery was achieved.

DISCUSSION

Mediastinal parathyroid adenomas can pose significant diagnostic and treatment challenges.

CONCLUSION

A robotic transthoracic approach demonstrates a safe method for the removal of parathyroid adenomas which are inaccessible transcervically, with low morbidity to patients.

Localization and surgical approach to mediastinal parathyroid glands

BACKGROUND

Hyperactive parathyroid glands (PTGs) are in the mediastinum 4.3% of the time. Historically, localization and resection of these glands can be challenging.

METHODS

We searched all operative notes involving a thoracic surgeon and a preoperative diagnosis of hyperparathyroidism from 2001 to 2019.

RESULTS

Eighty-five cases were reviewed, of which 63 were included. Only 14 patients (22%) had de novo hyperparathyroid operations. Seventeen patients (27%) had single-photon emission computed tomography with computed tomography fusion (SPECT-CT) as the only preoperative localization test (excluding chest radiography and ultrasound), and all were resected successfully. The initial surgical approach was transcervical for 16 (27%) patients, however only 7 remained transcervical. 4 (6%) patients had an exploration in which the target lesion was resected but it was not parathyroid tissue.

CONCLUSION

Most patients presenting with mediastinal PTG have had prior HPT surgery. The trend toward more focused HPT surgery may mean more de novo mediastinal PTG resections. An unambiguous functional and anatomic localization test, such as a spect-ct scan, is the best predictor of a successful resection. Ambiguous or discordant scans should be approached cautiously, and additional confirmatory tests are recommended. For suspected PTG located in the thymus, the thoracic surgeon should choose the most familiar approach to achieve complete thymectomy.

Comparison of the perioperative outcomes in antero-superior mediastinal tumor resection performed by transcervical resection and video-assisted thoracoscopic surgery

Background

It remains controversial that whether transcervical resection (TC) was associated with better outcomes than video-assisted thoracoscopic surgery (VATS) in the treatment of antero-superior mediastinal tumors. We aimed to compare the safety and reliability between TC and VATS.

Methods

Between 2010 and 2012, 80 consecutive patients underwent antero-superior mediastinal tumor resection via TC (n=31) or VATS (n=49). Perioperative outcomes were compared. A propensity score-matched analysis was performed to control the potential confounders.

Results

A total of 41 men and 39 women with median age of 52.5 years were enrolled. No patient died during the perioperative course. After propensity matching, TC group was associated with less intraoperative blood loss (35.1±18.7 vs. 93.7±136.1 mL, P=0.034), less postoperative drainage (65.6±76.8 vs. 335.0±154.9 mL, P<0.001), shorter length of postoperative hospital stay (3.2±1.2 vs. 4.1±1.3 days, P=0.003) and less hospitalization expense (22,252.3±4,761.7 vs. 26,514.2±4,052.8 CNY, P=0.002) compared to VATS group. One patient with VATS was converted to open surgery due to intraoperative vessels damage. The postoperative complication was null in TC group while it was 6.1% (n=3) in VATS group (P=0.279), including 1 case of prolonged chest tube drainage and 2 cases of recurrent laryngeal nerve injury.

Conclusions

TC for antero-superior mediastinal tumors is a safe procedure with better perioperative outcomes compared to VATS.

Prevertebral cervical approach: a pure endoscopic surgical technique for posterior mediastinum parathyroid adenomas

BACKGROUND

Parathyroid gland mediastinal ectopia is an unusual but challenging condition in surgical management of hyperparathyroidism. Posterior mediastinum parathyroid ectopia is rare, and glands need to be removed either with a broad open cervical or thoracic approach. In recent years, several minimally invasive approaches to mediastinal parathyroid glands have been described, but for posterior mediastinum adenomas, proposed techniques are transthoracic.

METHODS

The aim of this paper is to describe, to our best knowledge for the first time, a standardized pure endoscopic cervical technique to approach posterior mediastinal parathyroid adenomas which we have used in three patients.

RESULTS

The technique was applied in three patients which excellent surgical, postoperative, and cosmetic results.

CONCLUSIONS

Endoscopic prevertebral approach is a feasible, sure and inexpensive standardized pure endoscopic cervical approach to posterior mediastinal parathyroid adenomas, which may result in a less aggressive surgical option when compared with thoracic approaches.

Focused approach to ectopic mediastinal parathyroid surgery assisted by radio-guided navigation

PURPOSE

Surgical removal of a mediastinal ectopic parathyroid is always challenging. We attempted to apply intraoperative radio-guided navigation for the minimally invasive focused removal of ectopic hyperparathyroid lesions in the mediastinum, and evaluated its significance.

METHODS

Five cases with ectopic mediastinal hyperfunctioning parathyroid were treated by intraoperative radio-guided navigation surgery. MIBI (methoxyisobutylisonitrile)-SPECT (single-photon emission computed tomography) was used to plan the surgical approach. (99m)Tc-MIBI (11.1 MBq/kg) was administered 2 h before surgery, and a handheld gamma probe was used intraoperatively to detect radioactivity in the lesion.

RESULTS

Two lesions found on the aortic arch were excised by left thoracoscopic resection. Two other lesions on the tracheal bifurcation were approached by right thoracotomy. We could remove two hidden adenomas by en bloc resection with the adjacent lymph nodes under radio-guidance. Another lesion, located at the ligamentum arteriosum, was excised with sternal division. Accumulations of radioactivity were identified in all lesions removed, with decreased radioactivity in the surgical field.

CONCLUSIONS

Intraoperative radio-guided navigation is a useful tool for the focused removal of an ectopic mediastinal parathyroid by providing instant feedback to help guide the surgeon, while also providing precise localization of lesions.