Anterior mediastinotomy for parathyroidectomy

Mediastinal Cystic Parathyroid Adenoma Diagnosed by Somatostatin Receptor Scintigraphy

A 71-year-old man complained of nausea and loss of appetite for eight months prior to admission. He was transported to a hospital with disorientation and diagnosed with primary hyperparathyroidism by laboratory examinations. However, ultrasonography, computed tomography, and technetium-99m labeled methoxyisobutyl isonitrile (^99mTc-MIBI) with single-photon emission computed tomography did not yield definite results. In contrast, somatostatin receptor scintigraphy successfully identified the lesion responsible for the over-secretion of parathyroid hormone within the middle mediastinum. The tumor was successfully resected by surgery, and a histopathological analysis confirmed the parathyroid adenoma nature of the tumor.

Cognitive decline due to ectopic primary hyperparathyroidism

When you see a patient with cognitive dysfunction, hypercalcemia due to hyperparathyroidism is an important differential diagnosis. It is important to consider including chest computed tomography and 131I-MIBI SPECT examinations in patients with possible hyperparathyroidism and normal thyroid ultrasound.

Safety and efficiency of microwave ablation for recurrent and persistent secondary hyperparathyroidism after parathyroidectomy: A retrospective pilot study

BACKGROUND

Recurrent and persistent secondary hyperparathyroidism (SHPT) nodules have an incidence of 10-70% after surgery. The treatment of recurrent and persistent SHPT nodules is a challenge, and surgical resection of difficult-to-reach or post-operative adhesions often fails.

PURPOSE

The aim of this research was to study the safety and effectiveness of microwave ablation (MWA) for recurrent and persistent SHPT.

MATERIALS AND METHODS

This was a retrospective study of 11 patients enrolled with a total of 16 nodules, and MWA was employed to manage SHPT. The laboratory test results, including the intact parathyroid hormone (iPTH), serum calcium, phosphorus and alkaline phosphatase (ALP) levels, improvement of SHPT-related symptoms after ablation, and complications during and after MWA were recorded and analysed.

RESULTS

After ablation the value of iPTH was markedly decreased from 1570 ± 1765 pg/mL to 287 ± 239 pg/mL 1 day after MWA (p < 0.05). The levels of serum calcium and phosphorus decreased from 2.51 ± 0.23 mmol/L to 2.06 ± 0.27 mmol/L (p < 0.001) and 1.80 ± 0.43 mmol/L to 1.48 ± 0.32 mmol/L (p < 0.05), respectively, 1 day after MWA. There was no significant difference in the ALP value before and after MWA (p > 0.05). The clinical symptoms, including ostalgia, pruritus, disability, and restless legs, improved after MWA. Minor complications and side effects encountered during or after MWA include haematoma (1/11, 9%), transient hoarseness (2/11, 18.2%), hypocalcemia (6/11, 54.5%). No major complication occurred.

CONCLUSION

MWA may be safe and effective to manage recurrent and persistent SHPT nodules; a definite conclusion needs to expand the sample size with a longer follow-up time.

Save or sacrifice the internal mammary pedicle during anterior mediastinotomy?

Ligation and dissection of internal mammary vessels is the most under-estimated complication of anterior mediastinotomy. However, patients requiring anterior mediastinotomy may experience long survival that makes the development of ischemic heart disease throughout their life possible. Therefore, the un-judicial sacrifice of the internal mammary pedicle may deprive them from the benefit to have their internal mammary artery used as a graft in order to successfully bypass severe left anterior descending artery stenoses. We recommend the preservation of the internal mammary pedicle during anterior mediastinotomy, which should be a common message among our colleagues from the beginning of their training.

Multicenter study of 19 aortopulmonary window parathyroid tumors: the challenge of embryologic origin

BACKGROUND

Ectopic abnormal parathyroid glands are relatively common in the superior mediastinum but are rarely situated in the aortopulmonary window (APW). The embryological origin of these abnormal parathyroid glands is controversial. The purpose of this investigation was to investigate the embryological origin and the surgical management of abnormal parathyroid glands situated in the APW.

METHODS

The databases of patients operated on for primary, secondary, and tertiary hyperparathyroidism at eight European medical centers with a special interest in endocrine surgery were reviewed to identify those with APW adenomas. Demographic features, localization procedures, and perioperative and pathology findings were documented. The embryological origin was determined based on the number and position of identified parathyroid glands.

RESULTS

Nineteen (0.24%) APW parathyroid tumors were identified in 7,869 patients who underwent an operation for hyperparathyroidism (HPT) and 181 patients (2.3%) with mediastinal abnormal parathyroid glands. Ten patients had primary, eight had secondary, and one had tertiary HPT. Sixteen patients had undergone previous unsuccessful cervical exploration. In three patients, an APW adenoma was suspected by preoperative localization studies and was cured at the initial operation. Sixteen patients had persistent HPT of whom 15 were reoperated, resulting in 6 failures. Evaluation of 17 patients who had bilateral neck exploration allowed us to determine the most probable origin of the APW parathyroid tumors: 12 were supernumerary, 4 appeared to originate from a superior, and 1 from an inferior gland.

CONCLUSIONS

Abnormal parathyroid glands situated in the APW are rare and usually identified after an unsuccessful cervical exploration. Preoperative imaging of the mediastinum and neck are essential. The origin of these ectopically situated tumors is probably, as suggested by our data, from a supernumerary fifth parathyroid gland or from abnormal migration of a superior parathyroid gland during the embryologic development.

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

PURPOSE

Parathyroidectomy for ectopic mediastinal hyperfunctioning glands could be performed by transcervical approach, sternotomy, thoracotomy, and recently by thoracoscopic and mediastinoscopic approaches. This study was aimed to analyze the results of traditional and video-assisted parathyroidectomy for mediastinal benign hyperfunctioning glands.

METHODS

Fifty-one upper mediastinal exploration by a conventional cervicotomy, 12 by video-assisted approaches (two thoracoscopy and 10 transcervical mediastinoscopy) and six by sternotomy were performed in 63 patients with primary hyperparathyroidism.

RESULTS

Video-assisted and sternotomic parathyroid explorations achieved biochemical cure in all cases; following conventional transcervical mediastinal exploration, a persistent hyperparathyroidism occurred in 11.8% of patients, who were subsequently cured by sternotomic approach. No complications occurred after video-assisted parathyroidectomy, while an overall morbidity rate of 50% and 10% was found after sternotomic and conventional cervicotomic approaches. Postoperative pain and hospital stay were significantly increased following sternotomy; patient's subjective cosmetic satisfaction was significantly higher after video-assisted and conventional cervicotomic approaches.

CONCLUSIONS

Conventional cervicotomic parathyroidectomy may achieve satisfactory results, especially for upper mediastinal glands. Sternotomic approaches are effective, but should be limited because of invasiveness and increased morbidity. In case of deep and lower hyperfunctioning mediastinal parathyroids, video-assisted approaches represent a less invasive, effective, and safe alternative and might be the technique of choice.

Ectopic mediastinal parathyroid adenoma: a cause of acute pancreatitis

A 38-year-old male was admitted to our hospital with epigastric pain, and he was confirmed to have acute exudative pancreatitis. After the episode of acute pancreatitis subsided, laboratory investigation revealed increased serum calcium (12.0 mg/dl), decreased serum phosphorus (2.7 mg/dl), and increased serum parathyroid hormone (intact) levels (131 pg/ml). A computed tomography (CT) scan of the neck did not reveal any mass lesions in the parathyroid gland. However, (99m)Tc sestamibi scintigraphy revealed that there was one functioning parathyroid gland in the upper mediastinum. Combined (99m)Tc sestamibi scintigraphy and CT scan confirmed the diagnosis of primary hyperparathyroidism in the mediastinum. Microscopic examination revealed the presence of a parathyroid adenoma (1.3 x 0.4 cm(2)) adjacent to the atrophic parathyroid gland in right thymus gland. We report the case of a patient diagnosed with primary hyperparathyroidism due to an ectopic mediastinal parathyroid adenoma. An ectopic mediastinal parathyroid adenoma may manifest as an episode of acute pancreatitis. Preoperative investigation to determine the exact location of an adenoma should include two types of imaging studies, preferably (99m)Tc sestamibi scintigraphy and CT of the neck and chest.

Surgical strategy for sporadic primary hyperparathyroidism an evidence-based approach to surgical strategy, patient selection, surgical access, and reoperations

PURPOSE

Progress in parathyroid imaging has brought substantial changes in the surgical strategy to approach patients with sporadic primary hyperparathyroidism (pHPT). The present review is focused on the safety and efficacy of limited parathyroid exploration.

MATERIALS AND METHODS

Review of the literature focused on studies dealing with unilateral (two-gland exploration) or selective parathyroidectomy (one-gland exploration) in selected patients with pHPT and on the classification of published reports according to the degree of evidence.

RESULTS

Parathyroid exploration limited to a solitary parathyroid adenoma can be considered a minimally invasive procedure that can be performed by the minicervicotomy, video-assisted, or endoscopic approaches. In properly selected patients, it affords results comparable to those of four-gland bilateral exploration in terms of cure and recurrence. It causes less postoperative hypocalcemia.

CONCLUSIONS

Selective parathyroidectomy is an option for patients with positive preoperative localization tests undergoing first-time surgery who have no family history of pHPT, no goiter for which surgical therapy is proposed, and are not on lithium therapy.