Thoracoscopic resection of ectopic parathyroid glands

Thoracoscopic treatment of mediastinal ectopic parathyroid adenomas: a Latinamerica experience case series and literature review

BACKGROUND

Hyperparathyroidism (HPT) is a disease caused by hypersecretion of one or more parathyroid glands, it can be associated with ectopic mediastinal parathyroid glands (MEPA) in 2% of cases. The use of video-assisted thoracoscopic surgery (VATS) for the surgical resection of these glands is a safe, cost-effective, and low morbidity option for patients with MEPA. We report a case series of patients with this disease managed with VATS, the first in Mexico and Latinamerica.

METHODS

From 2008 to 2022, a retrospective study involving patients with MEPA and treated by VATS approach was performed in a tertiary hospital in Mexico city. Relevant biochemical and clinical variables such as imaging studies, pre and postoperative laboratory results, surgical strategy, outcomes and pathological analysis were analyzed.

RESULTS

Four cases of mediastinal parathyroid adenomas causing HPT were included. All patients were female with a median age of 52.5 years-old (range 46-59 years), half of the patients had primary HPT and the others tertiary HPT after kidney transplant. 75% of cases had a MEPA in the medium mediastinum, all had a preoperative positive SPECT-CT 99mTc Sestamibi scan. Mean preoperative PTH was 621.3pg/mL (182-1382pg/mL). All patients successfully underwent parathyroidectomy with a VATS approach, no deaths were reported.

CONCLUSIONS

VATS is a minimally invasive surgery that provides adequate access to mediastinal located glands, optimal visualization of mediastinal structures and has a high resection success rate with less complications and morbidity than open approaches.

A Surgical Management of Mediastinal Parathyroid Adenoma: A Regional Experience in Malaysia

Primary hyperparathyroidism (PHPT) usually presents with symptoms of hypercalcemia which is due to excessive secretion of parathyroid hormone (PTH). Surgical removal of the secreting tumor either adenoma or hyperplasia remains the mainstay of treatment. Around 2% to 25% of the lesions are located in the mediastinum. We reviewed our institution's surgical treatment and approach to mediastinal parathyroid adenoma (MPA). We retrospectively reviewed the demography, comorbidities, clinical presentation, surgical approach, and outcome for patients in our institution who underwent surgery for MPA from September 2019 until August 2023. All patients with MPA who underwent surgery were included in the review. The surgical approaches used were both video-assisted thoracoscopic surgery (VATS) and median sternotomy. There were three patients with PHPT due to MPA who underwent surgery. Out of the three patients, two were female. The mean age was 48.6 years old, ranging from 16 to 66 years old. All of them presented with PHPT with a raised mean serum calcium level of 3.52 mmol/L (range: 2.84-4.38 mmol/L) and a mean PTH or intact PTH (iPTH) level of 274.6 pmol/L (range: 8.87-695 pmol/L). Ultrasound of the neck was performed for all the patients before further investigations were done to look for the ectopic parathyroid gland. Computed tomography (CT) of the thorax showed mediastinal parathyroid mass in all the patients with an average size of 2.4 x 2.1 x 2.3cm (range: 1.3-3.8cm), which showed uptake in 99mTc-hexakis-2-methoxyisobuthylisonitrile (Tc99m-MIBI) scintigraphy. VATS was performed for two cases and an upper partial sternotomy was performed for one patient. Postoperatively, iPTH and serum calcium levels were reduced significantly for all patients. There were no post-operative complications in our study. Comprehensive diagnostic imaging and surgical planning are important for the localization of MPA. In our review, all cases were promptly diagnosed and underwent surgery without complication.

Giant Ectopic Parathyroid Adenoma Arising in the Posterior Mediastinum. Report of Case and a Review

We present a case of a greatly enlarged giant ectopic parathyroid adenoma that weighed 43 grams, which was located in the posterior mediastinum of a 74-year-old man. The patient presented with generalized weakness and decreased level of consciousness. He was found to have elevated level of serum calcium (19.9 mg/dl), and a subsequent assay of parathyroid hormone (PTH) was greatly elevated (2234 pg/ml). We report the course of management and outcome of the patient and present a review of the literature on giant ectopic parathyroid adenomas in the posterior mediastinum.

[Thoracoscopic resection of mediastinal parathyroid gland]

According to the modern literature, mediastinal parathyroid glands are diagnosed in 2-20% of cases. In the available Russian-language literature, there are few reports on successful resection of mediastinal parathyroid glands in impossible surgery through cervical approach. Despite the development of minimally invasive surgical approaches and their advantages, traumatic sternotomy was used in these cases. We report a successful thoracoscopic resection of mediastinal parathyroid gland in a patient with persistent hyperparathyroidism. Preoperative topical diagnosis was essential for successful surgery. Favorable postoperative outcome was confirmed by regression of symptoms and vascular calcification, as well as improved densitometric parameters in one year after surgery.

Minimal Invasive Radioguided Ectopic Parathyroidectomy in Upper Mediastinum

In this study we wanted to present a case with the history of multiple previous neck explorations and persisting upper mediastinal ectopic parathyroid adenoma who underwent a successful operation with radioguided minimal invasive approach.

Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid adenoma

Background

Primary hyperparathyroidism (PHPT), caused by an ectopic mediastinal parathyroid adenoma, is uncommon. In the past, when the adenoma was not accessible from the neck, median sternotomy was advocated for safe and successful parathyroidectomy. Video‐assisted thoracoscopic surgical (VATS) parathyroidectomy represents a modern alternative approach to this problem.

Methods

Information on patients undergoing VATS was obtained from a specific database, including clinical presentation, biochemistry, preoperative imaging, surgical approach and patient outcomes. A comprehensive literature review was undertaken to draw comparisons with other publications.

Results

Over a 2‐year period, nine patients underwent VATS parathyroidectomy for sporadic PHPT. Five patients had persistent PHPT following previous unsuccessful parathyroidectomy via cervicotomy, and four had had no previous parathyroid surgery. The median duration of surgery was 90 (range 60–160) min. Eight patients were cured biochemically, with no major complications. One patient required conversion to a median sternotomy for removal of a thymoma that had resulted in false‐positive preoperative imaging.

Conclusion

With appropriate preoperative imaging, multidisciplinary input and expertise, VATS parathyroidectomy is an effective, safe and well tolerated approach to ectopic mediastinal parathyroid adenoma.

Thoracoscopic removal of ectopic mediastinal parathyroid adenoma causing hyperparathyroidism: a rare entity

Ectopic mediastinal parathyroid adenomas are uncommon. Here, we report the successful thoracoscopic removal of a mediastinal parathyroid adenoma from a patient with hypercalcemia. A 58-year-old female patient was referred to our department with persistent hypercalcemia. Serum calcium and phosphorus levels were 13.2 mg/dl and 2.5 mg/dl respectively, while the intact parathormone level was 798.9 pg/ml. Parathyroid computed tomography revealed a solid and well-defined mass at the anterior mediastinum close to the distal aorta. Once the contrast was enhanced, our pre-diagnosis was ectopic parathyroid adenoma. The mass was detected at the anterior mediastinum, dissected free from the surrounding tissue and excised. The capsulated mass, which had a diameter of 3 × 1.5 × 0.7 cm, was confirmed as parathyroid adenoma histopathologically. Postoperative calcium and parathormone levels decreased dramatically to normal levels. Anterior mediastinal localization of an ectopic parathyroid adenoma is a rare entity. The transsternal approach is the most preferred method, but video-thoracoscopy can be used safely and effectively.

Mediastinal Parathyroidectomy Using a Cervical Approach Under a Pneumomediastinum

Video-assisted thoracoscopic surgery (VATS) and robotic surgery are minimally invasive surgeries for mediastinal parathyroid adenomas. However, a transthoracic approach is often difficult in the cervicothoracic transition area because of the limited visual field. We report a novel minimally invasive surgery for an ectopic parathyroid adenoma in the middle mediastinum using a cervical approach under a pneumomediastinum.

Preoperative Localization of Mediastinal Parathyroid Adenoma with Intra-arterial Methylene Blue

Ectopic parathyroid is found in 16% of patients with hyperparathyroidism. 2% of ectopic parathyroid adenomas are not accessible to standard cervical excision. In such cases, video-assisted thoracoscopic resection is the recommended definitive treatment. We present a case of mediastinal parathyroid adenoma localized preoperatively by injecting methylene blue within a branch of the internal mammary artery that is supplying the adenoma. Intra-arterial methylene blue injection facilitated visualization and resection of the adenoma. The preoperative intra-arterial infusion of methylene blue appears to be an effective and safe method for localization of ectopic mediastinal parathyroid adenomas and allows rapid identification during thoracoscopic resection.

Combined transcervical and thoracoscopic mediastinal parathyroid adenoma resection

The routine approach for excision of a parathyroid adenoma is transcervical, but this approach is inadequate when the gland is located in the mediastinum. Traditionally, these cases have required a sternotomy or thoracotomy. We used a combined transcervical and video-assisted thoracoscopic surgery approach to resect a parathyroid adenoma that extended to the middle mediastinum.

Surgical treatment for mediastinal parathyroid adenoma causing primary hyperparathyroidism

Background

Primary hyperparathyroidism is a rare disease characterized by excessive secretion of parathyroid hormone from parathyroid adenoma, hyperplasia, or malignancy. The clinical symptoms of the condition are those of hypercalcemia. Although the lesions are commonly located in the neck region, in about 1–2 % of cases, the lesions are ectopically located within the mediastinum, where surgical excision using the cervical approach is difficult. The principal treatment of the condition is surgical excision of the lesion. However, some patients require additional surgery because of recurrence due to intraoperative dissemination. Therefore, safe and accurate excision is essential for the treatment. We reviewed the surgical treatment used at our institution for mediastinal parathyroid adenoma that caused primary hyperparathyroidism.

Method

The subjects were four patients with primary hyperparathyroidism due to mediastinal parathyroid adenoma who underwent surgery at our institution within a period of 10 years, between January 2005 and December 2014. All of the patients were female, with a mean age of 64.5 years (range, 55–74 years). The examined variables included background factors, clinical condition, surgical method, and clinical outcome.

Result

In all of the patients, primary hyperparathyroidism was detected with symptoms of hypercalcemia. Laboratory tests revealed a mean serum calcium level of 11.85 mg/dL (range, 11.2–13.2 mg/dL) and a mean parathyroid hormone (intact PTH) level of 304.8 pg/mL (range, 126–586 pg/mL), indicating elevated levels for all patients. Chest computed tomography (CT) revealed tumors with a mean diameter of 2.8 cm (range, 10–45 mm) in the anterior mediastinum in all of the patients. On 99mTC-methoxy isobutyl isonitrile (MIBI) scintigraphy, abnormal accumulation was observed in all of the patients. Regarding the surgical methods, median sternotomy was used for three cases and upper partial sternotomy was used for one case. The surgery was safely and accurately performed, without postoperative complications. After surgery, the serum calcium levels immediately returned to normal and the symptoms improved.

Conclusion

We performed excision safely and accurately in all of the patients. In tumor identification, 99mTC-MIBI scintigraphy was useful. Accurate tumor identification and selection of the optimal surgical method are important for prevention of recurrence due to intraoperative dissemination.

Mediastinal Parathyroid Adenoma with Osteitis Fibrosis Cystica: Robot-Assisted Thoracic Surgical Resection

Mediastinal parathyroid adenomas can be resected by sternotomy or video-assisted thoracoscopic surgery. Robot-assisted thoracic surgical approaches have recently been described. We report robotassisted thoracic surgical resection of a mediastinal parathyroid in a morbidly obese patient. Additional comorbidities included multiple pathological fractures related to hypercalcemia. Intraoperative parathyroid hormone levels confirmed successful removal of the adenoma. Hungry bone syndrome developed after surgery but eventually resolved. Robotassisted thoracic surgery avoided the need for sternotomy and associated concerns related to poor bone healing. Robot-assisted thoracic surgery has potential advantages over video-assisted thoracoscopic surgery in patients with obesity because of easier instrument articulation within the thoracic cavity rather than at the chest wall.

Endobronchial ultrasound-guided biopsy to diagnose large posterior mediastinal parathyroid adenoma prior to video-assisted thoracoscopic resection

A 65-year-old woman was referred with hypercalcaemia and found to have a four cm retrotracheal mass on CT. The patient also suffered from neurofibromatosis and a recently diagnosed gastric mass. Tc(99) sestamibi scintigraphy revealed an area of intense uptake in the right upper mediastinum. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was used to confirm the diagnosis of parathyroid adenoma and thoracoscopic resection was subsequently performed. EBUS-TBNA biopsy can be a helpful diagnostic tool to confirm diagnosis of mediastinal parathyroid masses in patients with atypical or complex clinical presentations.

Intra-thoracic Parathyroid Adenomatosis: A Case Report

Ectopic mediastinal parathyroid adenomas are rare, but can be life-threatening. Resection is indicated in those cases accompanied by hypercalcemia, especially in young patients. Although most mediastinal parathyroid adenomas can be removed by a cervical approach, a transthoracic approach is needed when the adenoid tissues are located deep within the thoracic cavity. We describe the case of a 37-year-old female who underwent excision of an intrathoracic ectopic parathyroid adenoma after parathyroidectomy four months earlier.

Optimizing the minimally invasive approach to mediastinal parathyroid adenomas

BACKGROUND

Patients with refractory hyperparathyroidism after neck exploration may have a mediastinal parathyroid gland that has not been identified reliably with a single radiologic study. We report 17 patients who underwent minimally invasive resection for mediastinal parathyroid adenomas after confirmatory multipoint radiologic imaging.

METHODS

Fifteen patients underwent thoracoscopic procedures and 2 patients underwent mediastinoscopic procedures for resection of suspected mediastinal parathyroid adenoma. Preoperative localizing studies included sestamibi scan, computed tomography scan of the neck and chest, and selective venous sampling of parathyroid hormone levels. Once a mediastinal location was determined, thoracoscopic or mediastinoscopic resection was performed. Successful removal of parathyroid tissue was confirmed with a 50% or greater reduction in intraoperative parathyroid hormone levels.

RESULTS

Parathyroid adenoma was resected in 88% of patients after the operation. The cure rate was 100% in patients with two or more concordant studies locating parathyroid tissue in the mediastinum and 60% in those with one positive study. The thoracostomy tube was removed on median postoperative day 1 (range, 0 to 2 days). Median hospital stay was 3 days (range, 2 to 7 days). The most common complication was temporary hypocalcemia, which occurred in 18% of patients.

CONCLUSIONS

Minimally invasive parathyroidectomy is an effective treatment of hyperparathyroidism caused by mediastinal parathyroid tissue. Targeted exploration depends on the guidance of preoperative localization studies and measurement of intraoperative parathyroid hormone levels to verify successful resection. Selective venous sampling and high-resolution computed tomography scanning can be helpful in patients with negative sestamibi scans.

Diagnostic localization of ectopic parathyroid lesions: developmental consideration

Parathyroid glands arise from the third and fourth pharyngeal pouches. Parathyroid lesions sometimes develop ectopically. The aim of this article is to illustrate the knowledge of pharyngeal apparatus development to assist with diagnostic localization of ectopic parathyroid lesions. We retrospectively reviewed charts of 23 patients who received a diagnosis of ectopic parathyroid lesions. The ectopic lesions were widely distributed; cranially lesions were located on the carotid bifurcation, caudally in the right paraaortic region, ventrally on the surface of the sternohyoid muscle, and dorsally in the paraesophageal region. In most cases, parathyroid tissues were associated with structures related to the third or fourth pharyngeal pouches that traveled to regions where the ectopic lesions ultimately developed. In a few cases, lesions were not associated with these pouches and might have developed from parathyroid tissue that migrated due to an anomalous pathway of parathyroid travel. When patients present without entopic lesions, the presence of ectopic lesions should be evaluated based on an understanding of the developmental mechanisms of parathyroid glands and the frequency with which ectopic lesions have been found in specific locations. Systematic diagnosis can minimize the frequency with which ectopic lesions are missed during clinical care and maximize their accurate localization.

An unusual cause of a mediastinal mass

Primary hyperparathyroidism (PHPT) is a disorder resulting in hypercalcaemia due to autonomous over secretion of parathyroid hormone. Mediastinal parathyroid adenoma is a rare disorder which can present with a widened mediastinum on a plain film. Its always important to check calcium level in patients who present with a mediastinal mass to rule out PHPT. Recognition of this disorder is crucial to prevent long-term sequelae. The authors report an interesting case and discuss further about it, which would be of help both to a specialist and a general physician.

Thoracoscopic removal of mediastinal parathyroid glands: a critical appraisal of an emerging technique

OBJECTIVE

To retrospectively evaluate the feasibility of thoracoscopic removal of mediastinal parathyroids.

SUMMARY BACKGROUND DATA

Mediastinal exploration to resect ectopic parathyroid(s) is needed in approximately 2% of cases in hyperparathyroidism. Recent advances in thoracoscopic surgery allow for a minimally invasive treatment.

METHODS

From 1999 through 2007, 13 patients affected by primary hyperparathyroidism (11 females, mean age 60 years, range: 22-88) underwent thoracoscopic removal of mediastinal parathyroids. Scintigraphy produced positive results in 11 of 13 cases, computed tomography scan in 9 of 10, parathyroid hormone venous sampling in 10 of 10 patients, and magnetic resonance imaging in 5 of 7. Right thoracoscopic access was used in 9 patients, left in 4. Postoperative outcome was analyzed.

RESULTS

Thoracoscopy enabled retrieval of mediastinal parathyroids in 10 of 13 (78%) cases. Mean operating time was 92 minutes (range: 50-240). One procedure (8%) was converted. No perioperative deaths/major complications occurred. Mild complications occurred in 2 of 13 (15%) patients (pneumothorax/pneumonia, transient recurrent nerve palsy). Mean hospital stay was 4.7 days (range: 2-15). At a mean follow-up of 73 months (range: 16-105), parathyroid hormone and calcium venous concentrations were high in 3 patients. Unsuccessful procedures were related to doubtful or non-concordant preoperative localization.

CONCLUSIONS

The thoracoscopic approach for mediastinal parathyroidectomy is feasible and safe. An accurate preoperative work-up should be standardized to avoid useless procedures. In case of negative preoperative localization of the abnormal gland, thoracoscopy should not be adopted as a diagnostic tool.

Thoracoscopic resection of mediastinal parathyroids: current status and future perspectives

The location and removal of ectopic mediastinal glands represents one of the major problems in parathyroid surgery. Minimally invasive surgery for such indications has been evaluated to reduce the high morbidity and long reconvalescence of standard open approaches. The recent introduction of robotic surgical systems may offer new options for this purpose. A literature review of reports on thoracoscopic resections of mediastinal parathyroids is presented. The potential of a robotic surgical system for this indication is discussed. Between 1994 and 2002, 19 groups have reported on thoracoscopic parathyroidectomy in a total of 38 patients. In seven (18%) patients thoracoscopic identification had to be radioisotopically guided. Two (5%) conversions to an open approach were necessary. There were three (8%) moderate complications. Based on available data, video-assisted thoracic surgery (VATS) is a less invasive, effective and safe procedure for the removal of ectopic mediastinal parathyroids and can therefore be recommended as the standard approach. However, preoperative localization of the ectopic gland is a prerequisite. Surgical robotic systems have the potential to make this type of procedure even more accurate and thus safe.

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.

Thoracoscopic removal of mediastinal hyperfunctioning parathyroid glands: personal experience and review of the literature

BACKGROUND

The presence of a mediastinal hyperfunctioning parathyroid gland is a rare condition that occurs in about 1% to 2% of cases. We present our experience with video-endoscopic parathyroidectomy and a review of the literature.

METHODS

In seven patients (four male, three female; age 28-67 years) mediastinal hyperfunctioning parathyroid glands were removed by the thoracoscopic route (VATS). Six patients suffered from primary hyperpathyroidism and one woman from recurrent secondary hyperparathyroidism. Additionally, articles concerning endoscopic treatment of mediastinal parathyroid glands were collected from the medical databases. A total of 58 patients were found in the English and French literature.

RESULTS

Neither intraoperative nor postoperative complications occurred in our patients. Operating time was 90 minutes (range 40-180 minutes). After a mean follow-up of 29+/-12 months (range 3-64), all patients are biochemically cured. The cases in the literature showed healing in 57 of 58 cases. Their mean operating time was 112 minutes (range 40-240 minutes). One perioperative death due to myocardial infarction and a major complications rate of 7% are described.

CONCLUSION

The thoracoscopic approach to mediastinal parathyroidectomy is a safe, feasible technique with a low complication rate and good cosmetic outcome. It should become the standard surgical access for mediastinal hyperfunctioning parathyroid glands.

Anterior mediastinotomy for parathyroidectomy

BACKGROUND

Approximately 2% of ectopic parathyroid glands reside within the mediastinum in a location that requires a thoracic approach.

METHODS

All patients with mediastinal parathyroid tumors who underwent anterior mediastinotomy were included in this review.

RESULTS

Over the course of 16 years, 10 patients with primary hyperparathyroidism underwent anterior mediastinotomy. There were 6 men and 4 women with a median age of 65. Seven patients had undergone at least one previous cervical exploration. Preoperative calcium levels were 11.3 +/- .8 mg/dL. Nine patients had preoperative localization with radionuclide scans and 9 patients also had preoperative computerized tomography or magnetic resonance imaging scans. An abnormal gland was removed in all cases. Nine of 10 patients had normalization of their calcium levels.

CONCLUSIONS

Anterior mediastinotomy after preoperative imaging has proven to be a technically feasible, safe, and effective method for the surgical management of patients with sporadic primary hyperparathyroidism and mediastinal parathyroid tumors.

Gamma Probe Detection of Ectopic Parathyroid Adenoma

A 34-year-old man with hypercalcemia had a sestamibi scan that showed increased uptake that appeared to correspond with a 7 mm density in the mediastinum, adjacent to the aortic arch, on chest CT. This lesion was thought to be consistent with an ectopic parathyroid adenoma. Prior to surgical exploration, the patient was injected intravenously with 12.3 millicuries of Tc99m-sestamibi. The lesion identified preoperatively did not show abnormal radionuclide uptake using the intraoperative gamma probe, and was subsequently determined to be a hyperplastic lymph node. However, abnormal activity was localized to the thymus gland, from which an ectopic parathyroid adenoma was successfully excised. The patient recovered without incident. The use of the intraoperative gamma probe was critical in identifying and resecting the ectopic parathyroid adenoma in this patient, and in general, may reduce surgical time and reduce the morbidity and/or complications associated with surgical exploration.

Video-assisted mediastinoscopy (VAM) for surgical resection of ectopic parathyroid adenoma

Background

Ectopic mediastinal parathyroid adenomas or hyperplasia account for up to 25% of primary hyperparathyroidism (HPT). Two percent of them are not accessible by standard cervical surgical approaches. Surgical resection has traditionally been performed via median sternotomy or thoracotomy and more recently, via video assisted thoracoscopic surgery (VATS). We present our experience with the novel use of Video-Assisted Mediastinoscopy (VAM) for resection of ectopic mediastinal parathyroid glands.

Case presentation

4 patients underwent VAM for removal of an ectopic intramediastinal parathyroid gland. All of them had at least one previous unsuccessful neck exploration.

In all cases histology confirmed complete resection of ectopic parathyroid glands (3 parathyroid adenomas and one parathyroid hyperplasia). Two of the patients required a partial sternal split to facilitate exploration.

Conclusion

The cervical approach for resection of ectopic parathyroid adenomas is frequently unsuccessful. Previously, the standard surgical approach in such cases was sternotomy and exploration of the mediastinum. Recently, a number of less invasive modalities have been introduced.

We found that VAM has several advantages. It has a short theatre time does not require a complex anaesthetic and is performed with the patient in classic supine position utilising often a previous cervical scar with good cosmetic results. It offers a short hospital stay; it is cost effective with minimal use of fancy and pricy consumables with a comfortable incision and no violation of the pleural space.

Additionally the use of digital Video imaging has increased the sensitivity of the mediastinoscopy and has added safety and confidence in performing a detailed mediastinal exploration with an additional great training value as well.

Mediastinal hyperfunctioning parathyroids: incidence, evolving treatment, and outcome

BACKGROUND

The evaluation and treatment of hyperfunctioning mediastinal parathyroid gland(s) (MPG) is evolving. This study reports our overall experience with MPG in a tertiary referral center.

METHODS

A prospective database of 922 patients undergoing parathyroidectomy by 2 surgeons from 1982 to 2005 was reviewed.

RESULTS

Thirty-two of 922 (3.5%) patients had MPG. Nine (28%) patients had a prior failed parathyroidectomy. Sestamibi and computed tomography scans were correctly positive in 24/28 (86%) and 6/7 (86%) patients, respectively. MPGs were removed via cervical approach in 22 (69%). Eleven of 22 patients had a focused cervical approach. Nine MPGs required a limited sternotomy (n = 3) or a successful radioguided video-assisted thoracoscopic approach (VATS, n = 4) for removal. Two VATS were converted to a full sternotomy. One patient refused surgery. All patients who required sternotomy/VATS had MPGs caudal to the innominate vein. Twenty-nine of 31 (94%) patients were cured. Two are stable on calcimimetics. One patient has permanent hypoparathyroidism.

CONCLUSIONS

Most MPGs can be removed through a cervical approach. Preoperative Sestamibi and computed tomography scans can help the surgeon plan the best initial surgical approach. Those below the innominate vein require a thoracic procedure, preferably a radioguided probe-assisted thoracoscopic resection with intraoperative parathyroid hormone (ioPTH). An alternative to surgical removal is medical treatment.

Single-photon emission computed tomography/computed tomography in endocrinology

The introduction of fusion of functional and anatomical imaging modalities into the field of endocrinology led to a major breakthrough in diagnosis, staging, and follow-up of patients with endocrine tumors. The management of endocrine tumors is based on a wide variety of conventional techniques, including computed tomography, ultrasound, or magnetic resonance imaging, and on scintigraphic functional techniques, associated with unique uptake and transport mechanisms and with the presence of high density of membrane receptors on some of these tumors. Anatomical modalities provide accurate detection and localization of morphological abnormalities, whereas nuclear medicine studies reflect the pathophysiological status of the disease process. Lack of structural delineation and relatively low contrast hamper the precise anatomical localization of the abnormal functional findings in the presence of potential concurrent foci related to the physiological biodistribution of the radiotracer or to processes unrelated to the evaluated disease entity. The notion that anatomical high-resolution and functional imaging data act as complementary methods led to various combination techniques of these modalities. However, coregistration of the functional and anatomical data after the acquisition of the 2 imaging modalities on separate machines, in different sessions, fails to provide accurate alignment of data, and the mathematical modeling is too cumbersome to be used on a routine basis. In contrast, hybrid imaging devices of single-photon emission computed tomography/computed tomography in a single gantry enable the sequential acquisition of the two modalities, with subsequent merging of data into a composite image display. These hybrid studies have led to a revolution in the field of imaging, providing clinically relevant information that is not apparent on separate images. The present review evaluates the contribution of the integrated single-photon emission computed tomography/computed tomography technology to image analysis and management of patients with endocrine tumors.

Partial median sternotomy: an attractive approach to mediastinal parathyroid disease

BACKGROUND

Parathyroid exploration through a standard cervical approach is adequate for the resection of most mediastinal parathyroid glands. A subset of mediastinal parathyroid glands causing hyperparathyroidism, however, cannot be removed in this manner.

STUDY DESIGN

We reviewed our experience with the use of partial median sternotomy in the treatment of these patients.

RESULTS

Over a 14-year period, all but 10 of 937 (1.1%) consecutive patients explored for hyperparathyroidism by a single endocrine surgeon were treated by a cervical approach. Partial median sternotomy was performed in 10 cases and was successful in seven cases (70%), with conversion to a complete sternotomy being required in three cases. Six of these seven patients had failed a previous parathyroid exploration (86%), including one patient who had a previous complete sternotomy. Cure of hyperparathyroidism was achieved in all seven patients undergoing partial median sternotomy. In five patients a mediastinal parathyroid gland was removed (71%), and in one patient a parathyroid adenoma in the carotid sheath was eventually found, and the location of the hyperfunctioning parathyroid gland in one patient was never determined although the patient was cured. The mean length of hospital stay after a partial median sternotomy was 2.6 days. One patient sustained a recurrent laryngeal nerve injury at the time of a repeat cervical exploration and partial median sternotomy.

CONCLUSIONS

Rarely, mediastinal parathyroid glands cannot be resected through a cervical approach. In these cases the use of partial median sternotomy is an attractive technique in achieving cure of hyperparathyroidism and is associated with minimal morbidity and a short length of hospital stay.

Minimally Invasive Management of the Mediastinal Parathyroid Adenoma

INTRODUCTION/METHODS

Traditional surgical management of mediastinal parathyroid adenomas has required mediastinal exploration via sternotomy or thoracotomy. By contrast minimal access approaches to the mediastinum via videoscopic transthoracic or transcervical approaches can offer equivalent visualization, patient safety and decreased patient morbidity. The availability of sternal retractor systems, the rapid parathyroid hormone (PTH) assay for intraoperative confirmation of cure, recurrent laryngeal nerve monitoring technique and video-assisted thoracic surgery (VATS) instrumentation have made this possible. The purpose of this article is to discuss these approaches and the results with their application in five consecutive patients.

RESULTS

Five consecutive patients underwent mediastinal exploration of which three were performed transcervically and three transthoracically (one patient underwent both procedures). One patient had a negative thoracic exploration; one patient's course was complicated by transient recurrent laryngeal nerve injury which resolved spontaneously.

CONCLUSION

Transcervical approaches for resection of anterior mediastinal parathyroid adenomas are possible with the use of the Rultract Skyhook Retractor without the need for sternotomy. VATS provides excellent visualization of the middle and posterior mediastinum avoiding the morbidity of thoracotomy.

Technetium-99m-MIBI SPECT/CT in Primary Hyperparathyroidism

The novel trend toward focused parathyroidectomy requires precise preoperative localization of the parathyroid adenoma in patients with primary hyperparathyroidism (PHPT). The present study evaluated the impact of hybrid single photon emission computed tomography/computed tomography (SPECT/CT), using 99mTc-sestamibi (MIBI), on the surgical management of these patients. In a retrospective study of 36 patients with PHPT, SPECT/CT was undertaken when planar 99mTc-MIBI scintigraphy was negative or when an ill-defined focus in the neck or an ectopic site on planar views was visualized. Imaging data were compared with intraoperative findings, and the incremental value of SPECT/CT to lesion localization and surgical procedure was assessed. Three patients with both negative planar and SPECT/CT studies subsequently underwent bilateral neck exploration, with multiglandular hyperplasia diagnosed in two patients and a parathyroid adenoma in one. Of 33 patients with a positive MIBI study, parathyroid adenoma was confined to the neck in 23 patients and to the lower neck-mediastinum in 10. SPECT/CT facilitated the surgical exploration of all 10 ectopic parathyroid adenomas and 4 of 23 cervical parathyroid adenomas, the latter four either at reexploration or in patients with nonvisualization of the thyroid after thyroidectomy. SPECT/CT contributed to the localization of parathyroid adenomas in patients with PHPT and to planning the surgical exploration in 14 of 36 (39%) patients, predominantly those with ectopic parathyroid adenomas or who had distorted neck anatomy.

Excision of a Mediastinal Parathyroid Adenoma After Coronary Artery Bypass Surgery

In this report we describe the removal of a mediastinal parathyroid adenoma in a patient who had two previous coronary artery bypass graft procedures. The surgical approach and intraoperative localization of the adenoma under these unusual circumstances are reviewed.

One-gland exploration for mediastinal parathyroid adenomas: cervical and thoracoscopic approaches

BACKGROUND

In patients with sporadic primary hyperparathyroidism, preoperative localization studies may discover a solitary mediastinal parathyroid adenoma. In this circumstance a 1-gland mediastinal exploration, either cervical or thoracoscopic, may be curative.

METHODS

In an 18-month period, 5 of 120 consecutive patients underwent an initial 1-gland mediastinal exploration for a solitary mediastinal parathyroid adenoma and 2 patients had a 1-gland mediastinal exploration for persistent hyperparathyroidism. Clinical presentation, imaging studies, surgical techniques, and outcomes were reviewed.

RESULTS

Sestamibi scans showed a mediastinal parathyroid adenoma in all 7 patients. Computed tomography provided anatomic localization of middle mediastinal parathyroid adenomas. A cervical approach was used in 4 patients who had a superior mediastinal parathyroid adenoma. Thoracoscopic excision was performed in 3 patients with a middle mediastinal parathyroid adenoma. No complications occurred. Calcium and parathyroid hormone levels normalized in all patients.

CONCLUSIONS

Sporadic primary hyperparathyroidism caused by a solitary mediastinal parathyroid adenoma can be treated successfully with 1-gland mediastinal exploration either by a cervical or a thoracoscopic approach as indicated by localization imaging.

Thoracoscopy: the preferred method for excision of mediastinal parathyroids

Mediastinal exploration to resect ectopic parathyroid is required in approximately 2% of all cases of hyperparathyroidism. Traditionally, it has been performed through a midsternotomy or thoracotomy. A few reports about thoracoscopic resection of mediastinal parathyroid were published recently. We report here successful video-assisted thoracoscopic resection (VATS) of a mediastinal parathyroid and present a review of all previously reported cases. A 42-year-old woman presented with spontaneous fracture of the left femur and hypercalcemia. She had previously undergone cervical parathyroidectomy for primary hyperparathyroidism. A computed tomography (CT) scan of the chest and a technetium scan showed ectopic mediastinal parathyroid. The patient underwent successful thoracoscopic resection of ectopic parathyroid. A total of 26 patients were reviewed, 21 in the English literature and 5 in others. Of the 21 patients reported in the English literature, 16 had primary hyperparathyroidism (1 degrees HPT), whereas 5 had secondary hyperparathyroidism (2 degrees HPT). All but 3 patients had undergone previous cervical exploration. Ectopic mediastinal parathyroid was localized preoperatively in all by CT scans of the chest and nuclear scans. All 21 patients had successful thoracoscopic resection. All but 3 had parathyroid adenoma. Postoperatively, serum calcium (Ca ), phosphate (PO4 ), and parathormone (PTH) values returned to normal in all patients. Age and sex of the patient, type of hyperparathyroidism (1 degrees or 2 degrees ), size of the gland, its location within the anterior mediastinum, the approach used to resect it (right or left thoracoscopic), and final histopathology of the resected gland (adenoma or hyperplasia) had no bearing on the success of thoracoscopic resection. The data seem to suggest that thoracoscopic resection of mediastinal parathyroid is a less-invasive, effective, and safe procedure. Accurate preoperative anatomic localization by CT and nuclear scans of the chest is the key to success.

Radioguided parathyroidectomy via VATS combined with intraoperative parathyroid hormone testing: the surgical approach of choice for patients with mediastinal parathyroid adenomas?

Despite the excellent results with bilateral exploration, minimally invasive parathyroidectomy has become the procedure of choice for patients with hyperparathyroidism in which a single parathyroid lesion can be localized preoperatively. In this article, we discuss a patient who presented with primary hyperparathyroidism for the first time and had a Tc-99m sestamibi scan to localize a single parathyroid lesion in the left, anterior mid-mediastinum. We subsequently performed a radioguided parathyroidectomy via video-assisted thoracoscopic surgery (VATS) to resect this parathyroid adenoma and used intraoperative parathyroid hormone (PTH) testing to confirm cure and avoid neck exploration. We concluded that radioguided parathyroidectomy via VATS combined with intraoperative PTH testing is an effective approach for patients with primary hyperparathyroidism and mediastinal parathyroid lesions, and perhaps should be the technique of choice.

Intraoperative radioguided thoracoscopic removal of ectopic parathyroid adenoma

Twenty-five percent of primary hyperparathyroidism is caused by ectopic mediastinal parathyroid glands, with 2% of these not accessible to standard cervical surgical approaches. Advancement in video-assisted thoracoscopic surgical techniques has decreased the need for sternotomy to successfully remove these ectopic glands. The thoracoscopic approach, however, is limited by the surgeon's inability to always accurately visualize ectopic glands. Intraoperative radionuclide-guided dissection, using a thoracoscopic approach, provides a novel adjunct to the removal of occult ectopic parathyroid glands. We report a case of an occult ectopic parathyroid adenoma removed thoracoscopically using an intraoperative handheld gamma probe.

Expanded indications for transcervical thymectomy in the management of anterior mediastinal masses

BACKGROUND

Transcervical thymectomy (TCT) is an accepted though controversial approach for thymectomy in myasthenia gravis (MG). The suggestion of thymoma on computed tomography (CT) has been considered a contraindication to TCT. We sought to determine whether the indications for TCT could be safely expanded to include selected patients with thymomas as well as other types of anterior mediastinal masses.

METHODS

Between January 1992 and September 1999, we performed 121 TCTs: 98 in patients with MG and 23 in patients without MG. The patients' records were retrospectively reviewed.

RESULTS

Among the 98 MG patients, 28 had CT scans suspicious for thymoma. Of these, 14 had a thymoma pathologically. These were classified as stage I (5), stage II (8), and stage III (1). Five patients required extension of the incision for completion of the procedure. There have been no thymoma recurrences to date with a mean follow-up of 48 months (range 3 to 96 months). In the 23 patients without MG, 12 had new anterior mediastinal masses, 4 had a history of treated lymphoma, 1 had a history of treated germ cell tumor, and 6 had suspected mediastinal parathyroid adenoma. Diagnostic tissue was obtained in all patients undergoing the procedure for diagnosis, and in 4 of 6 patients, a parathyroid adenoma was successfully resected.

CONCLUSIONS

Transcervical exploration and thymectomy offers a less invasive approach to the diagnosis and/or definitive treatment of selected anterior mediastinal masses. We suggest that it is appropriate to expand its use to several clinical scenarios beyond the typical indication of thymectomy in MG patients without thymoma.