Thoracoscopy: the preferred method for excision of mediastinal parathyroids

Video-Assisted Thoracoscopic Surgery Is a Safe and Feasible Technique for Mediastinal Parathyroid Lesions

Introduction: Hyperfunctional ectopic parathyroid glands in the mediastinum pose a challenge to diagnosis and require optimal surgical management. Video-assisted thoracoscopic surgery (VATS) has emerged as a promising minimally invasive approach, offering potential benefits in terms of both patient comfort and oncological principles. This study aimed to evaluate the effectiveness and safety of VATS for the treatment of hyperfunctional ectopic parathyroid glands in the mediastinum. Methods: Among the 538 patients with mediastinal tumors who underwent thoracoscopic surgery at Istanbul University (2008-2021), 11 exhibited hyperfunctional ectopic parathyroid glands. The localization of the glands was performed using various diagnostic techniques, including neck ultrasound, sestamibi scan, CT (computerized tomography), and SPECT (Single-photon emission computed tomography). VATS (Video-assisted thoracoscopic surgery) was used to remove ectopic parathyroid glands in all 11 patients, with no need for conversion to open surgery. Results: The pathological results showed that VATS successfully removed the ectopic glands in all 11 patients. Serum parathyroid hormone (PTH) levels were monitored intraoperatively, and frozen sections were used to confirm the presence of parathyroid adenomas in all cases. Postoperative analysis showed that PTH levels dropped by at least 50% within 10-15 minutes after adenoma removal. Conclusion: VATS is a safe and effective method for the treatment of hyperfunctional ectopic parathyroid glands in the mediastinum with a low risk of complications.

Ectopic pure mediastinal parathyroid adenoma: A case report

Introduction and importance

The ectopic parathyroid adenoma is an important cause of refractory and recurrent hyperparathyroidism. The mediastinal location of ectopic parathyroid tissue is reported in up to 20% of cases of ectopic parathyroid adenomas. In around 2% of cases where cervical approach is unfeasible, the mediastinal route imposes a surgical challenge.

Case presentation

We describe a case of a twenty-five-year-old male patient with manifestations of hyperparathyroidism. Computed tomography of the chest showed an anterior mediastinal mass. Nuclear scintigraphy detected a functioning parathyroid tissue in the mediastinum. The mass was excised en block with the surrounding adipose tissue using a three-port video-assisted thoracoscopic surgery. The patient showed a full symptomatic and laboratory recovery.

Clinical discussion

Mediastinal parathyroid glands comprise a unique surgical entity with diagnostic and management difficulties.

Conclusion

Mediastinal parathyroid gland is a rare yet important cause of refractory hypercalcemia. The current localization tools improve the thoracoscopic management of MPAs. VATS can provide access and exposure to ectopic parathyroid adenoma with low morbidity.

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Ectopic mediastinal parathyroid glands are rare yet challenging cause of refractory or recurrent hypercalcemia.

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Most mediastinal parathyroids are approachable through a neck incision.

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Larger, deeper or totally mediastinal glands require thoracic access.

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Historically, in challenging cases, sternotomy or thoracotomy is performed with associated high morbidity in some cohorts.

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The video-assisted thoracoscopic surgery (VATS) allows surgeons to retrieve these glands guided with localization tools.

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 parathyroid cyst resected via a cervical incision using video-mediastinoscopy

Parathyroid cysts are rare, benign, cystic lesions usually located in the neck region, and those located in the mediastinum are extremely unusual. Traditionally, thoracotomy or sternotomy has been used to resect mediastinal parathyroid cysts, and recently, video-assisted thoracoscopic surgery has also been employed. Here, we describe a case of non-functional mediastinal parathyroid cyst that was successfully resected via a cervical incision using video-mediastinoscopy.

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.

Minimally invasive resection for mediastinal ectopic parathyroid glands

BACKGROUND

We reviewed our experience with ectopic mediastinal parathyroidectomy.

METHODS

Between March 1980 and September 2010, mediastinal parathyroidectomy was performed in 33 patients with hypercalcemia secondary to hyperparathyroidism.

RESULTS

Primary hyperparathyroidism was the main diagnosis in 32 patients (97%). Technetium-sestamibi scan was used in 23 (70%) for preoperative localization. Minimally invasive resections were performed in 18 patients (55%), and 15 (45%) underwent open surgery. The most common minimally invasive surgery approach was video-assisted thoracoscopy in 9 patients (27%); the most common open approach was median sternotomy in 11 (33%). Intraoperative parathyroid hormone monitoring was used in 22 patients (67%). The ectopic glands were intrathymic in 15 patients (45%), in the aortopulmonary window in 7 (21%), and in other intrathoracic locations in the remaining 11 (33%). Parathyroid adenomas were identified in 21 patients (64%); parathyroid hyperplasia and carcinoma were identified in 9 (27%) and 3 (9%), respectively. No early mortality occurred in either group. Reoperation was required in 1 patient in the minimally invasive surgery group because of hemothorax. Morbidity occurred in 8 patients (24%), the most common of which was hypocalcemia in 4 (12%). The mean length of stay was significantly shorter in the minimally invasive surgery group (2 versus 6 days; p < 0.001) but mortality and morbidity were not statistically different between the two groups (p = 0.05). Mean follow-up was 3 ± 3.7 years.

CONCLUSIONS

Minimally invasive mediastinal parathyroidectomy has similar outcomes to open surgery, with significantly shorter length of hospital stay.

Thoracoscopic resection of a giant mediastinal parathyroid cyst

Parathyroid cysts are a rare situation, unusually in the mediastinum. The preoperative diagnosis could be more difficult in some atypical topographies and imaging characteristics in particular in case of huge mediastinal cyst. In the following years traditionally, in case of intrathoracic parathyroid cysts, sternotomy or thoracotomy have been the preferred approaches. We report a case of an older patient with a huge mediastinal parathyroid cyst removed successfully using videothoracoscopy.

Pathologic fractures: a neglected clinical feature of parathyroid adenoma

The pattern of clinical presentation of primary hyperparathyroidism (pHPT) has changed dramatically from a severe disease to an asymptomatic condition in Western countries. The story is completely different in Eastern countries. Bone and joint related sign and symptoms like bone pain and multiple fractures are common in these patients. Imaging and nuclear medicine studies will be helpful specially in patient who candidate for surgical removal of the abnormal parathyroid gland. Here, we present a 48-year-old man with multiple typical fractures in long bones and a single adenoma in his right inferior parathyroid gland. pHPT is a severe, symptomatic disease with serious complications and high morbidity in Iran. Advanced skeletal disease is the most common pattern of presentation.

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.

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.

Hybrid SPECT/CT imaging for primary hyperparathyroidism: case reports and pictorial review

The utility of hybrid single photon emission computed tomography/computed tomography imaging for primary hyperparathyroidism is both intuitive and becoming increasingly apparent clinically, particularly for patients with prior failed surgery and for those with suspected ectopic adenomas. Second generation imaging equipment, capable of superimposing functional information on highly detailed anatomic images is proving useful in surgical planning, permitting the successful application of minimally invasive techniques. The clinical background and hybrid imaging modality are discussed, together with a selection of illustrative case images. Special emphasis is placed on the use of the technique for imaging ectopic parathyroid adenomas.

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.

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.

Nueva técnica quirúrgica para glándulas paratiroides intratorácicas: la videotoracoscopia con detección de Tc-MIBI intraoperatoria

Ectopic mediastinal parathyroid glands are uncommon (1-11% of all cases of hyperparathyroidism). Median sternotomy used to be performed to resect them, with large and painful incisions that prolonged the length of hospital stay. Current imaging techniques (thoracic computed tomography and Tc-mibi scan) can accurately locate the ectopic glands, allowing minimally invasive exploration. We report a new surgical technique: video-assisted thoracoscopic resection associated with intraoperative Tc-mibi scintigraphy for ectopic mediastinal parathyroid glands. This technique allows minimally invasive access and reduces complications and length of hospital stay. Therefore we believe that video-assisted thoracoscopy could become the technique of choice in patients with high surgical risk and a fifth ectopic parathyroid gland. We report the case of a 49-year-old man in whom surgery was successful.

Primary hyperparathyroidsm, amyloid and multiple myeloma: an unusual association

We report the case of a 76-year-old woman with a diagnosis of Primary Hyperparathyroidsm and Systemic Amyloidosis, in whom subsequent investigations revealed the presence of Multiple Myeloma. We discuss the relationship between these conditions and the implications for management.

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.

Accurate localization of supernumerary mediastinal parathyroid adenomas by a combination of structural and functional imaging

Reoperation for refractory or recurrent hyperparathyroidism following parathyroidectomy carries the potential for increased morbidity and the possibility of failure to localize and remove the lesion intraoperatively. Reported herein are three cases demonstrating the combined use of sestamibi scintigraphy, CT and MR for accurate localization of mediastinal parathyroid adenomas.