Surgical treatment for mediastinal parathyroid adenoma causing primary hyperparathyroidism

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.

Four-Dimensional Computed Tomography for Parathyroid Adenoma Localization: A Pre-Operative Imaging Protocol

OBJECTIVE

Primary hyperparathyroidism (PHPT) affects approximately 0.86% of the population, with surgical resection as the treatment of choice. A 4D computed tomography (CT) is a highly effective tool in localizing parathyroid adenomas; however, there is currently no defined role for 4D CT when stratified against ultrasonography (USG) and nuclear medicine Technetium Sestamibi SPECT/CT (SES) imaging.

STUDY DESIGN

Retrospective Study.

SETTING

University Hospital.

METHODS

All patients who underwent parathyroidectomy for PHPT between 2014 and 2019 at a single institution were reviewed. Patients who had a 4D CT were included. We compared outcomes of 4D CT as a second line imaging modality to those of USG and SES as first line modalities. An imaging algorithm was proposed based on these findings.

RESULTS

There were 84 patients identified who had a 4D CT after unsuccessful first line imaging. A 4D CT localized parathyroid adenoma to the correct quadrant in 64% of cases, and to the correct laterality in 75% of cases. Obese patients had significantly lower rates of adenoma localization with USG (33.4%), compared to non-obese patients (67.5%; P = .006). In determining multigland disease the sensitivity of 4D CT was 86%, while the specificity was 87%.

CONCLUSIONS

A 4D CT has impressive rates of accurate localization of parathyroid adenomas; however due to the radiation exposure involved, it should remain a second line imaging modality. PHPT patients should first be evaluated with USG, with 4D CT used if this is unsuccessful and patients are greater than 40 years old, have a high BMI, or are having revision surgery.

Surgical Treatment of Ectopic Mediastinal Parathyroid Tumors: A 23-Year Clinical Data Study in a Single Center

Background. Ectopic mediastinal parathyroid glands are parathyroid glands located completely below the clavicle. At present, most literature reports on ectopic mediastinal parathyroid tumors (EMPT) are case reports or small case sequences.Methods. This study conducted a retrospective analysis of ectopic mediastinal parathyroid tumors cases treated over the past 23 years, summarizing and analyzing general conditions, preoperative positioning, postoperative pathology, intraoperative conditions, and long-term follow-up results.Results. This study enrolled 28 patients. Among them, 27 patients underwent preoperative localization diagnosis using 99mTc-sestamibi scan (MIBI) in conjunction with chest computed tomography (CT), including 26 cases of the anterior superior mediastinum and 2 cases of middle mediastinum. Postoperative pathology revealed 23 cases of parathyroid adenoma, 4 cases of parathyroid hyperplasia, and 1 case of parathyroid cyst. In this study, 12 patients underwent video-assisted thoracoscopic surgery (VATS) and thoracotomy approaches. Using Mann-Whitney U test, we discovered that VATS approach group is significantly superior in surgical time (P = 0.039) and intraoperative bleeding (P < 0.001). Within one week of surgery, 26 patients with primary hyperparathyroidism (PHPT) experienced a significant decrease in blood parathyroid hormone (PTH) (P < 0.001) and blood calcium (P < 0.001), and all achieved long-term remission.Conclusions. EMPT is most frequently performed in the anterior superior mediastinum. EMPT is predominantly parathyroid tumors, and most of them are associated with PHPT. MIBI and chest CT combination can be used for preoperative lesion localization (positive rate 96.15%). VATS can be used as a better surgical approach. PHPT patients before surgery can achieve long-term symptom relief with surgical treatment.

Discovery of primary hyperparathyroidism following an endoscopic resection of the prostate: case report

Urological complaints related to primary hyperparathyroidism are frequently caused by the formation of urolithiasis. We report another rare clinical manifestation of primary hyperparathyroidism associated with urological symptoms. A 68-year-old man presented with dysuria related to benign prostatic hyperplasia. After undergoing endoscopic resection of the prostate, the patient's urinary complaints persisted for several months thereafter. Urinary ultrasound revealed numerous calcifications on the prostatic resection area, requiring a cystoscopy for excision and analysis of the calcifications. This was followed by an endocrine evaluation that revealed a primary hyperparathyroidism due to a single parathyroid adenoma, which was responsible for the prostatic calcifications and the patient's atypical symptomatology. The clinical evolution was favorable after parathyroidectomy. Symptomatic prostatic calcifications, due to primary hyperparathyroidism, on an area of the endoscopic prostate resection are uncommon. The only treatment is endocrine surgery.

Localization and management of mediastinal parathyroid adenoma – a case report

Ectopic parathyroid adenoma sometimes poses diagnostic challenge and can be a cause of persistent and recurrent primary hyperparathyroidism. Anterior mediastinum is one of the locations for ectopic parathyroid adenoma. Surgical excision is the only cure and for successful surgery, pre-operative localization is crucial. Chance of failed surgery is being increased without prior localization of the ectopic gland. The combination of single photon emission computed tomography (SPECT) and computed tomography (CT) has got high sensitivity for accurate localization of ectopic parathyroid. On the other hand, with accurate localization surgical outcome is excellent. Here we report, successful localization and management of a case of primary hyperparathyroidism due to adenoma in anterior mediastinum in 47-year-old man. IMC J Med Sci 2022; 16(2): 003. DOI: https://doi.org/10.55010/imcjms.16.013 *Correspondence: Dr. Nusrat Sultana, Room no-1620, Block-D, 15th floor, Department of Endocrinology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. Email: nusrat_sultana@bsmmu.edu.bd

Diagnosis and treatment of mediastinal ectopic thyroid tissue with normally located thyroid gland and primary hyperparathyroidism: a case report

Mediastinal ectopic thyroid tissue (ETT) is rare entity, accounting for 1% of all mediastinal tumours. A 53-year-old lady, presented with cough and atypical chest pain. A computed tomography (CT) scan of chest showed a 95 mm × 75 mm × 115 mm tumour mass; CT guided biopsy of mediastinal mass showed ETT. Thyroid scintigraphy with Technetium-99m (^99mTc) pertechnetate showed homogenous and intense uptake in the thyroid gland (TG) lodge and in the mediastinum. Primary hyperparathyroidism (PHPT) was diagnosed during laboratory evaluation. Technetium-99m sestamibi (^99mTc-MIBI) parathyroid scintigraphy with single photon emission CT (SPECT)/CT showed uptake of radionuclide in two locations, one in the eutopic position [right inferior parathyroid gland (PTG)] and second ectopic (mediastinal). After surgery, histopathological examination confirmed mediastinal ETT and two PTG adenomas. During follow-up, laboratory analyzes were maintained within the reference range and the patient remained stable and free of symptoms and clinical signs, which supports a good prognosis. The existence of an ectopic mediastinal thyroid and an ectopic parathyroid tissue may be partly explained by a similar embryological origin. Diagnosis of ectopic thyroid and parathyroid tissues is demanding; requires a multidisciplinary team and approach using highly accurate radiological and nuclear imaging. The simultaneous existence of mediastinal ETT, nodular eutopic TG and PHPT for which two adenomas are responsible (cervical eutopic and mediastinal ectopic) is a complex diagnostic and therapeutic challenge, which we have described so far as unique. Comprehensive and multidisciplinary surgery planning is a cornerstone of treatment, when recommendations in guidelines are lacking.

Changes in bone mineral density after parathyroidectomy in patients with moderate to severe primary hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism (PHPT) is relatively common in China and results in severe damage to the skeletal system. This study aimed to investigate changes in bone mineral density (BMD) over 2 years in patients with PHPT after parathyroidectomy.

METHODS

This retrospective cohort study included patients with PHPT who underwent parathyroidectomy between January 2010 and December 2015. BMD and T-scores and Z-scores of the lumbar spine (L1, L2, L3, and L4) and total hip (femoral neck, great trochanter, and Ward's triangle) at baseline and 2 years after surgery were measured by dual-energy X-ray absorptiometry.

RESULTS

Thirty patients with moderate to severe PHPT (17 men and 13 women) aged 38.90±15.48 years were included. BMD, and T-score and Z-score values at the lumbar spine and total hip at 6 months, 1 year, and 2 years after parathyroidectomy were significantly improved compared with preoperative values. Improvement in BMD was largest at L4 (46.7%) and smallest at L1 (37.4%) in the lumbar spine 2 years after parathyroidectomy. For the total hip, the increase in BMD was largest at Ward's triangle (42.6%) and smallest at the femoral neck (37.5%).

CONCLUSIONS

BMD of the lumbar spine and total hip is improved after parathyroidectomy in patients with PHPT.

How to do depends on where it settles: Mediastinal parathyroid adenomas

Background

In this study, we aimed to evaluate demographic characteristics, preoperative adenoma localization, surgical techniques selected according to the size and localization of adenoma, and clinical results of patients undergoing mediastinal parathyroid adenoma excision.

Methods

Medical records of a total of 11 patients (4 males, 7 females; mean age 52.6 years; range, 25 to 65 years) who underwent excision of mediastinal parathyroid adenoma in our clinic between January 2011 and June 2019 were retrospectively reviewed. Data including demographic characteristics, complaints, preoperative serum calcium, phosphorus, and parathyroid hormone levels, preoperative imaging methods, surgical method, localization and size of adenoma, length of hospital stay, and duration and amount of drainage were recorded.

Results

Adenoma was localized in anterior mediastinum in seven patients and in the middle mediastinum in four patients. The mean diameter calculated by taking into account the longest diameter of parathyroid adenoma was 21.1 mm. The mean drainage duration was 3.5 days in two patients undergoing median sternotomy, five days in one patient undergoing thoracotomy, 1.2 days in three patients undergoing video-assisted thoracoscopic surgery, and 0.6 days in five patients undergoing robotic surgery.

Conclusion

Minimally invasive approaches such as videoassisted thoracoscopic surgery and robotic-assisted surgery are safe and effective approaches for excision of mediastinal parathyroid adenoma.

Hypercalcemia in the Presence of an Ectopic Mediastinal Mass

A 72-year-old gentleman who presented to the outpatient clinic for a preventive health appointment with symptoms of depression and fatigue was found to have persistent hypercalcemia on routine laboratory monitoring. Initial laboratory testing was consistent with primary hyperparathyroidism with elevation in parathyroid hormone and low vitamin D levels. Further imaging demonstrated an ectopic mediastinal parathyroid adenoma. The ectopic lesion was treated surgically and lead to normalization of calcium levels and objective improvement in depressive symptoms. Primary hyperparathyroidism, which can be secondary to an adenoma, multigland hyperplasia, or neoplasm, can lead to the development of bone pain, fractures, and nephrolithiasis among other symptoms. The evaluation of hypercalcemia and the identification of primary hyperparathyroidism are important for the primary care physician to recognize so as to reduce disease morbidity as well as identify patients in need of further specialty care.

An Atypical Presentation of Primary Hyperparathyroidism in an Adolescent: A Case Report of Hypercalcaemia and Neuropsychiatric Symptoms Due to a Mediastinal Parathyroid Adenoma

Psychiatric disorders are rare clinical manifestations of hypercalcaemia in the pediatric population, are relatively more frequent during adolescence and are often overlooked in cases of severe hypercalcaemia. We described the case of a 17-year-old girl affected by anorexia nervosa, depression and self-harm with incidental detection of moderate hypercalcaemia. Clinical, laboratory and instrumental tests demonstrated that hypercalcaemia was secondary to primary hyperparathyroidism (PHPT) due to a mediastinal parathyroid adenoma in the thymic parenchyma. After parathyroidectomy with robot-assisted surgery, we observed the restoration of calcium and PTH levels in addition to an improvement in psychiatric symptoms. This case demonstrates that serum calcium concentration should be evaluated in adolescents with neurobehavioural symptoms and in cases of hypercalcaemia PHPT should be excluded. Surgery represents the cornerstone of the management of PHPT and may contribute to improving quality of life and psychological function in these patients. However, the complexity of neurological involvement in cases of hypercalcaemia due to PHPT requires further investigations to establish the real impact of this condition on the neurocognitive sphere.

The value of intraoperative parathyroid hormone assay in the surgery of mediastinal ectopic parathyroid adenoma (A case series)

Background and aims

Ectopic parathyroid adenoma is a rare entity. Its clinical management is challenging due to varying locations in the mediastinum. The aim of our study is to report our experience about the preoperative localization of the ectopic parathyroid adenoma and to emphasize the major role of the intraoperative parathyroid hormone assay in such circumstances.

Methods

It is a monocentric, retrospective study about patients diagnosed with EPA (ectopic parathyroid adenoma) from January 2015 to December 2016. Clinical aspects, preoperative management as well as the surgical procedures have been analyzed.

Results

There were 7 women, with an average age of 59.14 years. Six patients presented with biological disorders of the phosphocalcic metabolism such as spontaneous bone fracture and recurrent renal lithiasis. In one case, EPA was discovered in the setting of malignant hypercalcemia. The topographic preoperative assessment with a cervicothoracic CT (computed tomography) showed spontaneously hyperdense tissular masses of variable localizations in the mediastinum. A Tc-99 m (99mTc - MIBI) scintigraphy was performed in 5 patients and showed uptake in all cases. We performed cervicotomy in 1 case, manubriotomy in 2 patients, neck manubriotomy in 2 cases, total vertical sternotomy in 1 case, and posterolateral thoracotomy in 1 patient. The lesion was localized in the mediastinum in 1 patient in the perithymic fat in 1 case; EPA was laterotracheal in 1 case, retro tracheal in 1 case, intra-thymic in 2 cases, inter-jugulo-carotidian with contact with the left subclavial artery in 1 case, and anterior mediastinal in 1 patient. The 1-h after-parathormonemia following removal of the surgical specimens showed a decrease value of 45 and 80% of the baseline value. No surgical morbidity was noted after an average follow-up of 7.9 months (range of 5–18 months).

Conclusion

The preoperative topographic diagnosis of ectopic parathyroid adenoma is challenging for the surgeon despite progress in the morphological assessment. The intraoperative parathyroid hormone assay is a valuable tool for an appropriate surgical management.

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Thoracic surgeons faced difficulties in the management of ectopic parathyroid adenomas in the mediastinal location.

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The intraoperative assay of parathormonemia helps guide the surgeon in his strategy of complete excision of the ectopic parathyroid adenom

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Hypocalcemia is a constant postoperative complication and its absence may make questionnable the quality of the tumor resection.

VATS Resection of Large Ectopic Posterior Mediastinal Cystic Parathyroid Adenoma

Ectopic parathyroids can often present a diagnostic and therapeutic conundrum for clinicians. Mediastinal parathyroid adenomas are usually small and located anteriorly within thymic tissue. To our knowledge, this is the first reported case of a large cystic parathyroid adenoma presenting as a 6-cm posterior mediastinal mass. After a successful thoracoscopic resection, parathyroid hormone levels normalized and the patient was discharged home on postoperative day 2.

Ectopic Parathyroid Adenoma Presenting as a Mediastinal Mass

A parathyroid adenoma present in an ectopic site, in the anterior mediastinum, is a rare cause of persistent hyperparathyroidism. Though its occurrence in the mediastinum is unusual, existence has been noted in literature for more than a century. We describe a case of a 35-year-old male presenting with complaints of pain abdomen, clinically diagnosed as acute necrotizing pancreatitis, with raised serum calcium. Patient received symptomatic treatment for the pancreatitis which subsided. However, high levels of serum calcium persisted. Suspecting hyperparathyroidism, ultrasound neck was done, revealing apical thoracic mass. CT scan of neck revealed a large heterogeneous enhancing mass in superior mediastinum. Fine Needle Aspiration (FNA) of the mass done endoscopically was confusing as it showed features suggestive of a cystic teratoma. However, persistently raised calcium levels along with raised parathormone warranted a Technetium - 99 (Tc-99m) sestamibi scan which revealed positive uptake involving right inferior parathyroid extending to superior mediastinum. The mass was surgically excised and it was diagnosed as a parathyroid adenoma. This case helps bring to light the necessity to consider ectopic parathyroid adenoma as an important differential diagnosis in mediastinal tumour with persistent hypercalcaemia, and as a cause of hyperparathyroidism.

Rapid development of metastatic pulmonary calcifications in primary hyperparathyroidism: a case report and literature review

Background

Metastatic pulmonary calcification (MPC) is rarely reported in primary hyperparathyroidism, especially MPC develops quickly. We report such a case here with a literature review.

Case presentation

A 41-year-old woman presented with cough and dyspnea. Data from clinical, radiological, pathological, technetium (^99mTc)-methylene diphosphonate (MDP) bone scintillation imaging, and ^99mTc-methoxy isobutyl isonitrile (MIBI) thyroid imaging were studied. ^99mTc-MIBI thyroid imaging indicated hyperparathyroidism. Chest computed tomography (CT) scans showed rapidly progressive bilateral pulmonary multiple high-density shadows with mass consolidation and exudation in only five days. ^99mTc-MDP bone scintillation imaging indicated bilateral pulmonary calcifications. CT-guided lung biopsy showed multifocal irregularities of calcium deposition and calcified bodies in the pulmonary interstitium. The patient showed gradually clinical and radiological improvement after surgical removal of the parathyroid adenoma.

Conclusion

Rapidly progressive MPC tends to be misdiagnosed as many primary pulmonary diseases. ^99mTc-MDP bone scintillation imaging and pulmonary biopsy could be performed to differentiate metastatic pulmonary calcification from other diseases. Surgical resection of the parathyroid gland is helpful for treatment of MPC in patients with primary hyperparathyroidism and is regularly recommended.