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Tay YZ, Balasubbiah N, Awang RR, Retna Pandian BD, Sathiamurthy N. A Surgical Management of Mediastinal Parathyroid Adenoma: A Regional Experience in Malaysia. Cureus 2024; 16:e56792. [PMID: 38650780 PMCID: PMC11034996 DOI: 10.7759/cureus.56792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2024] [Indexed: 04/25/2024] Open
Abstract
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.
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Affiliation(s)
- Yen Zhir Tay
- General Surgery, Thoracic Surgery Unit, Kuala Lumpur Hospital, Kuala Lumpur, MYS
| | | | - Raflis Ruzairee Awang
- General Surgery, Breast and Endocrine Surgery Unit, Kuala Lumpur Hospital, Kuala Lumpur, MYS
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Mahmood SBZ, Jamal A, Mushtaq Z, Masood MQ. A Rare Occurrence of Ectopic Parathyroid Carcinoma Presenting as a Case of Recurrent Fractures. Cureus 2023; 15:e51404. [PMID: 38292973 PMCID: PMC10826897 DOI: 10.7759/cureus.51404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 02/01/2024] Open
Abstract
Ectopic parathyroid tumors are uncommon, accounting for only 6% of parathyroid adenomas, and even fewer cases are attributed to parathyroid carcinomas. While ectopic parathyroid carcinoma in the anterior mediastinum is a rare condition, the occurrence of recurrent skeletal fractures in the presence of mild hypercalcemia is even rarer. In this report, we present the case of a 52-year-old man with a medical history of hypertension, chronic kidney disease, and a previous right-sided intertrochanteric fracture of the femur one year earlier. He presented to the emergency room with left-sided hip pain and shortness of breath due to volume overload. Laboratory tests revealed mild hypercalcemia and hyperparathyroidism, with normal vitamin D levels. An X-ray showed a left neck of femur fracture. Further evaluation with a three-phase skeletal scintigraphy indicated the presence of metabolic bone disease. A contrast-enhanced computed tomography of the chest revealed a solitary soft tissue nodule in the anterior mediastinum, representing an ectopic parathyroid adenoma. The lesion was successfully removed using video-assisted thoracic surgery, and the histopathological analysis confirmed the diagnosis of parathyroid carcinoma. The combination of mild hypercalcemia and recurrent fractures is an unusual presentation of ectopic parathyroid carcinoma, underscoring the importance of considering this condition as a potential cause in similar cases to ensure timely and appropriate treatment.
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Affiliation(s)
| | - Aisha Jamal
- Internal Medicine, Aga Khan University Hospital, Karachi, PAK
| | - Zain Mushtaq
- Internal Medicine, Aga Khan University Hospital, Karachi, PAK
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Abraham BM, Sharkey E, Kwatampora L, Ranzinger M, von Holzen U. Mediastinal Intrathymic Parathyroid Adenoma: A Case Report and Review of the Literature. Cureus 2023; 15:e42306. [PMID: 37609099 PMCID: PMC10442188 DOI: 10.7759/cureus.42306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2023] [Indexed: 08/24/2023] Open
Abstract
The classic clinical vignette of primary hyperparathyroidism is well described as "bones, stones, abdominal moans, and psychiatric overtones" to reflect the effects of excess parathyroid hormone (PTH) and calcium. Most commonly, primary hyperparathyroidism is due to a functional parathyroid adenoma situated by the thyroid gland. Rarely, the primary focus of autonomously produced PTH is located ectopically within the mediastinum. A 19-year-old Caucasian female with no relevant past medical history presented to the emergency department with tachycardia, nausea, vomiting, and a five-day history of vague, mid-abdominal pain. Initial computed tomography (CT) with contrast of the abdomen and pelvis was negative for acute findings, and she subsequently underwent biochemical screening. The patient was found to have elevated serum calcium and PTH, raising suspicion for the diagnosis of primary hyperparathyroidism. Further evaluation for a parathyroid adenoma was negative by a CT scan of the neck and thyroid ultrasound. A nuclear medicine parathyroid single-photon emission computed tomography (SPECT)/CT with technetium (Tc) 99m sestamibi found an abnormal nodular uptake within the left prevascular mediastinum suggestive of an ectopic parathyroid adenoma. A left-sided, video-assisted thoracoscopic surgery (VATS) with successful excision of the ectopic mediastinal parathyroid adenoma was performed. Surgical pathology revealed that the parathyroid adenoma was completely excised and surrounded by thymus and adipose tissue. The patient tolerated the procedure well and was discharged without further complications. The rarity of mediastinal, intrathymic parathyroid adenomas resulted in delayed diagnosis in this patient, understandably so as errant embryogenesis does not occur commonly. Visualization with SPECT/CT and successful specimen excision by minimally invasive VATS resulted in the accurate diagnosis and ultimate cure of this patient's primary hyperparathyroidism.
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Mediastinal Parathyroid Cancer. Cancers (Basel) 2022; 14:cancers14235852. [PMID: 36497335 PMCID: PMC9739626 DOI: 10.3390/cancers14235852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/22/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Parathyroid cancer (PC) is rare, but its pre-operative recognition is important to choose appropriate access strategies and achieve oncological clearance. This study characterizes features of mediastinal parathyroid cancer (MPC) and explores criteria aiding in the pre-operative recognition of malignancy. We assembled data from 502 patients with mediastinal parathyroid neoplasms (MPNs) from a systematic review of the literature 1968−2020 (n = 467) and our own patient cohort (n = 35). Thirty-two of the 502 MPNs (6.4%) exhibited malignancy. Only 23% of MPC patients underwent oncological surgery. Local persistence and early recurrence at a median delay of 24 months were frequent (45.8%), and associated with a 21.7-fold (95%CI 1.3−351.4; p = 0.03) higher risk of death due to disease. MPCs (n = 30) were significantly larger than cervical PC (n = 330), at 54 ± 36 mm vs. 35 ± 18 mm (χ2 = 20; p < 0.0001), and larger than mediastinal parathyroid adenomas (MPA; n = 226) at 22 ± 15 mm (χ2 = 33; p < 0.01). MPC occurred more commonly in males (60%; p < 0.01), with higher calcium (p < 0.01) and parathyroid hormone (PTH) levels (p < 0.01) than MPA. Mediastinal lesions larger than 3.0 cm and associated with a corrected calcium ≥ 3.0 mM are associated with a more than 100-fold higher odds ratio of being malignant (OR 109.2; 95%CI 1.1−346; p < 0.05). The composite 3 + 3 criterion recognized 74% of all MPC with an accuracy of 83%. Inversely, no MPN presenting with a calcium < 3.0 mM and size < 3.0 cm was malignant. When faced with pHPT in mediastinal location, consideration of the 3 + 3 rule may trigger an oncological team approach based on simple, available criteria.
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Shao Y, Zeng Q, Lv B, Chen X, Sheng L. Case Report: Primary Hyperparathyroidism due to Posterior Mediastinal Parathyroid Adenoma With One-Year Follow-Up. Front Surg 2022; 9:893259. [PMID: 35711701 PMCID: PMC9193965 DOI: 10.3389/fsurg.2022.893259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022] Open
Abstract
Ectopic parathyroid adenoma, though rare, is one of the causes of persistent hyperparathyroidism and recurrence of hyperparathyroidism. Ectopic parathyroid glands can be seen in thymus, thyroid, and mediastinum. However, ectopic parathyroid adenoma occurred in the posterior superior mediastinum is extremely rare. Here, we report a case of primary hyperparathyroidism caused by ectopic parathyroid adenoma located in the posterior superior mediastinum. Serum parathyroid hormone, calcium, and vitamin D levels of the patient was followed up for one year.
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Affiliation(s)
- Yi Shao
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Qingdong Zeng
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Bin Lv
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Xu Chen
- Department of Pathology, Qilu Hospital of Shandong University, Jinan, China
| | - Lei Sheng
- Department of Thyroid Surgery, General Surgery, Qilu Hospital of Shandong University, Jinan, China
- Correspondence: Lei Sheng
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Khanh HQ, Van Khoi N, Vuong NL. Long-term outcome in mediastinal malignancies: video-assisted thoracoscopic versus open surgery. Indian J Thorac Cardiovasc Surg 2020; 37:44-52. [PMID: 33442207 DOI: 10.1007/s12055-020-01023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 11/25/2022] Open
Abstract
Purpose There are not many studies comparing long-term oncological outcomes between video-assisted thoracoscopic surgery (VATS) and open surgery for mediastinal malignancies. This study aimed to compare perioperative and long-term outcomes of these two techniques in the treatment of mediastinal malignancies. Methods This is a retrospective study: patients with mediastinal malignancies underwent VATS or open surgery from 2010 to 2013 and were followed until 2019. The primary endpoints were long-term oncological outcomes, including tumor recurrence and mortality. Secondary endpoints were perioperative outcomes (operative duration, blood loss, pain, chest drainage duration, hospital length of stay, and complications). Results There were 36 patients in the VATS group and 49 patients in the open group. The median follow-up duration was 90 months. VATS significantly reduced operation time (84.6 versus 124.8 min), blood loss (59.8 versus 235.2 ml), postoperative pain score (4.9 versus 6.7), the duration of chest tube drainage (2.1 versus 3.1 days), and postoperative hospital stay (5.2 versus 8.0 days). The two groups were comparable regarding the recurrence rate (2.4 versus 2.1/100 person-years) and mortality rate (0.8 versus 0.9/100 person-years). Conclusion Compared with open surgery, VATS is less traumatic, reduces postoperative chest drainage, and shortens hospital stay with comparable long-term oncological outcomes. We advocate the VATS approach as a favored option for the resection of mediastinal malignancies.
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Affiliation(s)
- Huynh Quang Khanh
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
| | - Nguyen Van Khoi
- Department of Thoracic Surgery, Cho Ray Hospital, Ho Chi Minh City, Vietnam
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Nguyen Lam Vuong
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Department of Medical Statistics and Informatics, Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
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Nagano H, Suda T, Ishizawa H, Negi T, Kawai H, Kawakami T, Tochii D, Tochii S, Hoshikawa Y. Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid tumor: subxiphoid and lateral thoracic approach. J Thorac Dis 2019; 11:2932-2938. [PMID: 31463122 DOI: 10.21037/jtd.2019.07.35] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to investigate the initial results of an endoscopic surgical approach for the treatment of intramediastinal ectopic parathyroid adenoma and to evaluate the effectiveness of a single-incision resection using the subxiphoid approach. Methods Five cases of patients (1.89%) were diagnosed with ectopic mediastinal parathyroid tumor and underwent resection from 2008 to 2017 in Fujita Health University Hospital. They were retrospectively analyzed. Results Four patients underwent single-port mediastinal tumor resection using the subxiphoid approach and 1 patient underwent multi-port mediastinal tumor resection using the lateral thoracic approach. The operation time was 134±83.52 min, and the amount of blood loss was 81.8±173.41 mL. The rate of conversion to thoracotomy was 0%, and no intraoperative or postoperative complications were observed. The amount of postoperative oral analgesics was 112.83±209.12 tablets, and their administration period was 561.6±1,229.5 days. The length of hospital stay was 4±2.35 days, and the duration of chest tube drainage was 1.33±1.95 days. The patient who underwent multi-port mediastinal tumor resection using the lateral thoracic approach reported postoperative pain. Serum calcium levels decreased from 10.56±1.52 mg/dL preoperatively to 8.96±0.5 mg/dL postoperatively, and serum phosphorous levels increased from 2.84±0.42 mg/dL preoperatively to 3.6±0.51 mg/dL postoperatively. Intact-PTH hormone levels decreased from 221±169.84 pg/dL preoperatively to 70.2±44.28 pg/dL postoperatively. No recurrence of hyperparathyroidism has been observed in any patient. Conclusions The single-incision mediastinal tumor resection via the subxiphoid approach, without going through the intercostal space, is considered as a useful endoscopic surgical approach for the treatment of mediastinal ectopic parathyroid adenomas due to the limited occurrence of post-thoracotomy pain syndrome and the superior esthetic outcomes associated with the procedure as compared to thoracotomy and median sternotomy.
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Affiliation(s)
- Hiromitsu Nagano
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Takashi Suda
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Hisato Ishizawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Takahiro Negi
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Hiroshi Kawai
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Toru Kawakami
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Daisuke Tochii
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Sachiko Tochii
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine, 1-98 Dengakugakubo Kutsukake, Toyoake, Aichi, Japan
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Isaacs KE, Belete S, Miller BJ, Di Marco AN, Kirby S, Barwick T, Tolley NS, Anderson JR, Palazzo FF. Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid adenoma. BJS Open 2019; 3:743-749. [PMID: 31832580 PMCID: PMC6887896 DOI: 10.1002/bjs5.50207] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/28/2019] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- K E Isaacs
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK
| | - S Belete
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK
| | - B J Miller
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK
| | - A N Di Marco
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK.,Department of Surgery & Cancer Imperial College London UK
| | - S Kirby
- Department of Radiology Imperial College Healthcare NHS Trust London UK
| | - T Barwick
- Department of Anaesthesia Imperial College Healthcare NHS Trust London UK
| | - N S Tolley
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK.,Department of Surgery & Cancer Imperial College London UK
| | - J R Anderson
- Department of Cardiothoracic Surgery, Hammersmith Hospital Imperial College Healthcare NHS Trust London UK
| | - F F Palazzo
- Department of Endocrine Surgery Imperial College Healthcare NHS Trust London UK.,Department of Surgery & Cancer Imperial College London UK
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Thoracoscopic approach in the treatment of ectopic thymic parathyroid adenoma. Wideochir Inne Tech Maloinwazyjne 2018; 13:270-277. [PMID: 30002763 PMCID: PMC6041573 DOI: 10.5114/wiitm.2018.73331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 01/07/2018] [Indexed: 11/17/2022] Open
Abstract
Primary hyperparathyroidism is overproduction of parathyroid hormone, causing hypercalcemia. Parathyroid adenomas have been found to be the etiology for 80% of cases of primary hyperparathyroidism, while almost a quarter of them are ectopic. We present a case of ectopic thymic parathyroid adenoma, treated by the thoracoscopic approach. Preoperative computed tomogram and technetium-99-sestamibi imaging showed an adenoma, located in the front mid-mediastinum, approximately 8 × 10 mm in size. Resection of the tumor was indicated according to the persistent hypercalcemia after unsuccessful surgical treatment performed 3 years ago. It was decided to perform a parathyroidectomy during thoracoscopy. The diagnosis of parathyroid adenoma was established on postoperative histopathology staining. The patient was discharged from hospital 5 days after the surgery. We found this minimally invasive operation to be an effective and well-tolerated treatment option, determined by the experience of the surgeon.
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Management of mediastinal parathyroid adenoma via minimally invasive thoracoscopic surgery: Case report. Int J Surg Case Rep 2017; 40:120-123. [PMID: 28988020 PMCID: PMC5635244 DOI: 10.1016/j.ijscr.2017.08.056] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION The most common cause of chronic hypercalcemia is primary hyperparathyroidism (PHPT). However, owing to the diverse presentation of hypercalcemia, the diagnosis often goes unnoticed culminating as a continuum of recurrence of symptoms. Nephrolithiasis, decreased bone mineral density and peptic ulcer disease are the main clinical sequelae. Among the causes of PHPT 80% are caused by parathyroid adenomas (PA). However, only rarely, these adenomas are found ectopically. PRESENTATION OF CASE We present the case of a 66-year-old female with a history of recurrent renal stones and peptic ulcer disease. She was found to have elevated serum calcium and PTH levels. However, subsequent high resolution CT scan of chest and neck failed to demonstrate any abnormality. Therefore, an anterior planar Technetium-99m-sestamibi (MIBI) scintigraphy scan using a single-tracer was done and it identified ectopic anterior mediastinal parathyroid adenoma. The patient was successfully managed with video-assisted thoracoscopic surgery and excision of the mass with follow up calcium level monitoring. DISSCUSSION An elevated calcium level should prompt a thorough workup, as sometimes it's the only clue to the unrelated and diversified systemic manifestations of hypercalcemia. Hyperparathyroidism due to ectopic adenoma is quite rare and possess a diagnostic and management challenge. CONCLUSION Symptomatic hypercalcemia and high level of PTH without local PA should alert physicians to search for ectopic locations through imaging. VATS is a safe and effective minimally invasive procedure for the resection of ectopic mediastinal PA and it should be considered as the first line approach for resection of these ectopic tumors.
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Rakovich G, Deslauriers J. Video-assisted and minimally-invasive open chest surgery for the treatment of mediastinal tumors and masses. J Vis Surg 2017; 3:25. [PMID: 29078588 DOI: 10.21037/jovs.2017.01.01] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 11/22/2016] [Indexed: 12/31/2022]
Abstract
This article reviews the anatomy of the mediastinum as well as indications, limitations, techniques, and results of video-assisted thoracic surgery (VATS) and other minimally-invasive open-chest surgery approaches currently used for the surgical management of mediastinal tumors and masses. It is written by two surgeons with vastly different backgrounds and thoracic surgical experience. One of them is young and very familiar with VATS approaches and technologies while the other is a senior surgeon relatively unfamiliar with minimally-invasive techniques. This combination of authorship is ideal to analyze the pros and cons of the use of minimally-invasive approaches for the surgical management of mediastinal lesions such as thymic epithelial tumors (TETs) or neurogenic tumors. This is important because several thoracic surgeons have expressed concerns about the ability of thoracoscopic procedures to maintain adherence to sound oncological principles.
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Affiliation(s)
- George Rakovich
- Department of Surgery at the University of Montreal, Montreal, Quebec, Canada
| | - Jean Deslauriers
- Department of Surgery, Laval University, Quebec City, Quebec, Canada
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12
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Salman R, Sebaaly MG, Wehbe MR, Sfeir P, Khalife M, Al-Kutoubi A. Preoperative Localization of Mediastinal Parathyroid Adenoma with Intra-arterial Methylene Blue. Cardiovasc Intervent Radiol 2017; 40:953-956. [PMID: 28138727 DOI: 10.1007/s00270-017-1578-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 01/11/2017] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Rida Salman
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mikhael G Sebaaly
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohammad Rachad Wehbe
- Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Pierre Sfeir
- Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mohamad Khalife
- Department of General Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Aghiad Al-Kutoubi
- Department of Diagnostic Radiology, American University of Beirut Medical Center, Beirut, Lebanon.
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13
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Naik D, Jebasingh KF, Ramprasath, Roy GB, Paul MJ. Video Assisted Thoracoscopic Surgery (VATS) for Excision of an Ectopic Anterior Mediastinal Intra-Thymic Parathyroid Adenoma. J Clin Diagn Res 2016; 10:PD22-4. [PMID: 27504353 DOI: 10.7860/jcdr/2016/18108.8023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/27/2016] [Indexed: 11/24/2022]
Abstract
Ectopic anterior mediastinal parathyroid adenoma is a rare cause of Primary Hyperparathyroidism (PHPT). Imaging studies such as Technetium-99m ((99m)Tc) sestamibi parathyroid scan along with a Single Photon Emission Computerized Tomogram (SPECT), and contrast enhanced Computerized Tomogram (CT) of the neck and thorax can precisely localize the ectopic mediastinal parathyroid adenoma. We report a 40-year-old gentleman who presented with persistent pain in the right shoulder following trivial trauma. His biochemical investigations showed an elevated serum calcium of 11.6mg% (Normal: 8.3-10.4 mg%) along with an elevated iPTH of 1443 pg/ml (normal: 8-70 pg/ml) which were suggestive of primary hyperparathyroidism. The localization studies revealed an ectopic cystic parathyroid adenoma in the anterior mediastinum that was not accessible from the neck. He underwent a Video Assisted Thoracoscopic (VAT) excision procedure with normalization of serum calcium and an uncomplicated recovery. The VAT approach is a successful minimally invasive technique for mediastinal parathyroidectomy.
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Affiliation(s)
- Dukhabandhu Naik
- Associate Professor, Department of Endocrinology, Diabetes and Metabolism, Christian Medical College , Vellore, India
| | - Kumaradoss Felix Jebasingh
- Senior Registrar, Department of Endocrinology, Diabetes and Metabolism, Christian Medical College , Vellore, India
| | - Ramprasath
- Assistant Professor, Department of Thoracic surgery, Christian Medical College , Vellore, India
| | - Gnanamuthu Birla Roy
- Professor, Department of Thoracic Surgery, Christian Medical College , Vellore, India
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Amer K, Khan AZ, Rew D, Lagattolla N, Singh N. Video assisted thoracoscopic excision of mediastinal ectopic parathyroid adenomas: a UK regional experience. Ann Cardiothorac Surg 2015; 4:527-34. [PMID: 26693148 DOI: 10.3978/j.issn.2225-319x.2015.09.04] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND To report the first series of video-assisted thoracoscopic surgery (VATS) resection of mediastinal ectopic parathyroid adenomas (MEPAs) in the UK. METHODS A case series of seven cases undergoing VATS between 2004 and 2009 to treat single gland hyperparathyroidism. Methylene blue (MB) was used in 5/7 cases immediately before exploration to identify the adenomas. Carbon dioxide (CO2) up to pressures of 10 mmHg was used safely to deflate the lung in two cases. RESULTS There were five women and two men with a mean age of 53 years (range, 27-72 years). Histopathology confirmed successful resection of the parathyroid adenoma in 6/7 cases. There was one conversion to open thoracotomy due to bleeding from the azygos vein resulting from excessive traction. Despite marked MB uptake, this patient proved to have tuberculoid adenopathy and no parathyroid tissue was identified. Postoperative plasma calcium returned to normal in 6/7 patients and parathyroid hormone (PTH) level in 6/7 patients. The median hospital stay was 2 days and there was no mortality in this series. CONCLUSIONS MEPAs can be safely resected using VATS with minimal surgical morbidity, short drainage time and short hospital stay. CO2 insufflation and the intraoperative use of MB are safe and help to accurately localise the ectopic adenoma. VATS should be considered as the first-line approach for resection of MEPAs.
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Affiliation(s)
- Khalid Amer
- 1 Thoracic Surgeons; 2 Endocrine and General Surgeon, Southampton General Hospital, Southampton, UK ; 3 Endocrine and General Surgeon, Dorset County Hospital, Dorchester, UK ; 4 Histopathologist, Southampton General Hospital, Southampton, UK
| | - Ali Zamir Khan
- 1 Thoracic Surgeons; 2 Endocrine and General Surgeon, Southampton General Hospital, Southampton, UK ; 3 Endocrine and General Surgeon, Dorset County Hospital, Dorchester, UK ; 4 Histopathologist, Southampton General Hospital, Southampton, UK
| | - David Rew
- 1 Thoracic Surgeons; 2 Endocrine and General Surgeon, Southampton General Hospital, Southampton, UK ; 3 Endocrine and General Surgeon, Dorset County Hospital, Dorchester, UK ; 4 Histopathologist, Southampton General Hospital, Southampton, UK
| | - Nicholas Lagattolla
- 1 Thoracic Surgeons; 2 Endocrine and General Surgeon, Southampton General Hospital, Southampton, UK ; 3 Endocrine and General Surgeon, Dorset County Hospital, Dorchester, UK ; 4 Histopathologist, Southampton General Hospital, Southampton, UK
| | - Neeta Singh
- 1 Thoracic Surgeons; 2 Endocrine and General Surgeon, Southampton General Hospital, Southampton, UK ; 3 Endocrine and General Surgeon, Dorset County Hospital, Dorchester, UK ; 4 Histopathologist, Southampton General Hospital, Southampton, UK
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