Angiographic ablation of mediastinal parathyroid adenomas: local experience and review of the literature

Ectopic Parathyroid Adenoma in an 11-Year-Old Girl: Case Report and Literature Review

Objective

Primary hyperparathyroidism secondary to an ectopic parathyroid adenoma is rare among children and adolescents.

Methods

We describe the case of an 11-year-old girl with incidentally diagnosed primary hyperparathyroidism secondary to an intrathymic parathyroid adenoma and performed a review of the related literature.

Results

^99mTechnetium sestamibi single-photon emission computerized tomography/computed tomography and 4-dimensional computed tomography confirmed the ectopic location of the adenoma. The patient underwent thoracoscopic thymectomy and remained normocalcemic with elevated parathyroid hormone showing a downward trend. Parathyroid hormone normalized 18 months after successful parathyroidectomy.

Conclusion

We review the case of a rare mediastinal parathyroid adenoma in a pediatric patient and summarize the epidemiologic profile, diagnosis, and management of similar pediatric cases.

Persistent hyperparathyroidism due to mediastinal parathyroid adenoma treated with selective arterial embolization with embosphere: first case in the literature

Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia in the clinical setting and affects 0.3% of the population. Parathyroidectomy is the only definitive cure. Unfortunately, even in the most experienced hands, persistent primary hyperparathyroidism (P-PHPT) occurs in 4.7% of the patients. Ectopic adenomas are difficult to localize before and during operation and usually end up with P-PHPT. Herein, we presented a case with P-PHPT due to mediastinal parathyroid adenoma that was successfully ablated with selective arterial embolization. A 57-year-old female patient was admitted to our endocrinology clinic with persistent hypercalcemia 4 months after the initial surgery for PHPT that had been performed in another center. The patient did not accept the second operation, and serum calcium and parathyroid hormone (PTH) remained high despite medical treatment with cinacalcet and IV zoledronate. In the 99-m Tc-MIBI scintigraphy with SPECT, a 18 × 12-mm-sized lesion in the mediastinum at the paratracheal region was detected which was confirmed to be a possible parathyroid adenoma with fluorocholine PET and chest computed tomography (CT). The right bronchial artery that was detected to supply the mediastinal mass in CT angiography was selectively catheterized and embolized with embosphere. Right after the procedure, serum PTH and calcium levels were normalized and remained normal in 23 months of follow-up. Selective arterial embolization is a treatment option for ectopically located adenomas which are difficult to resect and in cases with certain comorbidities which constitute a contraindication for surgery.

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.

Gamma probe-assisted excision of an ectopic parathyroid adenoma located within the thymus: case report and review of the literature

Primary hyperparathyroidism due to parathyroid adenomas may be associated with ectopic parathyroid gland localization in 20-25% of the patients. We report herein the excision of an ectopic parathyroid adenoma which was detected in the thymus gland by gamma probe intraoperatively. A 38-year-old patient presented to our clinic with a history of bilateral nephrolithiasis, chronic hypercalcaemia, and PTH elevation. A combination of Technetium-99 m sestamibi scintigraphy and Computed Tomography scan of the chest and neck revealed an ectopic parathyroid adenoma of 8.5 mm in its greatest dimension. The patient underwent sternotomy and the adenoma was found within the right lobe of the thymus gland with the intraoperative use of gamma probe. PTH detection and frozen biopsy were performed during surgery and confirmed the successful excision of the adenoma, while mild hypocalcaemia was noticed postoperatively. We conclude that accurate preoperative and intraoperative localization of an ectopic parathyroid adenoma is crucial to successful surgery. The use of at least two diagnostic modalities before surgical excision minimizes the risk of re-operation for recurrent hyperparathyroidism, while the intraoperative use of gamma probe offers a significant advantage over conventional techniques by reducing surgical time, morbidity and/or complications associated with surgical exploration.

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.

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.

Inframanubrial parathyroid glands in patients with primary hyperparathyroidism: alternatives to sternotomy

Deep inframanubrial parathyroid tumors have traditionally been excised through a median sternotomy. With the advent of minimally invasive surgical access, we chose to examine the treatment options and outcomes of patients with inframanubrial mediastinal parathyroid tumors. Patients with primary hyperparathyroidism seen at a university medical center over a 12-year period were retrospectively reviewed. The utility of localization studies, methods of treatment, complications, and outcomes were examined in patients with a parathyroid tumor located in the mediastinum inferior to the manubrium. Patients with parathyroid adenomas located at the thoracic inlet were excluded. Sixteen patients with inframanubrial mediastinal tumors were treated during the study period. Altogether, 81% of the patients had undergone at least one prior neck exploration for primary hyperparathyroidism. Preoperative calcium and parathyroid hormone levels were 12.4 +/- 0.36 mg/dl and 273 +/- 70 pg/ml, respectively. Localization studies identified mediastinal parathyroid adenomas in the following locations: anterior mediastinum (n = 8), middle mediastinum (n = 7), posterior mediastinum (n = 1). Mediastinal computed tomography and technetium-sestamibi scans demonstrated the best sensitivity, 92% and 85%, respectively. Seven patients underwent successful excision of the mediastinal adenoma by transcervical mediastinal exploration with the Cooper retractor. The other patients underwent angiographic ablation (n = 4), anterior mediastinotomy (n = 3), video-assisted thoracoscopy (VATS) (n = 1), and VATS plus thoracotomy (n = 1). The mean hospital stay for the study group was 2.9 +/- 0.7 days. The complication rate was 25%. All patients were normocalcemic after a mean follow-up of 15 +/- 7 months. Most inframanubrial mediastinal parathyroid tumors can be successfully managed without median sternotomy.

Persistent and recurrent hyperparathyroidism

More than 95% of patients with primary hyperparathyroidism (HPT) will be cured at initial operation by an experienced surgeon. Despite this success rate, persistent and recurrent HPT remain challenging clinical entities. The most cost effective and safest treatment for persistent and recurrent HPT is avoidance by successful first operation. The contributors to treatment failure can be categorized into factors related to the initial surgical procedure, anatomic variability, and the biology of disease. An understanding of the factors that commonly contribute to treatment failure can help prevent persistent and recurrent disease and plays an integral role in planning subsequent surgical approaches. Once a biochemical diagnosis of persistent or recurrent HPT is confirmed, a thorough evaluation of previous operative, pathology, and radiology reports is essential. Localization procedures supplement this information and help direct the reoperative approach. When complementary noninvasive studies, such as ultrasound, sestamibi, and magnetic resonance imaging are negative, equivocal, or discordant, invasive tests (eg, selective venous sampling for parathyroid hormone levels) are warranted. Intraoperative ultrasound and gamma-probe localization are of questionable value, but intraoperative parathyroid hormone assays help facilitate these challenging repeat dissections. Repeat parathyroid exploration is associated with more complications and fewer cures compared to the initial explorations and should only be undertaken by an experienced surgeon in a center that can provide expert preoperative localization, adjunctive intraoperative tools, and cryopreservation of parathyroid tissue when necessary. Although controversy exists regarding indications for reoperative treatment for persistent or recurrent HPT, parathyroidectomy remains the only curative treatment option. Surgery should be considered first-line treatment in most circumstances.

Excision of a Mediastinal Parathyroid Gland with use of Video-Assisted Thoracoscopy, Intraoperative 99MTc-Sestamibi Scanning, and Intraoperative Monitoring of Intact Parathyroid Hormone

OBJECTIVE

To report the complementary use of video-assisted thoracoscopic surgery (VATS) and intraoperative 99mTc-sestamibi scanning for persistent secondary hyperparathyroidism due to a mediastinal supernumerary parathyroid gland.

METHODS

We describe a patient with recurrent secondary hyperparathyroidism attributable to a mediastinal parathyroid gland who underwent parathyroidectomy with use of VATS, intraoperative 99mTc-sestamibi scanning (gamma probe), and intraoperative monitoring of intact parathyroid hormone (iPTH).

RESULTS

A 32-year-old man with chronic renal failure who had undergone a 4-gland parathyroidectomy with autotransplantation 14 years previously presented with symptomatic hypercalcemia. A preoperative single-photon emission computed tomographic (SPECT) sestamibi scan revealed a focus of mediastinal uptake, suggestive of an intrathymic gland. The patient underwent a cervical exploration, and the previously reimplanted parathyroid gland and the thymus were resected. iPTH levels failed to normalize, and the operation was terminated. A repeated SPECT scan again revealed an area of mediastinal uptake. Computed tomographic scan of the chest showed a mediastinal gland adjacent to the aortic arch. VATS and intra-operative sestamibi scanning aided in localization of the ectopic parathyroid gland. After removal of the hyperplastic gland, iPTH levels decreased appropriately.

CONCLUSION

In reoperative parathyroidectomy involving mediastinal glands, VATS, complemented by gamma probe localization and iPTH monitoring, may be used to minimize the operative dissection needed to cure hyperparathyroidism.

Dietary interventions to prevent disease

Changing dietary behaviors to prevent chronic disease has been an important research focus for the last 25 years. Here we present a review of published articles on the results of research to identify methods to change key dietary habits: fat intake, fiber intake, and consumption of fruits and vegetables. We divided the research reviewed into sections, based on the channel through which the intervention activities were delivered. We conclude that the field is making progress in identifying successful dietary change strategies, but that more can be learned. Particularly, we need to transfer some of the knowledge from the individual-based trials to community-level interventions. Also, more research with rigorous methodology must be done to test current and future intervention options.

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.

Thoracoscopic resection of ectopic parathyroid glands

BACKGROUND

The vast majority of parathyroid glands in hyperparathyroidism can be resected through a cervical approach. In approximately 2% of the cases, the ectopic gland is in the mediastinum in a location that requires a thoracic approach.

METHODS

We report 7 such cases that were resected using video-assisted thoracic surgery to avoid the need for an open surgical procedure.

RESULTS

All glands were successfully identified preoperatively and subsequently resected. Hospital stay averaged less than 3 days with only one minor complication.

CONCLUSIONS

Ectopic mediastinal parathyroid glands may be safely and accurately resected using video-assisted thoracic surgery to avoid open approaches.

Thoracoscopic parathyroidectomy of an ectopic mediastinal adenoma

Thoracoscopic parathyroidectomy in a patient with an adenoma in the lower mediastinum is described. This is a new method, probably reducing morbidity compared with median sternotomy, and has to the authors' knowledge not been described before.