Recurrent Primary Hyperparathyroidism in Multiple Endocrine Neoplasia Type 1 Syndrome

Primary hyperparathyroidism is a common endocrinopathy. Multiple Endocrine Neoplasia Type 1 (MEN1) is a rare autosomal dominantly inherited endocrine tumor predisposition syndrome, with one of main manifestations being primary hyperparathyroidism. We retrospectively evaluated a set of 1011 patients who underwent surgery for primary hyperparathyroidism between the years 2018-2022, and found 78 (8 %) patients who underwent reoperations and 27 patients with MEN1 syndrome. In the group of patients with MEN1 syndrome, 7 (35 %) needed reoperations. Patients with multiple endocrine neoplasia syndrome have a higher risk of needing reoperation. Genetic testing can help identify MEN1 syndrome preoperatively and to better evaluate the approach to surgery.

Surgical treatment of hyperparathyroidism with a pathologically changed parathyroid gland found in the mediastinum

The most common indication for surgical treatment of parathyroid gland pathology is primary hyperparathyroidism where extirpation of the pathologically changed parathyroid gland is the first-choice treatment. Embryonic development of the lower pair of parathyroid glands is quite complex and is closely related to the tissue of the thymus; for this reason it is not uncommon for a parathyroid adenoma to be located in the mediastinum or directly in the tissue of the thymus. The treatment of primary hyperparathyroidism is becoming a multidisciplinary issue in which radiodiagnostics and nuclear medicine methods play a significant role as they are needed to accurately localize the affected gland and to plan an adequate surgery. In case of intrathoracic localization of parathyroid adenoma, the therapy belongs in the hands of thoracic surgery. At our department, the endocrine surgery program, including parathyroid gland surgery, has a long tradition, and complicated patients are concentrated here, often patients with refractory hyperparathyroidism after a previous procedure. In the last 10 years, almost 2,300 procedures for parathyroid pathology have been performed at the IIIrd Department of Surgery of the 1st Faculty of Medicine, Charles University and University Hospital in Motol, of which some pathologies with mediastinal localization were managed using minimally invasive methods, i.e. videothoracoscopy or robotic-assisted surgery.

Concomitant thyroid disease in patients operated for primary hyperparathyroidism

INTRODUCTION

Parathyroid and thyroid diseases are ones of the most common endocrine diseases, but simultaneous surgical treatment of both endocrine systems is still under discussion.

METHODS

We retrospectively evaluated 1,574 patients operated for primary hyperparathyroidism at the 3rd Department of Surgery, 1st Faculty Medicine, Charles University and University Hospital Motol in Prague with the thyroid and parathyroid ultrasound reports available. The patients were divided into two groups - with and without thyroid surgery.

RESULTS

Thyroid surgery was performed in 34% of patients with primary hyperparathyroidism. Group 2, where thyroid surgery was performed, showed a higher proportion of reported abnormal thyroid sonographic findings (74%), a higher proportion of bilateral throat exploration (69%) and a longer hospital stay (3.3 days).

CONCLUSION

A patient indicated for surgery for parathyroid disease should also be indicated for possible thyroid surgery.

Thyroid tumors at the limit of operability

Comprehensive information about current thyroid carcinoma treatment options depending on its histology and extent of the disease, focusing on locally advanced findings at the limit of operability. Treatment of such a heterogeneous group requires interdisciplinary cooperation. We provide 6 unique case reports including imaging scans, description of the therapy and description of development of the condition.

Retrosternal goiter

INTRODUCTION

Retrosternal goiter is an enlarged thyroid mass of which more than 50% is located in the mediastinum. Indications for surgery of retrosternal goiter include ineffective pharmacological treatment, mechanical syndrome, suspicion of malignancy and thyrotoxicosis. Computed tomography is the gold standard in the diagnosis of retrosternal goiter. The surgery can be performed from a cervical incision, using sternotomy or thoracotomy.

METHODS

The aim of our study was to evaluate our own group of retrosternal goiters. In 2011-2019, 1739 thyroid surgeries were performed at the 3rd Department of Surgery, University Hospital Motol, Prague. We retrospectively followed the age, gender, retrosternal spreading, postoperative complications (especially hypocalcemia, bleeding and dysphonia) and the definitive histological finding.

RESULTS

Retrosternal goiters were presented in 202 (19.2%) of the total of 1739 thyroid surgery patients. Sternotomy was performed in 31 patients. Women (61%) predominated over men (39%). The mean operating time was 125 minutes. We did not detect any serious postoperative bleeding necessitating surgical revision. Temporary hypocalcemia was observed in 10 patients (32%) based on laboratory testing. Unilateral iatrogenic vocal cord paresis was observed in 6 patients (19.4%) and was permanent in 3 patients (9.3%). One patient passed away soon after the operation, nevertheless the death was related to a simultaneously planned cardiothoracic procedure.

CONCLUSION

The retrosternal goiter can be removed using the cervical approach in most cases. Total thyroidectomy using sternotomy is associated with higher morbidity and mortality, higher blood loss and longer hospital stay; nevertheless, it does not increase the risk of long-term postoperative complications. Procedures requiring sternotomy or thoracotomy should be done at centers experienced in these types of procedures.

History of thyroid surgery

The authors present an outline of the development of thyroid surgery from the ancient times to the beginning of the 20th century, when the defini-tive surgical technique have been developed and the physiologic and pathopfysiologic consequences of thyroid resections have been described. The key representatives, as well as the contribution of the most influential czech surgeons are mentioned.

[Videothoracoscopic excision of mediastinal parathyroid adenoma in primary hyperparathyroidism]

INTRODUCTION

Primary hyperparathyroidism is a disease caused by elevated secretion of parathyroid hormone from pathological parathyroid glands. After the diagnosis, the success of its surgical solution depends predominantly on surgical management and experience of the surgeons. A special group is formed by ectopic localizations of pathologically enlarged parathyroid glands in the mediastinum, which require a modified surgical approach. When the adenoma is deep in the mediastinum, sternotomy or thoracotomy is indicated; alternatively, a minimally invasive approach can be used - videothoracoscopic thymectomy.

CASE REPORT

We present a case of a patient with normocalcemic recurrent primary hyperparathyroidism. This patient underwent a minimally invasive video-assisted thymectomy after scintigraphic confirmation of parathyroid adenoma in the mediastinum.

CONCLUSION

The removal of parathyroid adenoma in the mediastinum using the videothoracoscopic method is safe. Compared to sternotomy, this method improves the postoperative period, reduces the length of stay and provides more comfort to patients. We recommend considering the videothoracoscopic method in cases where the pathologically enlarged parathyroid gland is localized in the inferior and anterior mediastinum.

KEY WORDS

primary hyperparathyroidism adenoma of glandula parathyroidea - mediastinum miniinvasive.

[Ectopic parathyroid glands. Imaging methods and surgical access]

We discuss the benefits of imaging methods in localizing ectopic parathyroid glands in patients with primary hyperparathyroidism. The ectopic localizations are discussed within the context of the orthotopic norm. In the sample of 123 patients, a 23% rate of ectopic parathyroid glands was detected. Three selected case studies are presented, supporting the benefit of SPECT/CT imaging in terms of surgical access strategy selection.

[Repeated surgery for parathyroid carcinoma]

INTRODUCTION

Carcinoma of the parathyroid glands is a rare cause of primary hyperparathyroidism with an incidence of 1%.

MATERIAL AND METHODS

This article presents an up-to-date review of the literature illustrated by three clinical cases in the form of case reports.

RESULTS

Parathyroid carcinoma is usually not detected before the first operation. Symptoms of carcinoma of the parathyroid glands are similar to those of benign adenoma. Patients with parathyroid carcinoma usually have a higher level of calcium in serum and a higher level of parathormone. Imaging methods such as neck ultrasound and 99mTc sestamibi scan can help localize pathologically enlarged glands, but they are not capable of distinguishing malignant disease. Fine needle aspiration is not recommended due to the possible associated risk of tumour seeding along the needle track. The radical excision of the tumour together with the ipsilateral thyroid gland removal remains the standard of treatment. Local recurrence is frequent.

CONCLUSION

Parathyroid carcinoma is a very rare disease and should be managed surgically in a specialized centre.

[Surgical therapy of primary hyperparathyrodism in the context of orthopaedic diagnosis and treatment: our experiences in 441 patients]

PURPOSE OF THE STUDY

Primary hyperparathyroidism is an endocrine disorder affecting calcium and phosphate metabolism. It is surgically treated by removing hyperfunctional parathyroid tissue. The aim of the study was to show, based on surgical results, that the introduction of serum calcium screening in orthopaedic therapy is effective. The detection of hypercalcemia and diagnosis of primary hyperparathyroidism allow for a good timing of endocrine surgery in relation to an orthopaedic procedure.

MATERIAL AND METHODS

This retrospective study included 441 patients in the age range of 18 to 83 years who underwent parathyroidectomy between 2004 and 2007. Skeletal disorders were diagnosed by clinical, radiographic and densitometric examination; calcium levels were measured after surgery. Bone repair after parathyroidectomy was followed up by the endocrinologist for 1 year.

RESULTS

Before surgery, 48 % of the patients had skeletal disorders. Adenoma was found in 87 %, double adenoma in 2 %, hyperplasia in 10 % and parathyroid carcinoma in 0.5 % of the patients. Complications involved transient paresthesia of the recurrent laryngeal nerve (1 %), transient hypocalcemia (0.5 %), transient post-operative arrhythmias (0.5 %), temporary psychological problems (0.7 %) and post-operative bleeding (0.5 %). None of the patients died. Serum calcium levels were as follows: 2.90 ± 0.01 mmol/L pre-operatively; 2.44 ± 0.01 mmol/L on the evening of surgery; 2.30 ±0.01 mmol/L on the 1st day; 2.19 ± 0.01 mmol/L on the 2nd day; and 2.18 ± 0.01 mmol/L on the 3rd post-operative day. On the 3rd post-operative day most of the patients were discharged from the hospital. Normal calcium levels were achieved in 98 % of the surgically treated patients.

DISCUSSION AND CONCLUSIONS

The study provides evidence for the efficiency of calcium screening in primary hyperparathyroidism and shows the feasibility of involving endocrine surgery in the course of orthopaedic treatment.

Ectopic parathyroid adenoma in child

A 10-year old girl presented with fatigue, hypercalcemia, and subperiosteal phalangeal osteolytic lesions. Ultrasonography and MIBI scintigraphy showed a structure near the lower pole of thyroid gland. The structure macroscopically appeared as adenoma, histologically it was thymic tissue. Bilateral neck exploration together with exploration of cervical thymic extensions was performed; adenoma was not found. During next two years, the level of calcium and parathormone raised, bone mineral density decreased. Ultrasonography, MRI, CT and PET/CT were negative. Adenoma was located by MIBI-SPECT/CT near the left border of jugulum. It was found dorsolateral to left common carotid artery and removed.

[Preliminary experience in minimally invasive video assissted parathyroidectomy]

Systematic bilateral neck exploration remains the gold standard for the treatment of primary hyperparathyroidism. Techniques of miniinvasive parathyroidectomy have been developing on the basis of the improvement of preoperative localization methods. The miniinvasive videoasissted parathyroidectomy was performed in 17 from 123 patients with primary hyperparathyroidism. All patients were examined using ultrasonography and sestamibi scintigraphy; the level of inactive parathormone was monitored peroperatively. One patient required a conversion to the bilateral neck exploration. Authors emphasize the necessity of the good knowledge of the classical bilateral neck exploration for the correct performance of the operation. Mininvasive videoasisted parathyroidectomy is a safe method in patients with a single, preoperatively localized adenoma.

[Problematic of reoperations for persisting and recurrent primary hyperparathyroidism]

Surgery provides final therapy for patients with primary hyperparathyroidism. Once the diagnosis is established, the outcome of surgery depends on the surgeon's experience and judgment. Our experience with 523 procedures (including 31 reoperations) performed from the beginning of 1994 to the end of 2004, have proved that complicated cases, including reoperations, should be concentrated in clinics with sufficient surgcial experience, rating hundreds of the cases.

Surgical anatomy of parathyroid glands with emphasis on parathyroidectomy

Number, location and surrounding structures of parathyroid glands with emphasis on parathyroidectomy were studied on 101 cadaverous bodies. Number of collected samples from all known locations of parathyroid glands varied from three to five in one individual, with mean 3.71 +/- 0.62. We identified 80% of samples as parathyroid glands. Mean number of correctly identified parathyroid glands in one individual was 2.77 +/- 1.06. The rest 20% of collected samples were lymph nodes, fat particles and thyroid or lipothymic tissue. Almost 30% more of inferior parathyroid glands were found in abnormal position in lipothymic tissue in comparison with their superior counterparts. We found several abnormities of vessels and cervical extensions of thymus. We also present case of brachiocephalic trunk, reaching the inferior pole of thyroid gland. We recommend beginning of parathyroidectomy in circumscribed area 2 cm in diameter, 1 cm cranially to the intersection of the inferior thyroid artery and recurrent laryngeal nerve followed by preparation on dorsal surface of thyroid gland, along the course of inferior thyroid artery and recurrent laryngeal nerve, in cervical extensions of thymus and in paraoesophageal and retropharyngeal region. Success of parathyroidectomy is based on the knowledge and experience of surgeon.

Chirurgische Therapie des primären Hyperparathyreoidismus und dessen Komplikationen: Erfahrungen an 453 Patienten

453 patients underwent surgery for primary hyperparathyreoidism between 1994 and 2003. In all patients, biochemical parameters were monitored and X-ray with USG of the neck was done. Struma nodosa was concommitantly present in 48 % of treated patients with primary hyperparathyroidism. In such cases, MRI offers better resolution of soft tissues. 98.6 % of treated patients had postoperative decrease of blood calcium to normal level. 5.4 % of cases were reoperations for primary hyperparathyroidism. In 12 % of cases, pathologically changed parathyroid glands in dystopic localization were found. In these dystopic localizations, pathologic parathyroid glands were found: in 3 % intrathyroid, in 7 % mediastinal and in 2 % of all 453 cases in other localization. In 4 % of patients, sternotomy was necessary. Persistent hypocalcemia was not registered in any patient. Transient hypocalcemia with necessity of infusion therapy was observed in 3.5 % of patients. Postoperative hypercalcemia persisted in 1.2 % of patients. Recurrent hypercalcemia was present in 0.2 % of cases. In three cases (0.7 %), unilateral injury of recurrent laryngeal nerve was observed.

Surgical contribution to the management of primary hyperparathyroidism

Surgical management of primary hyperparathyroidism is a very effective method. The target is to cure primary hyperparathyroidism and to reach normal calcium levels. This results in an improvement of health condition and resolution or at least moderation of symptoms. Complications are infrequent and mortality is very low. Surgical management is definite, safe and effective. Authors of this article address the diagnosis of primary hyperparathyroidism, clarify bone, metabolic and biochemical syndromes and present series of 151 patients that have been operated on at the 3rd Department of Surgery of the Motol University Hospital, Prague, with the diagnosis of primary hyperparathyroidism. The survey is focused on the primary hyperparathyroidism concomitant diseases and on the possible sequelae in the postoperative period.

[Omentoplasty of the sternum--surgical solution in a sternal defect due to sternal osteomyelitis in a female patient with mediastinal localization of a parathyroid adenoma. Case report]

We report here the case report of patient with empyema of the thorax and sternal osteomyelitis, which undertool removal of ectopic mediastinal parathyroid adenoma with omentoplasty of sternal defect. Osteomyelitis was cured; though empyema persisted for several months and it's healing was complicated with central venous catheter sepsis.

[Appendectomy--classical or laparoscopic?]

The authors demonstrate on a group of 219 patients, who had in last two years the appendectomy performed, results of care while using open and laparoscopic technique. They compare these depending on chosen parameters, which is the usage of analgetic, the time patients have to stay in hospital after performed operation and comparison of spirometry within specific patients before and after operation. Based on these parameters the authors did not prove clear advantages of laparoscopic appendectomy.

[Personal experience with a bilateral approach in the surgical treatment of primary hyperparathyroidism. (A group of 222 patients with surgery for primary hyperparathyroidism from 1994 to 2000)]

Surgical treatment offers a definite cure of patients with primary hyperparathyroidism. When making the diagnosis of primary hyperparathyroidism the success of a surgical solution depends on the experience and judgment of the surgeon. Our experience with 222 operations and re-operations convinced us on the preference of a bilateral approach, i.e. exploration of both sides of the neck. The ectopic localization of the parathyroid glands, the limited possibilities of an unequivocal interpretation of the histological examinations but also the frequent incidence of thyropathies leads the surgeon, in our opinion, to the complete exploration of both sides of the neck within the framework of the primary operation for primary hyperparathyroidism. This approach leads most probably to the best results. We use an aimed unilateral approach only in old patients who are in a very bad condition where we anticipate a benefit from a short operation.

[Surgical approach in mediastinal adenomas and parathyroid carcinomas]

The authors performed retrospective analysis of medical records in a group of 176 patients, who underwent surgical treatment of primary hyperparathyroidism. Surgical strategy was the major issue of interest. Cervical collar incision represented a first-choice approach to cervical exploration in most of cases except those, in whom ectopic mediastinal localization have been diagnosed before the operation. Partial sternotomy was the most common option in surgical re-explorations as a second step following failed parathyroid surgery. We conclude that partial sternotomy is necessary further step in patients with primary hyperparathyroidism complicated by malignant hypercalcaemia on condition that the surgeon is not able to reveal adenomas from neck exploration and sternotomy is than performed immediately during the same operation.

[Implantation Technique of a Non-cemented Conical Expansion Socket of the Balgrist Type.]

In the submitted paper the authors describe the principle and technique of implantation of a non-cemented self-expanding socket. On an anatomical model they demonstrate different technical details of implantation and provide a more accurate account of their own surgical technique. They draw attention to the most frequent errors the surgeon may comit. These errors include incorrect centering of the socket, a deep bed in the bone, poor settling of the anchoring portion, incorrect inclination of the socket, lack of verification of primary fixation, erroneous or inadequate application of spongious paste and complete settling of the articular insert. Key words: total endoprosthesis of the hip joint, expanding socket of the hip joint.