Ectopic Mediastinal Parathyroid Research Articles

Ectopic mediastinal parathyroid adenoma: Diagnostic and therapeutic difficulties across three cases

Ectopic mediastinal parathyroid adenoma: Diagnostic and therapeutic difficulties across three cases

Primary hyperparathyroidism related to mediastinal ectopic parathyroid adenoma: about 2 cases

Primary hyperparathyroidism related to mediastinal ectopic parathyroid adenoma: about 2 cases

A case of mediastinal ectopic parathyroid adenoma completely resected after identification using a radioisotope technique combined with intraoperative intact-PTH monitoring

A case of mediastinal ectopic parathyroid adenoma completely resected after identification using a radioisotope technique combined with intraoperative intact-PTH monitoring

Robot-Assisted Thoracoscopic Resection of Ectopic Parathyroid Tissue in Mediastinum: A Scoping Review.

Ectopic parathyroid tissue in the mediastinum represents a rare and potentially serious clinical entity with challenging diagnostic and surgical management. The main surgical approach for this issue is open thoracotomy, which is a safe technique but carries risks and complications associated with such as extensive surgery. The purpose of this study is to demonstrate robotic thoracic surgery as an alternative and potentially advantageous method to treat patients with ectopic parathyroid adenomas compared with open and video-assisted thoracoscopic surgery approaches. A total of 13 reports in the literature were identified that provided details in terms of complications, surgical approach, and results of minimally invasive surgical resection of mediastinal ectopic parathyroid tissue.

SAT201 A Rare Case Of A Mediastinal Atypical Parathyroid Adenoma Resulting In Severe Hypercalcemia And Brown Tumor

Abstract Disclosure: O.A. Aluko: None. D. Franey: None. R. Quiros: None. W. Burfeind: None. R.E. Amori: None. Introduction: Primary hyperparathyroidism is most often from parathyroid adenomas located usually in close association to the thyroid gland. Ectopic parathyroid glands result in significant variability in the position of the gland, however rarely in the mediastinum. We report a case of a patient with severe hypercalcemia from a large, ectopic mediastinal parathyroid adenoma. Case Report: A 53-year old male with a past medical history of hypercalcemia and nephrolithiasis was sent to the ER for evaluation of hypercalcemia after he was found to have a corrected calcium of 12.5 mg/dl (n8.4 - 10.2 mg/dl) on routine labs. Repeat blood work at presentation confirmed hypercalcemia with a corrected calcium 11.9 mg/dl and elevated ALP of 211 U/l (n 43 - 122 U/L), elevated initial PTH of799 pg/ml (n 18.4 - 80.1 pg/ml), Vit D 32.7 ng/ml (n 30 - 100 ng/ml), and low phosphorus 2.4 mg/dl (n2.7 - 4.5 mg/dl). Calcium slightly improved to 11.7 mg/dl after IV hydration. Chest CT showed a large mediastinal mass compressing trachea and esophagus, suspicious for parathyroid origin, with a smaller left sided lesion suspicious for parathyroid adenoma. CT also showed multiple bone lesions likely brown tumors. He underwent complete robotic resection of the mediastinal mass. Immediately prior to surgery, PTH was 1002.8 pg/ml, and fell to 131.1 pg/ml and 44.1 pg/ml following removal of the mediastinal mass. Adherence of the mass to surrounding structures made resection challenging, resulting in a right vocal cord paralysis. After surgery, he was empirically started on IV calcium and calcitriol for high clinical concern for hungry bone syndrome, both later discontinued as serum calcium remained within normal limits. Pathologic findings reported as highly suspicious, however not definitive for parathyroid carcinoma with no evidence of perineural or lymphovascular invasion. Given rarity, he was referred to a tertiary cancer center where he was diagnosed with Atypical parathyroid Adenoma (APA). He underwent a right pubic biopsy with pathology diagnosis of brown tumor of hyperparathyroidism. He started on cinacalcet 30 mg daily after surgery. There is a future plan for resection of the smaller left sided parathyroid adenoma. Conclusion: This case highlights two rare entities; a mediastinal ectopic parathyroid and atypical parathyroid adenoma. Atypical Parathyroid Adenoma is a not-well defined entity which could mimic a parathyroid carcinoma as seen in our case. The location of the mass in the superior mediastinum is unusual, making it more difficult to diagnose, and could increase risk of complications during resection. Delayed diagnosis of these entities can lead to severe hypercalcemia and skeletal complications infrequently seen in common primary hyperparathyroidism cases. Presentation: Saturday, June 17, 2023

Identification of micro-recurrent lesions using methylene blue for mediastinal ectopic parathyroid adenoma: a case report

BackgroundMediastinal ectopic parathyroid adenomas are rare, and several methods are used to diagnose and localize them preoperatively. Technetium-99m methoxy isobutyl isonitrile scintigraphy has been used to diagnose parathyroid tumors. However, it is difficult to identify tumors buried in adipose tissue during surgery.Case presentationWe report a case in which methylene blue effectively identified small recurrent lesions in a mediastinal ectopic parathyroid adenoma. After intravenous injection of methylene blue prior to surgery, the stained parathyroid adenoma was easily identifiable. Additionally, we identified other small recurrent lesions that could not be confirmed on preoperative imaging using real-time in vivo imaging guidance during surgery. Using this strategy, complete macroscopic resection can be performed during video-assisted thoracic surgery.ConclusionPreoperative intravenous methylene blue injection is useful for identifying small recurrent lesions, even in cases of mediastinal ectopic parathyroid adenoma with suspected recurrence.

Robotic resection of ectopic mediastinal parathyroid adenoma in multiple endocrine neoplasia 1

BackgroundHyperparathyroidism in patients with multiple endocrine neoplasia 1 is attributed to the excessive secretion of parathyroid hormone (PTH) from multiple parathyroid glands. This can be successfully treated through complete resection of the parathyroid glands; however, subsequent surgery is often required because of the presence of supernumerary or ectopic parathyroid glands. Therefore, identifying the locations of all functional glands is crucial for precise resection. Here, we report a case of ectopic mediastinal parathyroid adenoma that was successfully resected using robot-assisted thoracoscopic surgery.Case presentationA 53-year-old woman underwent a total parathyroidectomy with autotransplantation for multiple endocrine neoplasia 1-associated primary hyperparathyroidism. The patient previously underwent laparoscopic distal pancreatectomy for a pancreatic neuroendocrine tumor. She also presented with a mediastinal tumor and nonfunctional pituitary adenoma that could be followed up. Blood tests before total parathyroidectomy showed high levels of intact PTH (183 pg/mL) and calcium (Ca; 10.3 mg/dL); however, postoperative blood tests still revealed high levels of intact PTH (103 pg/mL) and Ca (11.4 mg/dL). Computed tomography and magnetic resonance imaging revealed a 45-mm-sized mass in the right upper mediastinum as a well-defined solid and cystic lesion, whereas 99mTc-methoxyisobutylisonitrile scintigraphy indicated a strong accumulation of tracers, suggesting an ectopic lesion in the mediastinum. Persistent hyperparathyroidism after total parathyroidectomy via neck incision was attributed to an ectopic parathyroid tumor in the mediastinum. Thus, we decided to resect the tumor using robot-assisted thoracoscopic surgery to perform the procedure gently and carefully. During surgery, a mediastinal tumor was identified as it was detected radiographically. Because it did not invade the surrounding tissues, it could be completely resected without injuring the capsule. The patient was discharged without complications. Postoperatively, Ca and intact PTH levels decreased back to normal. The final pathological diagnosis confirmed that the mass was an ectopic mediastinal parathyroid adenoma.ConclusionsMinimally invasive surgical resection of a remnant ectopic lesion was successfully performed in a patient with multiple endocrine neoplasia 1 using robot-assisted thoracoscopic surgery.

O160 The utility of pre-operative localisation scans (ultrasound and Tc99M Sestamibi) for primary hyperparathyroidism is limited in up to 40% of the patients

Abstract Introduction The aim of this study was to evaluate the diagnostic accuracy of pre-operative localisation scans for primary hyperparathyroidism (PHPT). Methods Patients with PHPT had pre-operative localisation scans; ultrasound (US) and Tc99m Sestamibi and were operated between 12/2020 and 12/2022. Patients with persistent/recurrence PHPT post-operatively were excluded. Results 97 patients with PHPT were included. The mean age was 60 (SD:13) years old. The male/female ratio was 1:4.4. The mean hospital stay was 1.1 days (SD:0.3). 94 and 91 patients had US and Tc99m Sestamibi scans respectively while 88 patients had both scans. There was 1 patient with an ectopic mediastinal parathyroid adenoma. On the histopathology, 72 patients had single-gland disease, 13 patients had 2 abnormal parathyroid glands, 9 patients had 4-gland hyperplasia. The diagnostic accuracy, sensitivity, specificity, Positive Predictive Value and negative predictive value of US scan was 62% (95%CI: 51-72%), 64% (95%CI: 53-74%), 20% (95%CI: 0.51-72%), 93% (95%CI: 90-96%) and 3% (95%CI: 0.5-16%), respectively. In 9 patients the US missed other/extra pathologic glands. The diagnostic accuracy, sensitivity and Positive Predictive Value of Tc99m Sestamibi scan was 63% (95%CI: 53-73%), 65% (95%CI: 54-75%) and 97% (95%CI: 97-97%) respectively. In 8 patients the Tc99m Sestamibi missed other/extra pathologic glands. Conclusion Parathyroid pathology in primary hyperparathyroidism is complex and the diagnostic accuracy of pre-operative localisation scans (ultrasound and Tc99m Sestamibi) is limited in up to 40%. The presence of negative pre-operative localisation scans should not be an obstacle to offering the patient a curative parathyroidectomy.

Abstract #1412272: A Case Report of an Ectopic Mediastinal Parathyroid Adenoma that was Challenging to Locate

Primary hyperparathyroidism from an ectopic parathyroid adenoma can pose diagnostic and management challenges when several different imaging modalities do not localize the adenoma and when it is not found on surgical exploration. We report a case of a 69-year-old Caucasian female with history of primary hyperparathyroidism complicated by the inability to localize the adenoma despite several imaging modalities. She underwent neck exploration twice by two different surgeons who were unable to locate a parathyroid adenoma. She underwent 2 separate parathyroid nuclear medicine scans with single photon-emission computed tomographic (SPECT) of the neck and chest done several years apart. The initial SPECT did not demonstrate a parathyroid adenoma in the neck or ectopically nor did several nuclear medicine scans of the neck. Ultimately, the 2nd SPECT of the neck and chest was able to detect a contrast-enhanced mass in the mediastinum. She was referred to a thoracic surgeon who was able to remove the ectopic parathyroid adenoma robotically. The histopathology of the mediastinal mass was consistent with a parathyroid adenoma. She was discharged home from the hospital on calcium and calcitriol supplementation. Her calcium normalized and she ultimately was able to come off calcium and calcitriol supplementation. Calcium and PTH have remained normal several months after surgery. The incidence of ectopic parathyroid glands is approximately 25%. In primary hyperparathyroidism approximately 6-16% of adenomas are located ectopically. Surgical intervention is the mainstay of therapy with preoperative imaging for localization of the adenoma being the standard of care. 4D CT has approximately 85% sensitivity and Sestamibi/SPECT CT has 65% sensitivity for location of a single adenoma with specificity of 92% and 98% respectively. Despite this, in our case the localization of parathyroid adenoma took 7 years, 4 different scans and 3 surgeries in order to successively localize and resect the ectopic parathyroid adenoma.

Ectopic PTH-producing parathyroid cyst inside the thymus: a case report

BackgroundThe hallmark of hyperparathyroidism is hypersecretion of parathyroid hormone (PTH) which results in hypercalcemia and hypophosphatemia. While hypercalcemia due to malignancy is often brought about by PTH-related protein in adults, PTH-producing tumors are quite rare in clinical practice. Additionally, from the point of embryology, it is very difficult to examine ectopic PTH-producing tissue such as ectopic parathyroid glands. Furthermore, clear histopathological criteria are not present.Case presentationA 57-year-old woman was referred to our hospital for hypercalcemia. Her parathyroid hormone (PTH) level was elevated, but there were no enlarged parathyroid glands. Although 99mTc-MIBI confirmed a localized and slightly hyperfunctioning parathyroid tissue in the anterior mediastinum, it was not typical as hyperfunctioning parathyroid. We finally diagnosed her as ectopic PTH-producing cyst-like tumor with venous sampling of PTH. She underwent anterosuperior mediastinal ectopic PTH-producing cyst-like tumor resection. It is noted that intact-PTH concentration of the fluid in the cyst was very high (19,960,000 pg/mL). Based on histopathological findings, we finally diagnosed her as ectopic PTH-producing parathyroid cyst inside the thymus. After resection of anterosuperior mediastinal thymus including ectopic PTH-producing parathyroid cyst, calcium and intact-PTH levels were decreased, and this patient was discharged without any sequelae.ConclusionsWe should know the possibility of superior mediastinal ectopic PTH-producing parathyroid cyst inside the thymus among subjects with ectopic PTH-producing parathyroid glands. Particularly when the cyst is present in the superior mediastinum, it is necessary to do careful diagnosis based on not only positive but also negative findings in 99mTc-MIBI. It is noted that the patient’s bloody fluid in the cyst contained 19,960,000 pg/mL of intact-PTH, and its overflow into blood stream resulted in hyperparathyroidism and hypercalcemia. Moreover, in such cases, the diagnosis is usually confirmed after through histological examination of ectopic PTH-producing parathyroid glands. We think that it is very meaningful to let clinicians know this case.

Supernumerary Ectopic Mediastinal Parathyroid Adenoma Combined With Parathyroid Hyperplasia

Primary hyperparathyroidism (PHPT) is a common endocrine disorder characterized by elevated parathyroid hormone levels. In most cases, the disease involves a single parathyroid adenoma, followed by parathyroid hyperplasia, but the incidence of ectopic parathyroid adenoma is rare. However, in cases where the parathyroid hormone level remains high even after parathyroid surgery, an ectopic parathyroid gland should be considered. Here in a case of a 60-year-old female who presented PHPT is reported. She had undergone a surgical removal of the parathyroid gland of suspected hyperplasia, but still represented persistent PHPT, postoperatively. Ectopic mediastinal parathyroid adenoma was identified by 99mTc-sestamibi parathyroid scan and surgical excision via a median sternotomy approach was performed. Thirty-eight months postoperatively, there was no evidence of recurrence. Preoperative localization assessment is critical for minimizing surgical failure in cases of PHPT.

Robotic resection of ectopic mediastinal parathyroid adenoma with intraoperative parathyroid hormone monitoring: a case report

BackgroundPrimary hyperparathyroidism is a disease caused by the secretion of excess parathyroid hormone (PTH) owing to the enlargement of the parathyroid gland. Ectopic parathyroid glands exist in the mediastinum in approximately 1–2% of cases, which is relatively rare. Intraoperative monitoring of serum PTH level is important to assess whether the source of hyperparathyroidism has been eliminated.Case presentationA 53-year-old asymptomatic woman was diagnosed with ectopic mediastinal parathyroid adenoma. A three-port robotic partial resection of the thymus containing the tumor was attempted, but bleeding from a swollen pericardial diaphragmatic vein led to the addition of an assist port along the way. The PTH level was measured intraoperatively. After confirming that the 15-min PTH level after removal of the tumor was less than 50% of the baseline value, the operation was completed. The tumor was positive for PTH and was diagnosed as an ectopic mediastinal parathyroid adenoma. Some small ectopic parathyroid gland tissues were observed in other parts of the thymic tissue. Serum calcium and PTH levels decreased and normalized.ConclusionsWe report the usefulness of robotic resection for ectopic mediastinal parathyroid adenoma with PTH monitoring. However, histopathologically, small parathyroid gland tissues may remain in the surrounding thymus. Hence, we believe that a strict follow-up is required for parathyroid function in the future.

Perioperative Clinical Features of Mediastinal Parathyroid Adenoma: A Case Series

Rare ectopic mediastinal parathyroid adenoma can result in persistent or recurrent hyperparathyroidism. In this article, we summarized the perioperative outcomes of six patients with mediastinal parathyroid adenoma. All patients underwent minimally invasive surgery (MIS). Abnormal accumulation of sestamibi was observed in four of five patients for preoperative localization of adenoma. Postoperatively, the blood calcium dropped quickly. In addition, we found adenoma function was negatively related to adenoma volume in these patients. In conclusion, although MIS is feasible for parathyroid adenoma, blood calcium should be monitored in a timely manner to avoid hypocalcemia postoperatively. In addition, sestamibi might be a potential pitfall when locating parathyroid adenoma.

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.

Large Mediastinal Ectopic Parathyroid Adenoma Causing Malignant Hypocalcaemia in a Young Female: A Case Report and Review of Literature

Ectopic parathyroid tissue can pose difficulties in diagnosis and management of patients with hyperparathyroidism. Due to the embryological origins of the inferior parathyroid glands from the 3^rd pharyngeal arch where they develop with the thymus; they can have variable anatomical locations, including the anterior mediastinum. While the incidence of ectopic parathyroid glands varies in the literature mediastinal parathyroid tissue is extremely rare.

Localization of Ectopic Mediastinal Parathyroid Adenomas Using Indigo Carmine Injection for Surgical Management: A Preliminary Report.

An ectopic parathyroid adenoma (EPA) is a rare entity. The aim of this study was to report our experience in the preoperative localization and surgical management of EPAs. This was a multicenter retrospective study involving patients diagnosed with an EPA (three males and seven females) from January 2005 to November 2021. The clinical features, preoperative management, and surgical procedures were analyzed. A cervical neck ultrasound was performed in all patients and showed a focus in eight patients. Cervicothoracic enhanced computed tomography was performed in all patients and showed a focus in nine patients. The 99mTc-MIBI scintigraphy was performed in eight patients and showed uptake in six of them. We performed a neck dissection and thoracotomy in one patient, a thoracoscopy in one patient, surgery with a focused approach in seven patients, four of whom were injected with indigo carmine blue, and surgery with a bilateral approach in one patient. 1 h following the parathyroidectomy, the parathyroid hormone (PTH) concentration was decreased to 40–80% of the baseline value. Establishing a preoperative diagnosis of an EPA is challenging for the surgeon, despite the progress in the morphologic assessment. An intraoperative PTH assay and injection of indigo carmine have been shown to be valuable tools in the appropriate surgical management of an EPA.

24 Mediastinal Ectopic Parathyroid Adenoma Causing Malignant Hypercalcaemia in a Young Female - a Case Report and Review of Literature

Abstract Ectopic parathyroid tissue can pose difficulties in diagnosis and management of patients with hyperparathyroidism. Due to the embryological origins of the inferior parathyroid glands from the 3rd pharyngeal arch where they develop with the thymus; they can have variable anatomical locations, including the anterior mediastinum. While the incidence of ectopic parathyroid glands varies in the literature mediastinal parathyroid tissue is extremely rare. This anatomical variation has important diagnostic and surgical ramifications for patients and is an important topic for trainees in medical endocrinology, endocrine surgery, and cardiothoracic surgery to be aware of. We present the case of a 22-year-old woman who presented as an emergency with severe hypercalcaemia. Who was subsequently found to have an ectopic mediastinal parathyroid adenoma. She underwent surgery within days of her initial presentation providing her with an immediate cure and restoring her calcium homeostasis. Despite diagnostic and operative challenges, combined care from our endocrine and cardio-thoracic surgical teams ensured an uneventful post-operative recovery for this patient.

Сложности диагностики первичного гиперпаратиреоза у пациента с эктопированной в средостение аденомой околощитовидной железы и полиоссальной фиброзно-кистозной остеодистрофией

Objective of the Paper: To demonstrate a rare variant of primary hyperparathyroidism in a patient with mediastinal ectopic parathyroid adenoma and polyossal fibrocystic osteodystrophy using a clinical example. Key points. Fibrocystic osteodystrophy is a specific manifestation of primary hyperparathyroidism, which in modern conditions belongs to the casuistically rare. Ectopia of the parathyroid gland into the mediastinum also refers to rare variants of the location of this organ. Our patient's attention is drawn to the poor clinical picture with the rapid development of bone changes. Conclusion. The variety of clinical manifestations of primary hyperparathyroidism, low awareness and alertness of doctors of related specialties in relation to this disease leads to an increase in the time of diagnostic search, the formation of incorrect diagnostic and therapeutic concepts. Determination of plasma calcium level is sufficient, in most cases, to exclude or confirm the diagnosis of primary hyperparathyroidism. Keywords: primary hyperparathyroidism, parathyroid adenoma, ectopic parathyroid adenoma, osteitis fibrosa cystica, brown tumor.

Mediastinal parathyroidectomy: Utilization of a multidisciplinary, robotic-assisted transthoracic approach in challenging cases

BackgroundThe majority of ectopic mediastinal parathyroid adenomas are accessible transcervically and those not amenable to this approach pose a significant clinical and technical challenge. MethodsRetrospective review of transthoracic robot-assisted mediastinal parathyroidectomy (TTRMP) for primary hyperparathyroidism between 2012 and 2019 at a single institution. Results16 patients underwent TTRMP, 63% were female with a mean age of 64 ± 2.0 years. Nine of 16 had prior parathyroidectomy; 80% had persistent disease and a mean 2.8-year delay from index operation until TTRMP. Locations included: intrathymic (8), AP window (4), carina (3), and retroesophageal (1). Two patients underwent parathyroid reimplantation. Mean post-operative calcium and PTH were 9.2 ± 0.2 mg/dL and 20.2 ± 5.6 pg/mL, respectively. Complications included: temporary hypocalcemia (4), permanent hypocalcemia (1), DVT (1), hoarseness (1), and subcostal neuralgia (1). ConclusionIn experienced hands, TTRMP is a safe and effective approach to mediastinal parathyroids not accessible transcervically. A multidisciplinary approach should be used in reoperative cases.

Robotic thoracoscopic parathyroidectomy for ectopic mediastinal parathyroid adenoma

The publication presents the successful experience of using the DaVinci robotic system for the treatment of persistent hyperparathyroidism caused by mediastinal ectopic parathyroid adenoma in 62 years old female patient. The role of single photon emission computed tomography in diagnostics was demonstrated.