Mediastinal Parathyroid Tumors Research Articles

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.

Thoracoscopic surgical case of an ectopic mediastinal parathyroid adenoma detected by chance: a case report

BackgroundEctopic mediastinal parathyroid tumor (EMPT) is a rare cause of primary hyperparathyroidism (PHPT); it is difficult to resect using the cervical approach. We describe a case of using video-assisted thoracic surgery (VATS) for EMPT resection.Case presentationA 67-year-old woman with a history of postoperative thyroid cancer had no symptoms. She was diagnosed with PHPT and underwent thyroid cancer surgery. She had serum calcium and intact parathyroid hormone (PTH) levels of 11.1 mg/dL and 206 pg/mL, respectively. Chest computed tomography showed a 10-mm nodule in the anterior mediastinum. Technetium-99 m methoxyisobutyl isonitrile scintigraphy showed an abnormal uptake lesion in the anterior mediastinum. She was diagnosed with PHPT caused by EMPT and underwent VATS. The pathological examination confirmed parathyroid adenoma. Her serum calcium and intact PTH levels were normal from 15 min after tumor resection. She has had no recurrence of EMPT.ConclusionsThe VATS approach was effective for the resection of EMPT.

Video-assisted thoracoscopic surgery for ectopic mediastinal parathyroid tumor: subxiphoid and lateral thoracic approach.

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. 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. 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. 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.

Comparison of video-assisted thoracic surgery with open surgery in the treatment of ectopic mediastinal parathyroid tumors.

To investigate the therapeutic effect of different surgical treatment for ectopic mediastinal parathyroid tumors and pathological features. A total of 21 patients who were diagnosed with ectopic mediastinal parathyroid tumors and underwent surgeries in our department from May 1995 to May 2015 were collected and retrospectively analyzed. Twenty-one patients including 8 female (36.4%) and 13 male (63.6%) were collected. Among these patients, 9 cases were treated with video-assisted thoracic surgery (VATS), while 13 cases were treated with open surgery (including one secondary open operation after thoracoscopic operation). The average size of mediastinal tumors was 2.17±1.22 cm. For the post-operational pathology, 16 cases (76.2%) were diagnosed as ectopic parathyroid adenoma; 4 cases (19.0%) were diagnosed as parathyroid hyperplasia, while only 1 case (4.8%) was diagnosed as parathyroid adenocarcinoma. Parathyroid adenoma accounts for the major pathological type of ectopic mediastinal parathyroid tumors. In addition, the correct diagnosis with precise preoperative location was the key for the treatment of ectopic mediastinal parathyroid tumors accompanied with hyperparathyroidism. Surgical intervention was demonstrated to be an effective way for the treatment of ectopic mediastinal parathyroid tumors with satisfied therapeutic outcome, especially for the VATS due to its unique clinical advantages. However, there may some difficulties when locating ectopic mediastinal parathyroid tumor less than 1 cm and the operators should be very cautious when performing thoracoscopic operations.

Ectopic mediastinal parathyroid carcinoma presenting as acute pancreatitis

Parathyroid carcinoma is a rare cause of hyperparathyroidism, accounting for fewer than 1% of cases. The incidence of acute pancreatitis in patients with hyperparathyroidism was reported to be only 1.5%. We report a very rare case of ectopic mediastinal parathyroid carcinoma presenting as acute pancreatitis. A 72-year-old man presented with acute pancreatitis and hypercalcemia. During the work-up for hypercalcemia, a mediastinal parathyroid tumor was identified by 99mTc-sestamibi scintigraphy and magnetic resonance imaging. The tumor was completely removed via a lower cervical collar incision. The histopathology revealed parathyroid carcinoma. There was no tumor recurrence or abdominal symptoms at 3-year follow-up.

The results of surgery for mediastinal parathyroid tumors: a comparative study of 63 patients

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. 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. 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. 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.

Anterior mediastinotomy for parathyroidectomy

Background Approximately 2% of ectopic parathyroid glands reside within the mediastinum in a location that requires a thoracic approach. Methods All patients with mediastinal parathyroid tumors who underwent anterior mediastinotomy were included in this review. Results Over the course of 16 years, 10 patients with primary hyperparathyroidism underwent anterior mediastinotomy. There were 6 men and 4 women with a median age of 65. Seven patients had undergone at least one previous cervical exploration. Preoperative calcium levels were 11.3 ± .8 mg/dL. Nine patients had preoperative localization with radionuclide scans and 9 patients also had preoperative computerized tomography or magnetic resonance imaging scans. An abnormal gland was removed in all cases. Nine of 10 patients had normalization of their calcium levels. Conclusions Anterior mediastinotomy after preoperative imaging has proven to be a technically feasible, safe, and effective method for the surgical management of patients with sporadic primary hyperparathyroidism and mediastinal parathyroid tumors.

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.

Section 1. Parathyroid: Thoracoscopic excision for ectopic mediastinal parathyroid tumor

Ectopic parathyroid adenoma or hyperplasia in the mediastinum are seen in a percentage of patients with hyperparathyroidism and have generally been treated by conventional open surgery. However, due to recent improvements in the ability of diagnostic imaging such as 99mTc-methoxyisobutylisonitrile (MIBI) scintigraphy to identify these lesions, we have been obtaining favorable results from thoracoscopic excision of mediastinal parathyroid tumors. In thoracoscopic surgery, three to four trocars were inserted between the fourth and seventh ribs from a lateral approach. Based on diagnostic imaging, tumors were identified and excised by the shortest possible route. Surgery time for four consecutive patients ranged from 50 to 140 min, and hemorrhage volumes were small. No intra- or postoperative complications were observed, and the postoperative course for these patients has been uneventful. Analgesia was required only a few times for each patient. In the most recent patient, radioisotope-navigated thoracoscopic excision was performed using 99mTc-MIBI. When thoracoscopic excision was combined with radioisotope navigation, tumor identification took less time, cutting the surgery time in half and ultimately placing less stress on the patient.

Closed Mediastinal Exploration in Patients With Persistent Hyperparathyroidism

Described are two patients with persistent hyperparathyroidism after unsuccessful neck explorations. Both had deep mediastinal parathyroid tumors located within the thymus gland. Formerly it had been the practice of the authors to perform a median sternotomy for the removal of such tumors. In the present cases, however, the neck was re-explored through a cervical incision and the entire thymus gland then was removed by the technique of "closed mediastinal thymectomy." An enlarged parathyroid gland was found embedded in the resected parenchyma of the thymus gland in each patient, and both were cured by the operation.

Resection of Select Mediastinal Parathyroid Adenomas Through an Anterior Mediastinotomy

Two patients who had undergone thorough surgical exploration of the neck were found to have adenomas of fifth parathyroid glands within the mediastinum. After localization with computed tomographic scanning or thallium-technetium imaging, or both, these tumors were resected through a parasternal approach (anterior mediastinotomy); thus, median sternotomy was obviated. This approach has not been described previously for the removal of mediastinal parathyroid tumors.

Mediastinal parathyroid tumors.

Mediastinal parathyroid tumors are a frequent cause of failed parathyroid operations. I therefore reviewed my experience with 285 consecutive patients treated surgically for hyperparathyroidism from January 1981 to Dec 31, 1986. Two hundred eighty-eight operations were performed on these patients (246 primary, 38 secondary, one error in diagnosis, and 53 reoperations). Mediastinal parathyroid tumors were present in 64 (22%) of the entire group of 285 patients with hyperparathyroidism, and 20 (38%) of 53 patients requiring reoperation for persistent or recurrent hyperparathyroidism. Fifty-two parathyroid tumors were situated in the anterior mediastinum and 12 were found in the posterior mediastinum; 56 of the mediastinal tumors were removed via a cervical approach. In four patients the mediastinal tumor was a fifth histologically documented parathyroid gland. Mediastinal tumors were identified by preoperative localization studies (ultrasonography, three [16%]; thallium-technetium, five of 17 [29%]; computed tomography, eight of 14 [57%]; magnetic resonance imaging, three of seven [43%]; and selective venous catheterization for parathyroid hormone, ten of 11 [91%]). Awareness of the relatively high occurrence of mediastinal tumors (52 anterior, 12 posterior) should decrease the risk of failed parathyroid operations.

High-resolution, real-time ultrasonography in the preoperative location of parathyroid tumors. Pilot study.

ON theoretic grounds, B-mode ultrasonography is an ideal tool for studying the parathyroids. It is a safe, noninvasive method, and operation of the equipment requires no special skills. To date, however, conventional diagnostic ultrasound instruments have lacked the necessary resolving power for accurate delineation of parathyroid tumors. Although computed tomography has proved useful in locating mediastinal parathyroid tumors,1 it does not reliably allow discrimination between parathyroid and thyroid tissue in the neck. There is also the unique problem, in patients facing reoperation, of sparkler artifacts produced by metal clips that have been used for hemostasis or for marking unresected glands . . .

Diagnosis and surgical treatment of mediastinal parathyroid tumors.

Experience and problems in the localization, diagnosis and surgical treatment of mediastinal parathyroid tumors are reported. Arteriography, pneumomediastinum and, especially, selective blood withdrawal with assay of parathyroid hormone, have proven valuable to the authors. Scintigram, intravital staining methods and venography are less productive. Retrosternal parathyroid tumors that can be removed from a Kocher incision should not, for practical reasons, be classified with the mediastinal tumors. The authors recommend the one-phase operation. If, after an intensive search of the neck and behind the sternum, no tumor has been found, it is advisable to incise the sternum step by step and revise the anterior mediastinum in the same session.

Middle Mediastinal Lesion

<h3>Common</h3> Aneurysm of aorta or major arteries; right aortic arch Azygos vein enlargement Bronchogenic cyst Esophageal lesion (eg, leiomyoma, carcinoma, achalasia, varices) Hiatal hernia Lymph node enlargement Thyroid tumor <h3>Uncommon</h3> Chemodectoma Enteric cyst Hematoma Sclerosing inflammatory mass; mediastinal abscess or fibrosis Mesenchymal tumor Pancreatic pseudocyst Parathyroid tumor Tracheal tumor or cyst Vagus or phrenic neurinoma <h3>Diagnosis</h3> Bronchogenic cyst. <h3>Comment</h3> In analyzing the gamut of this case, the retrocardiac position of the mediastinal mass is especially helpful, since this location effectively excludes such possibilities as large azygos vein, thyroid tumor, tracheal tumor or cyst, and parathyroid tumor. Lymph node enlargement is the most common cause of a middle mediastinal mass, but enlarged mediastinal nodes will usually be found around the carina tracheae or in the paratracheal area and are frequently accompanied by a more generalized adenopathy, including the parahilar nodes. Hiatal hernia occurs in the retrocardiac area

Mediastinal hyperfunctioning parathyroid tumors: review of 14 cases.

Mediastinal hyperfunctioning parathyroid tumors: review of 14 cases.