Supernumerary Parathyroid Glands Research Articles

Predictive value of characteristics of resected parathyroid glands for persistent secondary hyperparathyroidism during parathyroidectomy

BackgroundParathyroidectomy (PTX), an effective treatment for refractory secondary hyperparathyroidism (SHPT) in chronic kidney disease (CKD) patients, still has a high persistent rate. This study aimed to analyze the predictive value of characteristics of resected parathyroid glands for postoperative persistent SHPT.MethodsThe clinical data of patients with persistent SHPT and successful PTX controls who had or underwent total parathyroidectomy with forearm autotransplantation (TPTX + AT) was retrospectively collected. The characteristics including the number, minimum weight, maximum weight and total weight of resected parathyroid glands from each patient were recorded. Characteristics and cutoff value of resected parathyroid glands for the prediction of persistent SHPT were analyzed.ResultsA total of 227 patients (62 persistent SHPT patients and 165 successful PTX controls) were enrolled in the study. Forty-one (66%) persistent SHPT cases related to supernumerary parathyroid and the remaining 21 (34%) cases related to residual undetected parathyroid. In addition, ectopic parathyroid was found in 8 patients (13%) before PTX. The average number of resected glands in the persistent SHPT group and successful PTX group was 3.53 ± 0.72 and 3.93 ± 0.25 respectively (p < 0.001). There was significance in the number of patients with different resected parathyroid glands between two groups (p < 0.001). When the resected gland number was 4, minimum weight of the parathyroid was noted to be heavier in the persistent SHPT group than that in the successful PTX group (0.52 ± 0.31 g vs. 0.38 ± 0.19 g, p < 0.001). For persistent SHPT prediction, cutoff value of minimum weight was 0.535 g, with sensitivity of 46% and specificity of 82% (AUC = 0.611; p = 0.029).ConclusionsMajor reason for the persistent SHPT is the existence of supernumerary parathyroid glands or resection of less than 4 glands. When 4 glands were resected, a minimum total parathyroid gland weight heavier than 0.535 g implied the potential presence of a missed supernumerary parathyroid gland, which also contributed to the persistent SHPT.

Effect of total parathyroidectomy in patients with secondary hyperparathyroidism: a retrospective study

PurposeTo investigate the therapeutic efficacy, feasibility, and safety of total parathyroidectomy (tPTX) in the treatment of secondary hyperparathyroidism (SHPT).MethodsThe clinical data of 34 SHPT patients admitted to the Department of Nephrology, Yuxi People’s Hospital, from January 2018 to January 2021 who had received tPTX, were retrospectively analyzed. The indications for tPTX were severe SHPT that did not respond to medical treatment and was ineligible for kidney transplantation. tPTX without autotransplantation was adopted to compare the level of symptom relief and changes in serum intact parathyroid hormone (iPTH), blood calcium, and blood phosphorus pre- and postoperatively.ResultsIn 34 patients, 142 parathyroid glands were removed, including 21 ectopic parathyroid glands (14.78%). Six patients (17.64%, 6/34) had supernumerary parathyroid glands. At 6 h postoperatively, arthralgia and bone pain were significantly reduced to almost zero in 94.12% (32/34) of patients. At 24 h postoperatively, relief of bone pain and improvement of limb movement were observed in 100% (34/34) of patients, and pruritus almost disappeared in 86.36% (19/22) of patients. There were significant differences in iPTH (χ2 = 134.93, P < 0.05), calcium (χ2 = 23.02, P < 0.05), and phosphorus (χ2 = 102.11, P < 0.05) levels preoperatively and 40 min, 24 h, 1 week, half a year, and last available (> 1 year) postoperatively.The patients were followed up for 15–47 months (median 33 months). Hypoparathyroidism was observed in three patients, who underwent neck dissection or partial thymotomy concurrently for different reasons. No intractable hypocalcemia or adynamic bone disease occurred during the follow-up period.ConclusionIn SHPT patients who were ineligible for renal transplantation, tPTX was effective, safe, and reliable, with a low recurrence rate. However, when tPTX was performed alone without autologous transplantation, bilateral neck exploration was sufficient, and central neck dissection and thymic resection were inadvisable.

PSAT205 A Case of Persistent Primary Hyperparathyroidism Secondary to an Occult Supernumerary Parathyroid Adenoma

Abstract Background Persistent primary hyperparathyroidism accounts for the vast majority of patients who require reexploration. With the advancements in preoperative localization, surgical outcomes have improved over time. However, in patients with failed reoperative parathyroid exploration, an occult supernumerary parathyroid adenoma should be considered. Clinical Case A 60 year-old female diagnosed with primary hyperparathyroidism presented with recurrent nephrolithiasis, osteoporosis and declining eGFR. Initial laboratory evaluation showed elevated serum calcium (1.54 mmol/L, normal 1.09-1.30) and intact PTH (146 pg/mL, normal 18.50-88.0). 99mTc-sestamibi scintigraphy showed a sestamibi-avid focus in the inferior aspect of the right lobe hence, she underwent radionuclide-guided focused right parathyroidectomy. Post-operatively, her intact PTH level was still elevated (171.2 pg/mL). Histopathologic examination showed a normocellular parathyroid gland and a multifocal papillary thyroid carcinoma. The failed 1st surgery was attributed to the false positive scintigraphy from the papillary thyroid carcinoma. She then underwent total thyroidectomy with central neck dissection and 3½ parathyroidectomy with intraoperative parathyroid hormone assay. However, serial PTH monitoring after exploration and parathyroidectomy failed to decrease the PTH level by 50%. Histopathologic examination showed normocellular parathyroid glands. The bilateral carotid sheath, retropharyngeal region and superior mediastinum were explored but no ectopic parathyroid tissues were seen. Post-operatively, calcium and PTH were still elevated (1.48 mmol/L and 200.5 pg/mL, respectively). FDG PET CT imaging failed to show any ectopic parathyroid gland or adenoma. No further surgical intervention was done and she was medically managed with Cinacalcet 30 mg twice daily. 15 months after her parathyroid gland exploration, calcium and PTH were still elevated (1.46 mmol/L and 156.80 pg/mL, respectively). F18 Choline PET CT imaging was done showing a small hypoenhancing persistently FCH-positive focus in the left thyroid bed and sliver of enhancing tissue relating to a parathyroid adenoma. Conclusion This case highlights the diagnostic and therapeutic challenges in a patient with persistent primary hyperparathyroidism after a failed 2nd surgery. Occult parathyroid adenomas can cause significant symptoms regardless of its size and its imperceptible nature on imaging. The role of medical management is emphasized in this case when surgical management was not possible. Furthermore, re-evaluation for growth of the possible occult parathyroid adenoma should be done, which in this case took 15 months until its detection. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

PTH Spikes During Surgical Treatment for Secondary and Tertiary Hyperparathyroidism: A Prospective Observational Study.

The aim of the present study was to determine whether PTH spikes in renal hyperparathyroidism can interfere with the interpretation of intraoperative PTH monitoring and to determine its frequency and characteristics. This was a prospective observational study of consecutive patients who underwent surgical treatment in a single tertiary institution. Patients were divided into two groups: spike and no spike. Patients with secondary and tertiary hyperparathyroidism were analyzed separately. Intraoperative PTH monitoring by venous serial samples: two samples were taken before the excision of the parathyroid gland, and two others were taken after resection. PTH spikes occurred in 23.5% (53 of 226), and their occurrence was similar between secondary and tertiary hyperparathyroidism patients (p = 0.074). The relative PTH spike intensity was higher in transplanted patients than in dialysis patients (55 vs. 20%, p = 0.029). A characteristic of the secondary hyperparathyroidism patients was the highest frequency of surgical failure (23 vs. 7.5%, p = 0.016) and the higher occurrence of supernumerary glands in the spike group (23 vs. 10.3%, p = 0.035). Supernumerary parathyroid was associated with surgical failure [19.1 (6.5-55.7) odds ratio [confidence interval], p < 0.001). In the studies evaluating the diagnostic test validity for patients on dialysis and experiencing spikes, the most significant impacts were in the sensitivity, accuracy, and negative predictive value of the method. PTH spikes occurred in up to 23.5% of renal hyperparathyroidism surgical treatments and can negatively influence the intraoperative parathyroid hormone monitoring. Regarding the phenomenon of PTH spikes, it is prudent to think about the possibility of a hyperplastic supernumerary gland.

Recurrent Hyperparathyroidism Following Successful Four-Gland Parathyroidectomy and Normalization of Parathyroid Hormone in a Renal Transplant

Chronic kidney disease has an estimated prevalence of 10% in Australia and is predicted to rise in the coming years. Secondary hyperparathyroidism resulting from chronic kidney disease is an important cause of morbidity in these patients; and screening for secondary hyperparathyroidism is recommended in international guidelines. We present the case of a chronic kidney disease patient who developed recurrent hyperparathyroidism despite previous “total” parathyroidectomy and subsequent renal transplant. After targeted investigations he was diagnosed with an accessory parathyroid gland in his thorax, causing the recurrent hyperparathyroidism. He was managed with a thoracoscopic excision with a resultant drop in parathyroid hormone consistent with surgical cure. This case highlights the rare phenomenon of supernumerary and ectopic parathyroid glands. Cross sectional thoracic imaging can and should be used to detect and localize supernumerary glands not apparent at the time of original surgery. J Med Cases. 2021;12(4):141-144 doi: https://doi.org/10.14740/jmc3643

Sestamibi scan in renal parathyroidectomy: a worthwhile preoperative exam?

IntroductionSurgical treatment of hyperparathyroidism related to chronic kidney disease is a real challenge for Brazilian public health care. High cost medications and long waiting lines to perform preoperative exams, especially technetium Tc 99m Sestamibi (MIBI) are some of the reasons. Despite the reality that the aid of localization exams are questionable in this scenario, doctors are too apprehensive in performing surgery without it. ObjectiveThe study aimed at evaluating the efficacy of surgery for renal hyperparathyroidism without preoperative MIBI. MethodsA total of 114 patients were surgically treated. Total parathyroidectomy with autotransplantation and subtotal parathyroidectomy were carried out without preoperative MIBI. Results and conclusionAmong the 114 patients undergoing surgery, 37 had secondary hyperparathyroidism in dialysis replacement, and 77 patients had post-renal transplant persistent disease. We were successful in 107 cases with only 7 failures (93.8% of success rate). Among these failures, only one parathyroid gland was not found in 4 cases, 2 parathyroid glands were not found in 2 cases and in 1 patient the 4 glands were found but this patient remained hypercalcemic and a postoperative diagnosis of supernumerary parathyroid gland was made. Surgery for treatment of renal hyperparathyroidism proved to be an effective (93.8%) and reproductible procedure, even without MIBI.

Ectopic and supernumerary parathyroid glands in patients with refractory renal hyperparathyroidism

BackgroundThe aims of this study were to determine the rate of ectopic and supernumerary parathyroid glands and the outcome of surgical therapy in patients with refractory renal hyperparathyroidism. Materials and MethodsA retrospective review of all patients who underwent parathyroidectomy for refractory renal hyperparathyroidism was completed. Operative and pathology reports were reviewed, and the number and location of resected parathyroid glands, patient outcomes, and follow-up were determined. ResultsDuring the period 1993–2019, a total of 68 patients underwent subtotal or total parathyroidectomy for renal hyperparathyroidism. Of those, 59 patients (87%) were on dialysis for an average of 6.7 years. We determined that 18 patients (26%) had 24 ectopic parathyroid glands, including 9 (13%) patients with 11 supernumerary glands. A total of 2 patients had a supernumerary gland in a normal anatomic location. Of the 24 ectopic glands, 14 (58%) were in the thymus. After parathyroidectomy, 4 patients (5.9%) had persistent hyperparathyroidism, 6 patients (8.8%) developed recurrent hyperparathyroidism, and 2 patients (3%) had permanent hypoparathyroidism. ConclusionEctopic and supernumerary parathyroid glands occurred in 26% and 16% of patients with renal hyperparathyroidism, respectively, and the thymus was the most common location. Thorough neck exploration and transcervical thymectomy are important to help reduce persistent and recurrent hyperparathyroidism after parathyroidectomy for renal hyperparathyroidism.

A Deceptive Preoperative Imaging of an Ectopic Supernumerary Parathyroid Adenoma in a Secondary Hyperparathyroidism.

Ectopic and supernumerary parathyroid glands in the neck is a real surgical challenge especially in multi-gland pathologies. We report a supernumerary ectopic gland at a rare site in the neck in a chronic kidney disease patient which required a re-exploration following a deceptively successful bilateral neck dissection.

Persistent secondary hyperparathyroidism caused by parathyromatosis and supernumerary parathyroid glands in a patient on haemodialysis

BackgroundSecondary hyperparathyroidism (SHPT) is a common high-risk factor for mortality in end-stage renal disease, and parathyromatosis and supernumerary parathyroid glands are very rare causes of persistent SHPT. Preoperative diagnosis and removal of all hyperplastic parathyroid glands are challenging. We report a rare case of persistent SHPT due to parathyromatosis and supernumerary parathyroid glands and successful management by multiple imaging modalities.Case presentationA 53-year-old Chinese woman on haemodialysis experienced discomfort due to itching and bone pain due to persistent SHPT after parathyroidectomy. The supernumerary parathyroid glands and parathyromatosis were detected by multiple imaging modalities, including 99mTc-sestamibi (99mTc-MIBI) scans, ultrasonography and four-dimensional computed tomography (4D-CT) and then excised; pathological confirmation was performed. During follow-up, her serum calcium and parathyroid hormone levels were stable in the appropriate ranges, and no complications arose.ConclusionsBecause of persistent SHPH after parathyroidectomy in patients with haemodialysis, multiple imaging modalities, including 99mTc-MIBI scans, 4D-CT and ultrasonography, are helpful for detecting supernumerary parathyroid glands and parathyromatoses. Accurate preoperative localization of this rare lesion is important for management, enabling the removal of all affected parathyroid tissues.

Results of 150 Subtotal Parathyroidectomies for Secondary Hyperparathyroidism

We evaluated our experience of subtotal parathyroidectomy (SP) for secondary hyperparathyroidism (SHP) cases. We evaluated retrospectively our 150 SP operations due to SHP. Serious hypocalcemia (< 6.5 mg/dL) developed in 23 (15.3%) patients, and we performed cryopreserved parathyroid cell autotransplantation in four cases with successful results. Recurrent hyperparathyroidism developed in 3 (2%) cases, and persistent hyperparathyroidism was observed in 22 (14.6%) cases. Upon reoperation in nine persistent hyperparathyroidism cases, we found supernumerary parathyroid glands in three cases, remnant tissue hyperplasia in four cases, and ectopic parathyroid glands in two cases. Among cases in which four glands cannot be found during surgery, the permanent HP rate is high. Serious hypocalcemia may develop postoperatively, and cryopreserved parathyroid autotransplantation may be inevitable in some of these cases.

Exploration on total parathyroidectomy for secondary hyperparathyroidism

Objective: To evaluate the clinical significance of dissection parathyroidectomy for secondary hyperparathyroidism (SHPT) in patients with renal disease on maintenance dialysis. Methods: We retrospectively reviewed 195 patients with SHPT treated in the Department of Otolaryngology & Head and Neck Surgery of Beijing Civil Aviation General Hospital between September 2009 and September 2017, including 92 males and 103 females, aged from 23 to 77 years old. There were 167 patients by operated firstly and 28 patients by operated secondly for persistent or recurrent SHPT after operation. All patients received dissection parathyroidectomy with parathyroid autograft in the sternocleidomastoid. The easement of symptoms, the levels of serum intact parathyroid hormone (iPTH), serum-ionized calcium, phosphorus, and hemoglobin were compared before and after operation. Data were analyzed by SPSS 22.0 software. Results: Confirmed by postoperative pathology, a total of 804 hyperplastic parathyroid glands were removed in 195 patients with SHPT. Among them, 765 parathyroid glands were clearly identified and located with naked eye. The anatomic distribution of the glands showed 577 (75.4%) in the tracheoesophageal groove. The incidence of ectopic parathyroid glands was 24.6% (188/765). Other 39 (4.9%) hyperplastic parathyroid glands from 22(11.3%) patients, which were not identified and located with naked eye during operation, were pathologically detected in the dissected tissue specimens. Among 195 patients, 28(14.4%) showed supernumerary parathyroid glands. No serious complications occurred after operation. Within 6 months after the operation, the bone pain and skin itch symptoms were completely relieved and, also, the symptoms of muscle weakness, restless leg, anemia and poor sleep quality were significantly alleviated. Following-up at 6 months after surgery showed the serum levels of iPTH [(70.31±60.12) pg/ml], calium [(2.13±0.22) mmol/L], and phosphorus [(1.17±0.27) mmol/L] decreased significantly respectively compared with the preoperative serum levels of iPTH [(1 501.02±167.26) pg/ml], calium [(2.40±0.32) mmol/L], and phosphorus[(2.27±0.50)mmol/L], all with statistically significant differences (P<0.01); the levels of hemoglobin [(120.32±10.63) g/L] and hematocrit [(39.20±3.21)%] were higher than the preoperative levels of hemoglobin[(104.11±15.17) g/L] and hematocrit [(31.25±5.12)%], both with statistically significant differences (t valve was 12.22,18,37,respectively, all P<0.05). Conclusions: Dissection parathyroidectomy is a beneficial and safe surgical procedure for patients with medically refractory SHPT.

Unusual recurrent renal secondary hyperparathyroidism caused by hyperplastic autograft with supernumerary parathyroid adenoma

Rationale:Secondary hyperparathyroidism (SHPT) is often complicated with chronic renal failure. Though the total parathyroidectomy (TPTX) with forearm autotransplantation (FAT) has been commonly used to treatment refractory renal SHPT, the recurrence of SHPT is not infrequent, resulting from hyperplastic autograft, remnant parathyroid tissues, and supernumerary parathyroid gland (SPG).Patient concerns:A 67-year-old man undergoing TPTX+FAT 4 years previously for renal SHPT, who received regular hemodialysis with active vitamin D supplements of Rocaltrol treatment postoperatively, was admitted to our hospital with progressively elevated serum intact parathyroid hormone (iPTH) from 176 to 1266 pg/mL for 8 months and bilateral ankle joints pain for 1 month. 99mTc-sestamibi dual-phase imaging with single positron emission tomography (SPECT)/computed tomography (CT) revealed a nodule in suprasternal fossa, besides a nodule in autografted site, accompanied with intense radioactivity.Diagnosis:Recurrent SHPT was easily diagnosed based on previous medical history, painful joints, increased serum iPTH level and positive findings of 99mTc-sestamibi imaging. Routine postoperative pathology showed that the nodules were consistent with an adenomatoid hyperplasic autograft and a supernumerary parathyroid adenoma in suprasternal fossa, respectively.Interventions:Reoperation for removing nodules in suprasternal fossa and autografted site was performed 1 month later. Then regular hemodialysis 3 times a week with Rocaltrol was continued.Outcomes:During 12 months of follow-up, the joints pain improved obviously and the serum iPTH level ranged from 30.1 to 442 pg/mL.Lessons:Although rare, recurrent renal SHPT may be caused by a coexistence of both hyperfunctional autograft and SPG after TPTX+FAT. The 99mTc-sestamibi parathyroid imaging with SPECT/CT is helpful to locate the culprits of recurrent renal SHPT before reoperation. To prevent recurrence of renal SHPT, the present initial surgical procedures should be further optimized in patient on permanent hemodialysis.

Recurrent tertiary hyperparathyroidism due to supernumerary parathyroid glands in a patient receiving long-term hemodialysis: a case report

BackgroundRenal hyperparathyroidism is a common complication of chronic kidney disease (CKD) or end-stage renal disease (ESRD) characterized by elevated parathyroid hormone levels secondary to derangements in the homeostasis of calcium, phosphate, and vitamin D. Rapid correction of severe and prolonged hyperparathyroidism by surgical parathyroidectomy in long-term hemodialysis patients occasionally causes hungry bone syndrome. These patients then exhibit severe and long-lasting secondary or tertiary hyperparathyroidism with high bone turnover.Case presentationWe report a case of recurrent tertiary hyperparathyroidism after total parathyroidectomy due to supernumerary parathyroid gland in a patient with long-term hemodialysis. Supplementation with intravenous calcium, oral calcium, and vitamin D immediately after patient surgery helps to prevent and treat hungry bone syndrome.ConclusionsWe should prompt a search for the supernumerary parathyroid glands in ESRD patients, who have recurrent or persistent hyperparathyroidism after total parathyroidectomy. ESRD patients are more likely to develop hungry bone syndrome after parathyroidectomy. Prevention and treatment of hungry bone syndrome may be required after ectopic parathyroidectomy in clinical practice.

A study on development and morphogenesis of parathyroid gland in the developing human embryo

Background: Development of parathyroid gland starts at 5 week of intra-uterine life but it is visible histologically only after 14 weeks. Objectives: To study the histological changes of the developing parathyroid gland in human fetus at different periods of gestations. Methods: Parathyroid from 50 fresh human fetuses belonging to both sex and gestational age ranging from 14-40 weeks were studied using Hematoxylin- Eosin, and Masson Trichrome stains. Results: Early developing parathyroid gland is visible between trachea and oesophagus as small collection of cells invaded by blood vessels and surrounded by loosely arranged connective tissue at 14th week. It is found between trachea and thyroid gland at 16th week with uniformly arranged round cells having vesicular nuclei and pale cytoplasm. A solid nodule with groups and cords of chief cells is visible at 18th week. Blood filled sinusoidal capillaries appear at 24th week. A definite capsule is well visualized at 26th week. A supernumerary parathyroid is also present. Parathyroid can be differentiated from the surrounding adipose tissue, thymus and thyroid follicles at 32nd, 36th and 40th weeks respectively. Conclusion: Due to diffuse and variable growth, parathyroid gland is not visible on naked eye examination. Histologically it is first observed at 14th week of gestation as small collection of fibroblastic cells which finally form well-defined encapsulated and vascular parathyroid gland. It maybe present near thyroid as its organisation occurs side by side with folliculogenesis of thyroid gland. It maybe present within thymus as both develop from same source. Early division of the primordium may lead to the supernumerary parathyroid.

Opportunity for cardiovascular risk factor reduction in AAA surveillance programs: a systematic review and meta-analysis of cardiovascular mortality in patients with small AAA

Opportunity for cardiovascular risk factor reduction in AAA surveillance programs: a systematic review and meta-analysis of cardiovascular mortality in patients with small AAA

Aortopulmonary window parathyroid gland causing primary hyperparathyroidism in men type 1 syndrome

Primary hyperparathyroidism (HPT) is the most common endocrinopathy in Multiple Endocrine Neoplasia type 1 (MEN1) syndrome. Supernumerary and/or ectopic parathyroid glands, potentially causes of persistent or recurrent HPT after surgery, have been previously described. However, this is the first ever described case of ectopic parathyroid gland localized in the aortopulmunary window causing HPT in MEN1. After a consistent concordant pre-operative imaging assessment the patient, a 16 years old male affected by a severe hypercalcemia, underwent surgery. The parathyroid was found very deeply near the tracheal bifurcation, hidden by the aortic arch itself and for this reason not visible at the beginning of the dissection but only after being identified by palpation for its typical consistence. The intraoperative PTH decreased at normal level 10 min after removal of the ectopic gland. The patient remained with normal value of calcemia and PTH during the 10 months of follow-up.

SURGICAL ANATOMY OF PARATHYROID GLANDS IN PATIENTS WITH SECONDARY HYPERPARATHYROIDISM

Ectopic or supernumerary parathyroid glands (PTg) can be the reason of surgical failure in treat- ment of secondary hyperparathyroidism in patients, who underwent dialysis. The aim of this study is to estimate the number and localization of PTgs in patients with secondary hyperparathyroidism. We included 165 patients, who underwent total parathyroidectomy with heterotopic autotransplantation of parathyroid gland tissue or subtotal parathyroidectomy. All identified PTgs were separated in two groups: eutopic and ectopic. Preoperative localization was performed by multispiral computed tomog- raphy of neck and mediastinum, neck ultrasonography, two-isotope Tc99 MIBI of PTgs. In postopera- tive period, we estimated the level of parathyroid hormone in the serum and performed morphological verification. There were found 659 PTgs. 12 (7,2%) patients had 3 parathyroid glands, and 11 (6.7%)had 5 PTgs. 4 Ptgs were found in 142 (86,1%) patients. 520 (78,9%) PTgs were eutopic, 139 (21,1%) - ectopic. The most common ectopic place for upper PTgs were paraesophageal and retrotracheal spaces, carotid sheath. Ectopic lower PTgs were most commonly located in the horns of the thymus. All super- numerary PTg were ectopic and often located in area between lower pole of the thyroid lobe and the thymus.Conclusion. During the operation in case when ectopy is suspected, upper PTgs should be located in in paraesophageal and paratracheal areas or in carotid sheath, if it necessary. If lower PTgs is absence, surgery should be completed cervical thymectomy.

Supernumerary Parathyroid Glands in a Patient with Tertiary Hyperparathyroidism : Case Report

Supernumerary parathyroid glands could be affected by tertiary hyperparathyroidism after long-term phosphate therapy in an adult-onset hypophosphatemic Osteomalacia, and it may be the cause of refractory hyperparathyroidism. We Report a 63-years old Jordanian man who has been diagnosed at age of 26 years as having sporadic adult-onset hypophosphatemic Osteomalacia and developed tertiary hyperparathyroidism as a complication of prolonged oral phosphate therapy, which requires repeated surgical interventions. This patient had six parathyroid glands all ended with tertiary hyperparathyroidism, the 5th and the 6th gland were activated serially. This rare association is discussed along with a review of literature.

Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy

IntroductionHyperparathyroidism is an expected metabolic consequence of chronic kidney disease (CKD). Ectopic and/or supernumerary parathyroid glands (PT) may be the cause of surgical failure in patients undergoing total parathyroidectomy (PTX). AimTo define the locations of ectopic and supernumerary PT in patients with renal hyperparathyroidism and to correlate intraoperative findings with preoperative tests. Materials and methodsA retrospective study was conducted with 166 patients submitted to PTX. The location of PT during surgery was recorded and classified as eutopic or ectopic. The preoperative localizations of PT found by ultrasonography (USG) and Tc99m-Sestamibi scintigraphy (MIBI) were subsequently compared with intraoperative findings. ResultsIn the 166 patients studied, 664PT were found. Five-hundred-seventy-seven (86.4%) glands were classified as eutopic and 91(13.6%) as ectopic. Eight supernumerary PT were found. The most common sites of ectopic PT were in the retroesophageal and thymic regions. Taken together, USG and MIBI did not identify 56 (61.5%) ectopic glands. MIBI was positive for 69,7% of all ectopic glands located in the mediastinal and thymic regions. ConclusionThe presence of ectopic and supernumerary PT in patients with renal hyperparathyroidism is significant. Although preoperative imaging tests did not locate most of ectopic glands, MIBI may be important for identifying ectopic PT in the mediastinal and thymic regions.

Minimally Invasive Resection for Mediastinal Ectopic Parathyroid Glands

We reviewed our experience with ectopic mediastinal parathyroidectomy. Between March 1980 and September 2010,mediastinal parathyroidectomy was performed in33 patients with hypercalcemia secondary to hyperparathyroidism. Primary hyperparathyroidism was the main diagnosis in 32 patients (97%). Technetium-sestamibi scan was used in 23 (70%) for preoperative localization. Minimally invasive resections were performed in 18 patients (55%), and 15 (45%) underwent open surgery. The most common minimally invasive surgery approach was video-assisted thoracoscopy in 9 patients (27%); the most common open approach was median sternotomy in 11 (33%). Intraoperative parathyroid hormone monitoring was used in 22 patients (67%). The ectopic glands were intrathymic in 15 patients (45%), in the aortopulmonary window in 7 (21%), and in other intrathoracic locations in the remaining 11 (33%). Parathyroid adenomas were identified in 21 patients (64%); parathyroid hyperplasia and carcinoma were identified in 9 (27%) and 3 (9%), respectively. No early mortality occurred in either group. Reoperation was required in 1 patient in the minimally invasive surgery group because of hemothorax. Morbidity occurred in 8 patients (24%), the most common of which was hypocalcemia in 4 (12%). The mean length of stay was significantly shorter in the minimally invasive surgery group (2 versus 6 days; p < 0.001) but mortality and morbidity were not statistically different between the two groups (p= 0.05). Mean follow-up was 3 ± 3.7 years. Minimally invasive mediastinal parathyroidectomy has similar outcomes to open surgery, with significantly shorter length of hospital stay.