Preoperative Localization of Parathyroid Adenoma in Patients with Concomitant Thyroid Nodular Disease

We have previously demonstrated the role of high-resolution ultrasonography (US) in preoperative localization of parathyroid adenoma in patients with primary hyperparathyroidism (PHPT) and no thyroid abnormalities. The present study prospectively evaluated the possible additional value of ^99mTc-sestamibi (MIBI) in patients with PHPT and concomitant multinodular thyroid disease (MND). Patients with PHPT underwent US and MIBI scintigraphy prior to neck exploration. Imaging data were correlated with the site and pathology of the parathyroid tissue removed and were analyzed separately for patients with MND and those with a normal thyroid gland. Among 77 patients with a solitary parathyroid adenoma at surgery, 40 had concomitant MND, whereas 37 patients had no morphologic changes in the thyroid gland, on US or at surgery. Prior to surgery, MIBI scintigraphy depicted 58 of the 77 adenomas (75%) and US localized 51 (66%); the combined sensitivity was 87% (67/77). Among the 37 patients with no thyroid nodules, MIBI located 29 (78%) and US identified 30 (81%) of the adenomas; the combined sensitivity was 89%. In the 40 patients with MND, MIBI identified 29 adenomas (73%) and US localized only 53% (21/40); the combined sensitivity was 85%. Overall, the positive predictive value (PPV) of MIBI for detecting a solitary parathyroid adenoma was 94%, for US it was 88%, and with the two tests combined it was 97%. In patients with no thyroid abnormalities, the PPV of MIBI and US was 97%, but it decreased to 91% and 78%, respectively, in patients with MND. Two patients with false-positive findings on both MIBI and US had associated thyroid disease. Hence MIBI scintigraphy contributes to localization of a solitary parathyroid adenoma mainly in patients with concomitant MND. The combined MIBI and US modalities result in sparing these patients bilateral neck exploration.     

Breast Radiation Correlates with Side of Parathyroid Adenoma

Background  

Prior head and neck irradiation is a known risk factor for hyperparathyroidism. It is not clear whether irradiation for breast cancer, which may expose the neck to radiation, is also a risk factor for hyperparathyroidism. The present study analyzes the association between the side of radiation to the chest following breast surgery and the side of subsequent parathyroid adenoma development.     

Intraoperative Secretion of Intact Parathyroid Hormone and Amino-Terminal Parathyroid Hormone Fragments from Normal Parathyroid Glands Associated with Solitary Parathyroid Adenoma

p < 0.05 for both). Because the reduction was more pronounced for i-PTH than for N-PTH, the N/i ratio increased from 0.54 ± 0.33 to 3.76 ± 1.62 ( p < 0.05). Furthermore, the levels of i-PTH and N-PTH were higher centrally than peripherally both before and after adenoma excision ( p < 0.05). The results therefore suggest that the secretion of i-PTH and N-PTH in the remaining normal-size parathyroid glands is not completely suppressed. Furthermore, in these parathyroid glands the secretion of amino-terminal PTH fragments is relatively predominant when compared to the release of the intact PTH. The findings underscore the importance of the N-terminal PTH fragment for maintaining calcium homeostasis during the early postoperative period after surgery for pHPT and may explain the rarity of prolonged hypocalcemia after parathyroidectomy.     

Identification and Management of Intravagal Parathyroid Adenoma

Intravagal parathyroid adenomas are rare, with only three cases reported in the English literature. The objective of this report is to describe two additional patients with hyperfunctioning parathyroid glands found within the vagus nerve and to define the anatomy of this finding. Both patients presented with a history of persistent hyperparathyroidism despite multiple therapeutic interventions. A high cervical localization was established in both cases by selective venous sampling. In each patient successful removal of the intravagal parathyroid gland was achieved with subsequent resolution of calcium and parathyroid levels. Each adenoma was located within the vagus nerve below the level of the carotid bifurcation and was enucleated without sacrificing the vagus nerve. In our cases and those reported previously, the parathyroid glands were supernumerary, representing parathyroid tissue embryologically derived from the third branchial pouch. Exploration for hyperparathyroidism requires a complete, meticulous surgical dissection to identify all parathyroid glands and to search for possible accessory tissue in selected cases. Our experience and a review of the literature serve to emphasize that, although rare, intravagal parathyroid adenomas do occur. Examination of the vagus nerve should therefore be strongly considered when four normal glands are found, as intravagal adenomas appear to represent accessory ectopically located parathyroid tissue.     

Case Report on Giant Parathyroid Adenoma with Review of Literature

Symptomatic primary hyperparathyroidism is still predominant form in developing countries. Sumit Shukla et al. (2008) Most of these lesions are usually less than 2 cm in diameter with serum calcium levels between 11 to 13 mg/dl. Our case had 3.9?×?2?×?1.7 cm non palpable right inferior parathyroid adenoma extending into superior mediastinum, serum calcium 17 mg/dl and vomiting as presenting symptom a case report.     

Impact of Adenoma Weight and Ectopic Location of Parathyroid Adenoma on Localization Study Results

Although the sensitivity of preoperative localization techniques is high for solitary parathyroid adenomas, negative imaging study results are inevitable. The weight and location of the parathyroid adenoma may contribute to the negative results. We aimed to study the impact of adenoma weight and ectopic location of the parathyroid adenoma on ultrasonography and sestamibi scan results. The patients were divided into two groups according to adenoma location. Group 1 consisted of 36 patients with ectopic location, and group 2 consisted of 149 patients with normal location. Parathyroid adenoma weight and the results of imaging studies were determined in all patients. Of 185 patients operated on for hyperparathyroidism, 36 (19.4%) had ectopic parathyroid glands. There was a positive correlation between adenoma weight and positive imaging studies, whereas ectopic location did not correlate with negative imaging study results. There was no significant difference between the ectopic adenoma ratio of patients with negative and positive imaging study results. The weight of the ectopic parathyroid adenoma was significantly lower in patients with negative imaging study results than in patients with positive imaging study results (p = 0.001). According to the analysis of variance, patients with higher-weight adenomas have positive imaging study results irrespective of ectopic location. For both normal and ectopic adenoma locations, adenoma weight was found only to be a factor that positively influences imaging study results.     

Functional Histology of Salivary Gland Pleomorphic Adenoma: An Appraisal

The complex microstructure of salivary gland pleomorphic adenoma is examined in relation to function. Events related to secretion of macromolecules and absorption, responses to the altered microenvironment and controversies concerning epithelial–mesenchymal transition versus modified myoepithelial differentiation are explored. Their effects on tumor cell phenotypes and arrangements are emphasized. Heterotopic differentiation and attempts at organogenesis are also considered. The approach allows interpreting microstructure independently of histogenetic perceptions, envisaging the tumor cells as a continuum, endorsing luminal structures as the principal components, and defining pleomorphic adenoma as a benign epithelial tumour characterized by variable epithelial–mesenchymal transition, secretion/differentiation and metaplasia.     

Intra-operative Parathyroid Hormone Monitoring in Patients with Parathyroid Cancer

Background Intra-operative parathyroid hormone (PTH) monitoring (IPM) is 97% accurate in predicting postoperative eucalcemia in sporadic primary hyperparathyroidism (SPHPT). However, its usefulness in parathyroid cancer has not been demonstrated. This study reports IPM accuracy during surgical resections for parathyroid cancer. Methods Eight of 556 consecutive patients with SPHPT underwent parathyroidectomy using IPM and had parathyroid cancer. Operative success was defined as eucalcemia > six months and operative failure/persistent cancer as hypercalcemia within six months of parathyroidectomy. The IPM criterion for operative success was defined as a >50% decrease of peripheral PTH levels from the highest either pre-incision or pre-excision values, 10 minutes after resection. Results In eight patients, 11 operations were performed. Ten operations (91%) resulted in >50% intra-operative PTH decrease. However, in only seven (70%) of these resections, eucalcemia was achieved for >6 months with five of these seven (71%) procedures being initial en bloc resections. The remaining 3/10 (30%) operations with >50% intra-operative PTH decrease resulted in operative failures. In the last operation, intraoperative parathormone monitoring (IPM) correctly predicted operative failure. IPM sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy in predicting outcome were 100, 40, 70, 100, and 75%, respectively. Conclusions IPM with the criterion of >50% PTH drop from the highest level is less accurate in predicting operative success in parathyroid cancer when compared to SPHPT. A >50% intra-operative PTH level decrease in patients with parathyroid cancer, particularly in reoperative cases, is less predictive of complete resection. The initial recognition of this disease followed by proper resection remains essential in the treatment of parathyroid cancer.     

Parathyroid Adenoma Manifested by Mediastinal Hemorrhage: Report of a Case

Acute mediastinal hemorrhage is rarely caused by a rupture of mediastinal neoplasms. We herein report a 70-year-old man who presented with mediastinal parathyroid adenoma manifested by the sudden onset of mediastinal bleeding. Preoperatively, he showed no symptoms or complications associated with hypercalcemia. No particular findings were found in the thorax except for a small nodule in the upper mediastinum. The nodule was resected through a collar incision, and pathohistology showed a parathyroid adenoma, with an intracapsular hemorrhage. Received: July 17, 2001 / Accepted: March 5, 2002     

肝硬变患者胃肠道壁增厚的MSCT表现特点及临床意义

目的 探讨肝硬变患者胃肠道壁增厚的发生率、多层螺旋CT(MSCT)的表现特点及其临床意义.方法 回顾性分析四川大学华西医院的109例肝硬变患者和130例非肝硬变患者的MSCT资料,计算二者胃肠道壁增厚的发生率,评估肝硬变患者胃肠道壁增厚的特点(分布、对称性和增强方式).结果 胃肠道壁增厚发生率肝硬变患者为66%(72例),非肝硬变患者为9%(12例),前者发生率明显高于后者(P＜0.005).肝硬变患者中空肠和升结肠最易受累,分别占44%(32/72)和43%(31/72),常累及2个以上解剖结构(64%),均表现为同心性增厚,均匀性强化.结论 肝硬变患者易发生胃肠道壁增厚,主要表现为多节段分布,其中空肠和升结肠最易受累,MSCT对诊断肝硬变引起的肠壁增厚有重要价值.     

垂体泌乳素大腺瘤患者术后内分泌的变化及临床疗效分析

目的:探讨手术治疗垂体泌乳素大腺瘤的临床疗效,以及对机体内分泌的影响。方法:收集符合标准的患者45例,观察手术前后血清泌乳素(PRL)、雌二醇(E2)、促卵泡素(FSH)、黄体生成素(LH)、孕酮(P)和睾酮(T)等水平变化以及对应各种激素刺激后FSH、LH和睾酮(T)的变化,并对患者临床疗效进行评定。结果:患者术后3个月、6个月和1年进行临床疗效评价,有效率分别为37.78%、60.00%和75.56%;患者术后1年血清PRL水平与术前比较,显著下降。术前促卵泡素(FSH)、黄体生成素(LH)的水平分别为(10.52±8.17)和(6.28±4.74)mIU/mL,GnRH激素刺激后,LH水的峰值达到(12.34±1.78)(P<0.05),而FSH的最高峰值为(11.28±2.30)(P>0.05);术后LH和FSH与手术之前相比显著升高。睾酮(T)术前与术后的水平有统计学意义,但是hCG反应的峰值没有显著区别。结论:泌乳素大腺瘤通过下丘脑-垂体-性腺轴影响一系列促性腺激素的释放进而影响生殖器官的功能,手术治疗垂体泌乳素大腺瘤临床疗效确切,可以显著改善患者内分泌激素水平。     

Unusual Presentation of a Giant Parathyroid Adenoma: Report of a Case

Parathyroid adenomas account for most cases of primary hyperparathyroidism (1° HPT). Certain symptoms and biochemical abnormalities alert the surgeon to their presence, since these benign tumors are rarely evident on physical examination. Moreover, because they are usually very small, preoperative localization using sestamibi scanning or ultrasonography is required to avoid bilateral neck exploration. Parathyroid adenomas rarely attain huge proportions. We report a case of a parathyroid adenoma measuring 8 × 5 × 3.5cm and weighing 110g; to our knowledge the greatest mass reported in the literature. Interestingly, despite its huge size it did not cause many of the hypercalcemic symptoms usually associated with larger adenomas, but rather it manifested with symptoms of local pressure, another unusual property of this atypical tumor.