Day-case minimally invasive excision of a giant mediastinal parathyroid adenoma

Inferior parathyroid adenomas in the mediastinum can be a troublesome cause for hypercalcaemia, requiring a full collar incision or, occasionally, a sternotomy. We report a case of a giant parathyroid adenoma in a 61-year-old woman on warfarin, which we excised via a minimally invasive transcervical approach after radiological localisation. The procedure was performed as a day case and, at six weeks, the patient had recovered fully with biochemical resolution of hypercalcaemia. This case demonstrates that focused transcervical excision of giant parathyroid adenomas is a viable option and should be considered prior to neck exploration or sternotomy.     

Preoperative evaluation of patients with parathyroid adenoma: role of high-resolution ultrasonography.

BACKGROUND: Unilateral parathyroid exploration with adenoma removal and identification of a normal parathyroid gland is a controversial surgical approach to the treatment of primary hyperparathyroidism. The aim of this study was to evaluate the ability of high-resolution ultrasonography to localize adenomas preoperatively and to assess the effect of such localization on operative time. METHODS: One hundred twenty consecutive previously non-operated patients with primary hyperparathyroidism underwent ultrasonography before surgery, which consisted of unilateral neck exploration. The procedure was changed to bilateral exploration when justified by the surgical findings. RESULTS: The sensitivity and positive predictive value of the ultrasonographic examinations were 89% and 98%, respectively. These results were obtained regardless of the size of the adenoma. No significant difference was found in the presence of thyroid multinodular disease (p =.2). A positive sonographic examination decreased the operative time to an average of 59 minutes. The average size of the adenomas was 19 mm (range, 4-55 mm). A positive and highly statistically significant correlation was found between adenoma size and both preoperative calcium level (p =.01) and parathyroid hormone level (p =.0001). CONCLUSIONS: In experienced hands, high-resolution ultrasonography can be a cost-effective means of localizing parathyroid adenomas when unilateral neck exploration is considered the acceptable surgical approach.     

Important hypercalcaemia due to hyperparathyroidism induced by lithium

Lithium treatment, which is still extensively used in bipolar affective disorders, may give rise to hypercalcaemia induced by hyperparathyroidism. We present a patient of 50-year-old treated with lithium for 19 years for bipolar illness and who developed an important hypercalcaemia. After symptomatic treatment of the hypercalcaemia and extrarenal dialysis the clinical evolution was favorable but measurements of serum calcium and parathormon showed that he had developed hyperparathyroidism. Neck exploration was performed and parathyroid adenomas, which had been detected by scintigraphy was removed. The lithium treatment expose to many side effects. Among other biologically and clinically important effects of lithium the possible induction of hyperparathyroidism was first suggested in 1973. Since, 1973, since about forty case reports have been described. Few cross-sectional studies show a relationship of lithium to hyperparathyroidism. Unusual metabolic features are associated with hyperparathyroidism and long-term lithium treatment: low urinary calcium excretion, normal urinary cyclic AMP excretion. The mechanism probably results from lithium linking with the calcium receptor on the parathyroid and then stimulating PTH secretion. The cessation of lithium therapy does not lead to normocalocaemia and a parathyroidectomy is usually indicated.     

Preoperative imaging in primary hyperparathyroidism before first cervicotomy

A primary neck exploration for primary hyperparathyroidism can be performed without any previous morphological investigations. However, ultrasonography, CT scan and thallium technetium isotope scan can facilitate the surgical procedure as they frequently reveal and localize a parathyroid adenoma, due to the frequently large size of most adenomas. Although not all of these morphological investigations are always successful, we strongly recommend the use, in particular, of ultrasonography which is a non-invasive and inexpensive method. The other investigations, which are more expensive and less widely available can be discussed for each individual patient. These morphological investigations are obviously indicated in persistent recurrent primary hyperparathyroidism.     

Localization of abnormal parathyroid glands using thallium-201

Ectopically located parathyroid adenomas may be difficult to find during initial neck exploration. They account for over 70 percent of missed adenomas found at reexploration. Preoperative localization of parathyroid adenomas would reduce unnecessary dissection and possibly reduce the number of negative results of initial neck exploration. Before reoperative parathyroid surgery is performed, some means of localization is mandatory to detect ectopic adenomas in the neck and mediastinum. Computed tomography and ultrasonography cannot effectively evaluate the mediastinum. Angiography and venous parathyroid hormone sampling are invasive, costly, and tedious to perform. We have shown that thallium-201 will accurately localize ectopic parathyroid adenomas. All 10 adenomas found in positions not immediately adjacent to the thyroid gland were detected by thallium-201 scintigraphy. One was a mediastinal adenoma resected with a median sternotomy. Our results suggest that thallium-201 scintigraphy should be the initial localization procedure of choice before all reexplorations. Its use before initial explorations, as well, will enable the surgeon to immediately direct attention to the area of the localized adenoma. If mediastinal uptake is found to be present, then median sternotomy may be performed during initial surgery provided a thorough neck exploration is performed first.     

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??Clinical features and diagnosis of parathyroid adenoma with cystic degeneration??A report of 8 cases ZHAO Hai-ying, CUI Yong, ZHOU Yong, et al. Department of General Surgery, Affiliated Shengjing Hospital, China Medical University??Shenyang 110004, China
Corresponding author??LIU Jin-gang, E-mail??liujg@sj-hospital.org
Abstract Objective To evaluate the clinical features and diagnosis of parathyroid adenoma with cystic degeneration. Methods The clinical data of 8 cases of parathyroid adenoma with cystic degeneration and 50 cases of parathyroid adenoma without cystic degeneration performed surgery and identified by pathology between January 2003 and August 2012 in Department of General Surgery, Affiliated Shengjing Hospital of China Medical University were analyzed retrospectively. The serum calcium, serum parathyroid hormone (PTH), parathyroid crisis, lesion size and diagnosis methods between cystic degeneration group and no cystic degeneration group were compared and analyzed. Results There was no difference in serum calcium, serum PTH and incidence of parathyroid crisis between two groups. The mean largest diameter of lesion in cystic degeneration group was ??37.1±13.8??mm, in no cystic degeneration group it was ??23.6±11.4??mm, there was statistical difference between two groups (P??0.01). In all parathyroid adenomas, the sensitivity, accuracy, positive predictive value in ultrasonography, CT and MIBI scintigraphy was 82.1%, 79.3%, 95.8%; 66.7%, 66.7%, 100.0%; 71.4%, 68.2% and 93.8% respectively. There was no statistical difference among the three groups. The sensitivity of ultrasonography in cystic degeneration group was 37.5%, lower than it in no cystic degeneration group (89.6%), there was statistical difference between two groups (P??0.01). Conclusion In both parathyroid adenoma with cystic degeneration group and no cystic degeneration group, the clinical feature is the same. There is no difference in serum calcium and serum PTH, and cystic degeneration does not increase the incidence of parathyroid crisis, while size is larger in cystic degeneration group. When cystic degeneration happened, the misdiagnosis increases, it should use both ultrasonography and MIBI scintigraphy for the diagnosis.     

Comparison of ultrasonography and computed tomography in preoperative location of parathyroid adenomas

The value of high-resolution real-time ultrasonography in locating parathyroid adenomas was compared with that of computed tomography (CT). In 21 patients with a single parathyroid adenoma verified at neck exploration, preoperative ultrasonography and CT detected the adenoma in 15 and 11 cases, respectively. Ultrasound gave false-positive results in four patients and false-negative in two, whereas CT was false-positive in four patients and false-negative in six. Most false-positive reports were due to misinterpretation of small thyroid nodules. For acceptable accuracy both methods require an experienced radiologist. Technical and interpretive problems seem to be somewhat less frequent with ultrasonography than with CT. Ultrasonography has therefore become the method of choice for preoperative location of enlarged parathyroid glands at our hospital, and CT is used as a complementary procedure, e.g. when a mediastinal adenoma is suspected.     

Familial hypocalciuric hypercalcaemia as a differential diagnosis of hyperparathyroidism: studies in a large kindred and a review of surgical experience in the condition

We have studied 46 members of a large kindred with familial hypocalciuric hypercalcaemia (FHH) after a neck exploration failed to cure hypercalcaemia in an asymptomatic patient. Serum calcium, serum phosphate, plasma parathormone and vitamin D metabolites do not distinguish affected members from patients with hyperparathyroidism. Because of the continuing debate as to whether or not FHH is a variant of, or distinct from, hyperparathyroidism, we have carried out a review of surgical experience with subtotal parathyroidectomy in hyperparathyroidism secondary to parathyroid hyperplasia and in FHH. Whereas the procedure is successful in 90 per cent of the former cases only one case of FHH has been cured by it. This provides evidence for the two conditions being aetiologically distinct. Before patients with asymptomatic hypercalcaemia are referred for parathyroid surgery the calcium:creatinine clearance ratio should be measured using a 2 h urine sample collected after an overnight fast and a fasting blood sample. If this ratio is less than 0.01 then screening of first degree relations should be undertaken before any parathyroid surgery is performed. Unnecessary surgery can therefore be avoided.     

A new method with high sensitivity and specificity for localization of abnormal parathyroid glands.

A novel method for localization of abnormal parathyroid glands involving color-processing of nuclear scintigrams of the neck after injection of Thallium-201 and Technetium pertechnetate is presented with surgical correlation. Preoperative localization of single parathyroid adenomas was successful in 88% of previously unoperated patients and in 85.7% of those with adenomas not located at previous surgery. Eighty-three per cent of glands with secondary hyperplasia, 66% of glands with primary hyperplasia, and one carcinoma were localized. No abnormal studies were seen in non-hyperparathyroid hypercalcemia, and no false positive studies were seen. Localization appeared related to larger adenomas (300-5000 mg), although one of 60 mg was localized. Color-comparison dual-isotype scintigraphy was useful for localization of parathyroid adenomas and hyperplastic glands and exceeded the reported sensitivity of either ultrasonography or computerized tomography. It deserves wider evaluation in preoperative management of at least hyperparathyroidism of the primary or persistent types.     

Using technetium 99m tetrofosmin parathyroid imaging to detect parathyroid adenoma and its relation to P-glycoprotein expression

BACKGROUND: The purpose of this study was to retrospectively evaluate technetium 99m tetrofosmin (Tc-TF) uptake in parathyroid adenomas and compare the results with their expression of multidrug resistance-mediated 170-kDa P-glycoprotein (Pgp). METHODS: Twenty patients with larger parathyroid adenomas (> 1.5 g) and the other 40 patients with smaller parathyroid adenomas (0.5-1.5 g) underwent early and delayed (10-minute and 2-hour) Tc-TF parathyroid imaging before operation. In this retrospective study, immunohistochemical analyses were performed on multiple nonconsecutive sections of the 40 parathyroid adenomas and 40 normal control specimens (20 normal parathyroid glands and 20 normal thyroid specimens) to detect Pgp expression. RESULTS: The Tc-TF parathyroid image accurately localized 17 larger and 16 smaller parathyroid adenomas, but not the remaining 3 larger and 4 smaller adenomas. The 17 larger and 16 smaller parathyroid adenomas with significant Tc-TF uptake on the delayed 2-hour parathyroid images revealed negative Pgp expression, but the 3 larger and 4 smaller adenomas without significant Tc-TF uptake, as well as 20 normal parathyroid glands and 20 normal thyroid specimens, revealed positive Pgp expression. CONCLUSIONS: Not only the size of parathyroid adenomas, but Pgp expression also limited the sensitivity of Tc-TF parathyroid image to localize parathyroid adenomas before the operation.     

The reasons for persistent hypercalcaemia after cervical exploration for presumed primary hyperparathyroidism

Of 500 consecutive patients who underwent cervical exploration for presumed primary hyperparathyroidism, 461 (92.2 per cent) were cured, as judged by an immediate return of serum calcium levels to normal. Thirty-nine patients (7.8 per cent) had persistent hypercalcaemia after the initial operation. The clinical profiles, operative and pathologic findings, surgical procedures performed and subsequent management of these 39 patients were reviewed. At reevaluation, 4 patients were noted to have been cured of their hyperparathyroidism. Twenty-one patients had persistent hyperparathyroidism: in 6, all 4 parathyroid glands had not been identified at the initial operation and in 15, hypercalcaemia persisted after the identification of 4 glands. One patient had recurrent hyperparathyroidism after the removal of a 720 mg adenoma and the identification of 3 normal parathyroid glands. Nine patients had nonparathyroid causes for the hypercalcaemia: 2 had occult malignant neoplasms, 6 had benign familial hypocalciuric hypercalcaemia and 1 had immobilization hypercalcaemia. In 4 patients the reason for the persistent hypercalcaemia remained unclear. We suggest a schema that may be used as a guideline in the investigation and management of patients with persistent hypercalcaemia after primary neck exploration for presumed hyperparathyroidism.     

Parathyroid Ultrasonography in Renal Secondary Hyperparathyroidism: An Overlooked and Useful Procedure

In secondary hyperparathyroidism (SHPT), ultrasonography (US) can accurately define the size and structure of parathyroid glands as well as differentiate diffuse and nodular hyperplasia. US may be also useful to predict the response of SHPT to vitamin D analogs and cinacalcet and to assess for regression of parathyroid glands hyperplasia by measurement of parathyroid gland volume. There is increasing evidence that US can potentially identify patients who will benefit from prompt surgical intervention. Therefore, US should be part of the diagnostic armamentarium in the treatment of SHPT in the daily clinical practice.     

Parathyroid Adenoma Causing Persistent Hypercalcaemia After Rhabdomyolysis-Induced Acute Renal Failure

Persistent hypercalcaemia developed in a 26-year-old man afterrhabdomyolysis-induced acute renal failure. Although severalserum parathyroid values were normal following recovery of renalfunction, primary hyperparathyroidism was suspected after 9months of prolonged hypercalcaemia. A single parathyroid adenomawas removed and serum calcium as well as serum parathyroid hormonereturned to normal values. The persistence of increased serumcalcium concentrations after rhabdomyolysis-induced acute renalfailure should lead one to consider other causes of hypercalcaemia,and particularly primary hyperparathyroidism.     

Oxyphil parathyroid carcinomas: a clinicopathologic and immunohistochemical study of 10 cases

Oxyphil parathyroid carcinomas are uncommon neoplasms, and the clinicopathologic features of these tumors are largely unknown. We evaluated the clinicopathologic features of oxyphil parathyroid carcinomas and the expression of cytokeratin 14 (CK14), the high-affinity glucose transporter-4 (Glut-4), as well as the cell cycle proteins p27 and Ki67 and compared these with oxyphil parathyroid adenomas and chief cell parathyroid adenomas and carcinomas. Formalin-fixed, paraffin-embedded archival tissues from primary (n = 6) and recurrent (n = 4) oxyphil carcinomas were analyzed and compared with chief cell parathyroid carcinomas (n = 12), oxyphil parathyroid adenomas (n = 38), and chief cell parathyroid adenomas (n = 17) by immunohistochemistry for CK14, Glut-4, p27, and Ki67 using the avidin-biotin peroxidase system. Patients with primary oxyphil and chief cell carcinoma presented with high levels of serum calcium (n = 15.5 and 13.7 mg/dL, respectively). Approximately half the patients in each group died of disease. The Ki67 labeling index was higher (4.9 vs 1.9) and the p27 index lower (23 vs 66) in primary oxyphil carcinoma compared with primary oxyphil adenomas. CK14 was expressed in most oxyphil adenomas (35 of 38 cases) but not in oxyphil carcinomas (0 of 10 cases). Glut-4 was more commonly expressed in both groups of adenomas compared with carcinomas. These results show that oxyphil parathyroid carcinomas are functional malignancies similar to chief cell carcinomas and are associated with hypercalcemia, recurrence, and death. Expression of CK14 is very different in oxyphil adenomas compared with carcinomas. Although distinction between parathyroid adenomas and carcinomas can only be made by histopathologic and clinical findings, these results suggest that immunostaining for CK14, p27, and Ki67 may provide additional information to help distinguish between difficult cases of parathyroid adenomas and carcinomas. These findings also indicate that the same histopathologic features should be used to diagnose oxyphil and chief cell parathyroid carcinomas.     

Technetium 99m-MIBI-SPECT: A highly sensitive diagnostic tool for localization of parathyroid adenomas

BACKGROUND: The aim of this study was to assess the value of technetium 99m-MIBI scintigraphy using the single photon emission computed tomography (SPECT) technique for preoperative localization of smaller (相似文献   

The calcium sensing receptor: from understanding parathyroid calcium homeostasis to bone metastases

The cloning of the calcium sensing receptor (CaR) confirmed that parathyroid cells monitor extracellular calcium concentration ([Ca2+]ext) via a receptor-type mechanism. This lead to the hypothesis that abnormalities in the expression and/or function of the CaR could explain the biochemical abnormalities in primary hyperparathyroidism (PHPT). Cultured cells from parathyroid adenomas of patients operated for PHPT were used to monitor real-time changes in intracellular calcium concentration ([Ca2+]i) as measured by fluorescent microscopy using the Fura-2/AM dye. We found that CaR agonists trigger release of intracellular calcium pools and such responses are amplified by increasing the affinity of IP3 receptors. Using confocal microscopy to monitor membrane trafficking in living parathyroid cells labelled with the fluorescent dye FM1-43, we found that a decrease in [Ca2+]i rather than an absolute change in [Ca2+]ext is the main stimulus for exocytosis from human parathyroid cells. These data suggest that, in PHPT, a defective signalling mechanism from the CaR allows cells from parathyroid adenomas to maintain low [Ca2+]i with uninhibited PTH secretion in the face of hypercalcaemia. Over longer periods of time, CaR controls parathyroid proliferation via changes in tyrosine phosphorylation. We found that multiple proteins of molecular weight 20-65 kDa are phosphorylated within 10-60 min in response to CaR agonists. Further work demonstrated that high [Ca2+]i stimulates the expression of bcl-2 oncoprotein in cultured human parathyroid cells and that, in parathyroid adenomas, predominant expression of bcl-2 rather than bax oncoprotein might prevent apoptosis and explain the slow growth rate of these tumours. More recently, it became apparent that CaR stimulates cell proliferation in several cell types not involved in calcium homeostasis. Using archived histological material from 65 patients who died with metastatic breast cancer, we identified CaR expression predominantly in tumours from patients who developed bone rather than visceral metastases (35 of 49 versus 7 of 16; P < 0.01, chi-squared test). These data suggest that CaR expression has the potential to become a new biological marker predicting the risk of bone metastases in patients with breast cancer. A prospective study should investigate if patients with CaR-positive tumours are more likely to develop bone metastases and whether they could benefit more from prophylactic treatment with bisphosphonates or the newly developed CaR antagonists.     

Large retrosternal parathyroid carcinoma with primary hyperparathyroidism

Parathyroid carcinoma is an uncommon cause of parathyroid hormone (PTH)-dependent hypercalcaemia, accounting for less than 1% of all cases of hyperparathyroidism. Parathyroid carcinoma is an indolent tumour with rather low malignant potential. Consideration of parathyroid carcinoma in the differential diagnosis of hypercalcaemic disorders is important because the morbidity and mortality are substantial and the best prognosis is associated with early recognition and surgical resection. Clinical indicators favouring parathyroid carcinoma over benign disease include markedly raised serum calcium levels, PTH and alkaline phosphatase. A palpable neck mass with both kidney and skeletal manifestations also give a high index of suspicion of parathyroid carcinoma. Histopathology alone is not sufficient to diagnose parathyroid cancer; it has to be correlated with the clinical findings. The initial and most effective treatment for parathyroid carcinoma is complete resection of the primary lesion, and repeated operations for recurrence are useful. The prognosis of parathyroid carcinomas is quite variable; 5-year survival rates vary from 40% to 86%, while the 10-year survival rate is approximately 49%. We report a case of parathyroid carcinoma occurring in a 55-year-old woman who presented with bone pain and hypercalcaemia.     

Hypercalcaemia due to parathyroid adenoma and hypertrophic cardiomyopathy. A case report

A patient with hypercalcaemia due to a parathyroid adenoma, and hypertrophic cardiomyopathy (HCM) is described. Although both conditions are common, it is suggested that the association between HCM and parathyroid hypercalcaemia may be more frequent than is accounted for by coincidence.     

Tuberculosis complicating tertiary hyperparathyroidism in a patient with end-stage renal disease: a case report

A 36-year-old Nigerian woman on thrice-weekly dialysis presented with symptoms and signs of hypercalcaemia. Laboratory findings were consistent with tertiary hyperparathyroidism. Parathyroid hormone levels remained elevated and she underwent elective parathyroidectomy. Intra-operatively all 4 parathyroid glands and local lymph nodes showed necrotising granulomas with occasional acid-fast bacilli, pathognomonic of tuberculosis (TB). Post-operatively she completed a full course of anti-TB therapy and at 9 months she experienced complete resolution in her plasma biochemistry and was essentially symptom-free. This is a rare yet fascinating cause of hypercalcaemia in a dialysis patient and is the first recorded case of tubercular involvement of parathyroid tissue in a case of tertiary hyperparathyroidism. This report demonstrates the coexistence of 2 diseases that simultaneously worsened hypercalcaemia and thus emphasises the importance of the differential diagnosis and of careful histological examination post-operation.     

The tiny parathyroid adenoma

In the past 11 years we have operated on three patients with "tiny" parathyroid adenomas (less than 60 mg). Two of these adenomas were virtually indistinguishable visually from the normal glands. (The third adenoma was found only after fixation and permanent sections.) Despite frozen-section diagnoses of "probable hyperplastic tissue" in two cases, these small hyperplastic glands proved confusing at operation. This was especially true of the hyperactive gland embedded within mediastinal tissue that, on initial examination of gross material, had been missed by surgeons and pathologists alike and was discovered only on permanent serial sections. The preoperative laboratory data did not vary substantially from that of other hyperparathyroid patients with larger adenomas; in each case two or more endocrinologists had agreed that parathyroidectomy was indicated and had referred these patients for operation. Permanent microscopic sections confirmed the diagnosis of parathyroid adenoma in all three patients. The clinical and laboratory postoperative data strongly indicate that these small adenomas, masquerading as normal-sized glands, were responsible for the hypercalcemia. These tiny adenomas should be added to the other anatomic and pathologic variations of the parathyroid glands that can prove confusing at operation.