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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 826-830
Mediastinal parathyroid adenoma


1 Department of Surgery, College of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
2 Department of Nephrology, King Abdulaziz Hospital and Oncology Centre, Jeddah, Saudi Arabia

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Date of Web Publication2-Sep-2009
 

   Abstract 

We present two cases that developed clinical, biochemical and radiological evidences of primary and secondary hyperparathyroidism. In the first case the adenoma was removed through a transcervical incision and in the second case the supernumerary adenoma was removed through sternotomy. Post operatively, patients had normal serum calcium and iPTH with complete disappearance of symptoms.

How to cite this article:
Al-Mashat F, Sibiany A, Faleh D, Kary K, Alfi AY, El-Lakany MM. Mediastinal parathyroid adenoma. Saudi J Kidney Dis Transpl 2009;20:826-30

How to cite this URL:
Al-Mashat F, Sibiany A, Faleh D, Kary K, Alfi AY, El-Lakany MM. Mediastinal parathyroid adenoma. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2019 Nov 22];20:826-30. Available from: http://www.sjkdt.org/text.asp?2009/20/5/826/55370

   Introduction Top


Primary hyperparathyroidism is most commonly due to an adenoma, while hyperplasia is the un­derlying etiology in secondary hyperparathy­roidism. Most adenomas are located in the neck, while a small proportion descend and re­main in the mediastinum. Majorities of adeno­mas can be removed through the cervical inci­sion. But in a small number of patients, me­diastinal exploration is needed.

We present two cases in which a deeply lo­cated mediastinal adenoma was resected transcervically, while a supernumerary mediastinal adenoma required sternotomy.


   Case 1 Top


A 60 year old female with Sheehan's syndrome on replacement therapy presented with gene­ralized bone pain for few months. Systemic re­view was unremarkable. Basic blood investiga­tions and chemistry were within norml limits. Both serum calcium and iPTH were elevated, 3.0 mmol/L (2.0-2.6) and 1248 pg/mL (15-65), respectively. Neck ultrasound showed a 1 cm nodule in the right thyroid lobe together with a mass at the lower pole of the right thyroid lobe. Technetium Thallium (99m Tc-201 Th) sub­traction scintigraphy demonstrated a parathy­roid adenoma at the lower pole of right thyroid lobe with suspicion of another one at the upper pole. Neck exploration through a cervical inci­sion revealed a nodule in the right thyroid lobe with normal looking upper parathyroid gland. Additionally a mediastinal adenoma on the right side of anterior mediastinum was deeply located, below the division of innominate artery into common carotid and subclavian arteries, [Figure 1]. The mass was dissected sharply and deli­vered intact, together with right lobectomy and isthmectomy. Post-operatively patient developed transient hypocalcemia which was treated with calcium. Histopathology confirmed a parathyroid adenoma and multi nodular goiter.


   Case 2 Top


A 29 year old female patient suffering from end stage renal disease (ESRD) secondary to essen­tial hypertension had living unrelated renal trans­plant. Three months following renal transplant, she had generalized bone pain and soft tissue calcification. Her complete blood count (CBC), renal (graft) function tests, clotting profile and liver function tests were within normal limits. Biochemical tests revealed high serum calcium 3.1 mmol/L (2.0-2.6); low serum phosphorous 0.6 mmo1/L (0.9-1.5); low serum magnesium 0.5 mmo1/L (0.7-1.1); high serum alkaline phos­phatase 1264 u/L (64-306) and elevated iPTH 1493 pg/mL (15-65). Neck ultrasound failed to show enlarged parathyroids. Technetium thallium (99mTc-201Th) subtraction scintigraphy demon­strated a large parathyroid ademona at the lower pole of the right lobe of thyroid gland. She was managed with subcutaneous injections of calci­tonin 100 units daily resulting in partial lowering of serum calcium. Bilateral neck exploration revealed four normal looking parathyroids. Three and a half parathyroidectomy was performed. We were not convinced that the adenoma was removed. A thorough exploration of the superior mediastinum, carotid sheath, para-oesophageal and retro-oesophageal regions failed to show the adenoma. Frozen sections showed normal para­thyroid tissues. Post-operative serum calcium and iPTH were still high. The patient was started on one alpha 4 mcg three times weekly but without benefit since the patient refused any further sur­gical exploration. Eight months later, she pre­sented with severe generalized aches, big brown tumour of the right mandible and broken left tibia [Figure 2]. Re-evaluation showed high se­rum calcium, alkaline phosphatase and i-PTH. Sestaemibi parathyroid scan demonstrated the same previous adenoma at the same location [Figure 3]. Magnetic Resonance Imaging (MRI) revealed a 3 cm mass located between innomi­nate bifurcation and apex of right lung, behind right subclavian artery [Figure 4], extending from just behind the right sternoclavicular joint to the thoracic spine. The mass was completely excised through sternotomy with preservation of the right vagus, recurrent laryngeal and phrenic nerves [Figure 5]. [Figure 6] shows the resected ade­noma with intact capsule (a) and a yellow cut surface (b).

Post-operatively patient developed right basal atelectasis which resolved with chest physiothe­rapy and antibiotics. She also developed hungry bone syndrome which was corrected by intrave­nous calcium infusion. Her serum iPTH returned to normal on 3 rd post operative day. Histopatho­logy confirmed a parathyroid adenoma [Figure 7]. Two months after surgery, her brown tumor of the jaw showed marked spontaneous regre­ssion with progressive healing of the tibial frac­ture.


   Discussion Top


Autonomous hyperpathyroidism is common in patients with ESRD. The treatment of choice is either subtotal parathyoidectomy or total para­thyroidectomy with autologus autotransplanta­tion. [1] Surgical resection is the treatment of choice for mediastinal parathyroid adenoma. In the majority of patients, this can be achieved through a transcervical incision. In up to 30% of cases, supernumerary parathyroid glands are present. [2],[3],[4] Most of them are adjacent to the Thymus and are resected through transcervical incision. However, for deeply located adenomas surgical excision with sternotomy, thoracotomy or via video-assisted thoracic surgery (VATS) is required. The advent of accurate pre-operative localization with ultrasound, computed tomo­graphy (CT) and Sestamibi scan and the rapid intraoperative PTH assay have changed the tra­ditional four gland exploration to less invasive approaches directed at removal of the abnormal gland. The lower parathyroids with the thymus may be found commonly within the antero su­perior mediastinum. On the other hand, the su­perior parathyroids may be located in the poste­rior mediastinum. [3],[5] Para-oesophageal or retro­oesophageal parathyroid tumours arise from su­perior parathyroid glands, have normal blood supply from the inferior thyroid artery and are not embryologically considered ectopic. [3],[5]

Two percent of mediastinal parathyroid ade­nomas are situated below the thoracic inlet re­quiring mediastinal exploration. [6],[7] This explora­tion can be achieved through sternotomy or tho­racotomy with their associated morbidity of up to 21%. [8],[9] These complications include respira­tory failure, pneumonia, atrial fibrillation, blee­ding, infection and phrenic nerve injury. [10] Pre­operative localization is the key to successful parathyroid resection. [11] The sensitivity of US in detecting an adenoma is 60-90%, while Sesta­mibi scan has a sensitivity of 70-80%. [12] Anato­mic localization by CT scan and confirmation of its physiological function as being parathyroid with Sestamibi scanning is ideal. [13] CT/Sesta­mibi fusion scans (Sestamibi single photon emi­ssion computed tomography, Sestamibi SPECT) are now available to facilitate this and allow directed approach with a sensitivity approaching 87%. [12] In the first case, the adenoma was suc­cessfully removed through the traditional cer­vical incision, which is the incision of choice for resecting majority of adenomas located in the mediastinum. In the second case MRI and Sestamibi scan showed the adenoma clearly lying low in the mediastinum which cannot be approached transcervically. Therefore, a sternotomy was done and the adenoma was com­pletely resected with preservation of the sur­rounding blood vessels and nerves. Post opera­tively, patient developed chest infection which was treated with antibiotics and chest physio­therapy. VATS is therefore the ideal procedure of choice because of excellent visualization and lower morbidity.

Minimal invasive radio-guided parathyroidec­tomy (MIRP) with gamma probe is very suc­cessful alternative to transcervical parathyroi­dectomy. [13]

In conclusion, missed or supernumerary me­diastinal parathyroid adenomas requires accu­ rate preoperative localization. Minimal invasive procedures should be offered to patients to avoid the complications of sternotomy and thoracotomy.


   Acknowledgment Top


We would like to thank department of histo­pathology at King Abdulaziz Hospital and Oncology Center and Mrs. Joy Dislva for her secretarial help.

 
   References Top

1.T Tominaga Y. Surgical management of secon­dary hyperparathyroidism in uremia. Am J Med Sci 1999;317:390-7.  Back to cited text no. 1    
2.Pattou FN, Pellissier LC, Noel C, Wambergue F, Huglo DG, Proye CA. Supernumerary para­thyroid glands: Frequency and surgical signi­ficance in treatment of renal hyperparathy­roidism. World J Surg 2000;24:1330-4.  Back to cited text no. 2    
3.Ewing P, Hardy JD. The mediastinum. In Glenn's Thoracic and Cardiovascular Surgery, Volume 1. 5 th edn, In Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS. (eds). Connecticut: Appleton & Lange; 1991:569-594.  Back to cited text no. 3    
4.Richards ML, Bondeson AG, Thompson NW. Mediastinal parathyroid adenomas and carci­nomas. I general thoracic surgery, Volume 2, 5th edn, In Shields TW, Locicero III J, Ponn RB. (Eds). Philadelphia: Lippincot Williams & Wilkins; 2000:2383-90.  Back to cited text no. 4    
5.Nguyen BD: Parathyroid imaging with Tc-99m Sestamibi Planar & SPECT scintigraphy. Radiographics 1999;19:601-614.  Back to cited text no. 5    
6.Ipponsugi S, Takamori S, Suga K, et al. Medias­tinal parathyroid adenoma detected by 99mTc­methoxyisobutylisonitrile: report of a case. Surg Today 1997;27:80-3.  Back to cited text no. 6    
7.Prinz RA, Lonchyna V, Carnaille B, Wurtz A, Proye C. Thoracoscopic excision of enlarged me­diastinal parathyroid glands. Surgery 1994;116: 999-1004;discussion 1004-5.  Back to cited text no. 7    
8.Conn JM, Goncalves MA, Mansour KA, McGarity WC. The mediastinal parathyroid. Am Surg 1991;57:62-6.  Back to cited text no. 8    
9.Russell CF, Edis AJ, Schalz DA, Sheedy PF, van Heerden JA. Mediastinal parathyroid tumours: experience with 38 tumours requiring medias­tinotomy for removal. Ann Surg 1981;193:805-9.  Back to cited text no. 9    
10.Pearson FG, Deslauriers J, Ginsberg RJ, et al. Thoracic surgery. New York, NY: Churchill Livingstone 1995.  Back to cited text no. 10    
11.Medrano C, Hazelrigg SR, Landreneau RJ, Boley TM, Shawgo T, Grasch A. Thoracoscopic resec­tion of ectopic parathyroid glands. Ann Thorac Surg 2000;69:221-3.  Back to cited text no. 11    
12.Lalwani AK. In current diagnosis and treatment in otolaryngology head and neck surgery 2004; 605-609. Lange medical books / McGraw-Hill.  Back to cited text no. 12    
13.Sukumar MS, Komanapalli CB, Cohen JI. Mini­mally invasive management of the mediastinal parathyroid adenoma. Laryngoscope 2006;116: 482-8.  Back to cited text no. 13    

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Correspondence Address:
Faisal Al-Mashat
Department of Surgery, King Abdulaziz University Hospital College of Medicine, King Abdulaziz University, P.O. Box 143, Jeddah 21411
Saudi Arabia
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PMID: 19736482

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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    Abstract
    Introduction
    Case 1
    Case 2
    Discussion
    Acknowledgment
    References
    Article Figures
 

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