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Ann Thorac Surg 1995;59:236-238
© 1995 The Society of Thoracic Surgeons

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Case Report

Thoracoscopic Removal of Mediastinal Parathyroid Adenoma

Section of General Thoracic Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania

Accepted for publication May 17, 1994.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
Mediastinal parathyroid tissue hyperfunctions in as much as 25% of the patients with primary hyperparathyroidism, and this may be responsible for causing conventional operative procedures to fail in as much as one-third of the cases. When lesions prove to not be accessible through a cervical incision, or when a mediastinal adenoma is diagnosed before cervical procedures, median sternotomy and angiographic ablation have been considered the only options for removal. However, thoracoscopy has theoretic advantages over both. Two patients underwent successful thoracoscopic removal of a hyperfunctioning ectopic mediastinal parathyroid adenoma and their cases are presented here.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
In up to a third of the cases, cervical exploration for primary hyperparathyroidism fails because of the presence of ectopic hyperfunctioning mediastinal parathyroid tissue [1]. Although removal of an ectopic parathyroid gland through a cervical incision may be successful in many patients, a median sternotomy is often required, a procedure with the potential for causing more morbidity and associated with an up to 12% incidence of complications in such patients [2].

Thoracoscopic surgical removal of these lesions offers many of the same advantages of median sternotomy, namely the potential for directly visualizing the gland, gaining access to the entire mediastinum, and preserving parathyroid tissue for autotransplantation if needed. In addition, it offers the potential benefits of lower morbidity and a shorter hospital stay, points that have argued in favor of angiographic ablation rather than conventional surgical ablation procedures [3].

We report here 2 cases in which hyperfunctioning mediastinal parathyroid tissue was successfully removed using a thoracoscopic approach.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
Patient 1
Patient 1 was a 55-year-old woman with a medical history significant for rheumatic heart disease. During a routine visit to her primary care physician, a mild convexity of the right superior mediastinal paratracheal contour and a retrotracheal soft-tissue density were noted on a plain chest roentgenogram. Computed tomography showed a smooth-surfaced, heterogeneous, low-density mass posterior to the superior vena cava and phrenic nerve and lateral to the trachea in the right mediastinum without evidence of other parenchymal, pleural, or nodal disease. Noteworthy laboratory values included an elevated serum calcium level of 11.4 mg/dL, a parathormone level of 15.8 pmol/L (high normal, 6.8 pmol/L), and a phosphorus content of 2.6 mg/dL.

After intraoperative bronchoscopy that revealed normal findings, the patient underwent a right-sided thoracoscopic procedure. After positioning and placement of a double-lumen endotracheal tube, incisions were made in the fourth intercostal space of the right midaxillary line for the insertion of dissecting instruments and a fiberoptic camera. A mass was immediately noted caudal and posterior to the confluence of the superior vena cava and the right innominate vein (Fig 1). The mediastinal pleura was incised, and the mass was easily dissected free from the trachea and the phrenic and vagus nerves, and then removed from the thoracic cavity through the original posterior incision. A neuroendocrine neoplasm was diagnosed on the basis of frozen section findings. Before extubation, a 28F thoracostomy tube was inserted through the inferior incision.

View larger version (2K): [in this window] [in a new window]   Fig 1. . Mediastinal parathyroid adenoma viewed through a fiberoptic camera during thoracoscopic removal. (large arrow = adenoma; triple dots = superior vena cava; small arrows = phrenic nerve.)

Patient 2
Patient 2 was a 57-year-old man with Buerger's disease and end-stage renal disease secondary to Henoch-Schönlein purpura for which he was on continuous ambulatory peritoneal dialysis. In 1991, the patient was noted to have a mildly elevated serum calcium level of 10.6 mg/dL and an elevated serum parathormone level of 332 mEq/L (high normal, 132 mEq/L). During the next year, severe bone pain developed and the serum calcium and parathormone levels increased to 11.4 mg/dL and 589 mEq/L, respectively. A presumptive diagnosis of secondary hyperparathyroidism was made, and, on September 21, 1992, the patient underwent a total cervical parathyroidectomy which involved use of a left forearm autograft. Mild focal hypercellularity and nodularity were noted in all four resected glands.

Postoperatively, the patient's serum calcium level remained elevated at 10.8 to 12.4 mg/dL, and thallium pertechnate-enhanced scanning performed on September 29, 1992, revealed a region of abnormal thallium uptake in the left brachiocephalic region. A magnetic resonance imaging scan of the chest showed a 1.5-cm to 2.0-cm mass in the anterior mediastinum immediately anterior to the left brachiocephalic vein. No other parenchymal, pleural, or mediastinal lesions were noted.

The patient underwent a left-sided thoracoscopic procedure on October 5, 1992. After the induction of anesthesia and placement of a double-lumen endotracheal tube, incisions were made in the fourth intercostal space of the left anterior and posterior axillary lines and in the seventh intercostal space of the left midaxillary line for the insertion of dissecting instruments and a fiberoptic camera. The thymus was removed from the surrounding mediastinal structures using small surgical clips for hemostasis. The lesion was removed from the thoracic cavity through the original anterior incision. Before extubation, a 28F thoracostomy tube was placed through the inferior incision. On frozen section analysis, hypercellular parathyroid tissue was identified.

The thoracostomy tube was removed on the first postoperative day and the patient was discharged home on the third postoperative day, at which time his chest roentgenogram was normal. The final pathologic diagnosis was parathyroid adenoma. A follow-up serum calcium level measured approximately 5 weeks after discharge was 8.6 mg/dL, and normal serum values have persisted since that time.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
Ectopic hyperfunctioning mediastinal parathyroid tissue is found in 11% to 25% of all those patients with primary hyperparathyroidism [4], and many of these patients may require a median sternotomy for removal of the hyperfunctioning gland. Because of concerns about the increased morbidity associated with this approach, a multidisciplinary study was recently conducted, and the findings suggested that angiographic ablation should be attempted in these patients, with surgical treatment reserved for those in whom this intervention fails [3]. Based on the foregoing case reports, we suggest that thoracoscopic removal should be considered as another viable alternative.

Mediastinal thoracoscopy is not a new procedure [5], and, in recent reports, its efficacy for procedures such as thymectomy has been suggested [6, 7]. Percutaneous diagnostic procedures for evaluating the mediastinum have historically proved unsatisfactory, and this has prompted the performance of open procedures such as mediastinoscopy and sternotomy [8]. In a recent case series reported on by Kern and associates [9], a diagnosis was successfully reached in 86% of 22 patients with mediastinal masses who underwent thoracoscopic procedures. The patients in this series required chest tube drainage for an average of 2 days and the average hospital stay was only 6 days.

If thoracoscopic removal of ectopic hyperfunctioning parathyroid tissue is to be considered a superior alternative to either median sternotomy or angiographic ablation, it must offer theoretic advantages. In comparison to median sternotomy, thoracoscopy offers all the same benefits of surgical resection and the added potential of a marked decrease in the general morbidity and hospital stay. In both patients described here, the hospital stays were only 3 days; this compares with a median of 9 days cited for sternotomy in the report published by Doherty and colleagues [3]. In addition, thoracoscopy offers a superior cosmetic result. Even though angiographic ablation may obviate the need for surgical resection, in a study comparing this intervention with sternotomy, 40% of the attempts were found to be unsuccessful [3], and this technique does not provide tissue for autotransplantation, if it is needed. There is also an admittedly rare chance of angiographic ablation being attempted in the treatment of a mediastinal malignancy that mimics a parathyroid adenoma by secreting a parathormone or parathormone-like substance, with no tissue then available for pathologic study.

There has been one report in which removal of ``select'' mediastinal parathyroid adenomas through an anterior mediastinotomy was described [10]. Like thoracoscopy, this procedure may represent a less morbid method of removal, thus shortening the hospital stay and allowing for the surgical removal of these lesions in patients deemed inappropriate candidates for sternotomy. However, the authors admitted that tumors deeper in the mediastinum should be approached through a sternotomy, and these areas are easily accessible using thoracoscopic techniques.

In conclusion, we present 2 cases of successful thoracoscopic removal of ectopic hyperfunctioning parathyroid adenoma, and suggest that this approach is a viable alternative in those patients considered for either median sternotomy or angiographic ablation.

	Addendum

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
Subsequent to the submission of this report, a third patient has undergone a successful right-sided thoracoscopic resection of a mediastinal parathyroid adenoma at our institution.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 
Address reprint requests to Dr Kaiser, Section of General Thoracic Surgery, Department of Surgery, Hospital of the University of Pennsylvania, 4 Silverstein, 3400 Spruce, Philadelphia, PA 19104.

	References

Top Footnotes Abstract Introduction Case Reports Comment Addendum References

 

1. Levin KE, Clark OH. The reasons for failure in parathyroid operations. Arch Surg 1989;124:911–5.[Abstract/Free Full Text]
2. Norton JA, Schneider PD, Brennan MF. Median sternotomy in reoperation for primary hyperparathyroidism. World J Surg 1985;9:807–10.[Medline]
3. Doherty GM, Doppman JL, Miller DL, et al. Results of a multidisciplinary strategy for management of mediastinal parathyroid adenoma as a cause of persistent primary hyperthyroidism. Ann Surg 1992;215:101–6.[Medline]
4. Nudelman IL, Deutsch AA, Reiss R. Primary hyperparathyroidism due to mediastinal parathyroid adenoma. Int Surg 1987;72:104–8.[Medline]
5. Smythe WR, Kaiser LR. History of thoracoscopy. In: Kaiser LR, Daniel TM, eds. Thoracoscopic surgery. Boston: Little, Brown, 1993:1–16.
6. Landreneau RJ, Dowling RD, Castillo WM, Ferson PF. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 1992;54:142–4.[Abstract]
7. Kaiser LR, Bavaria JE. Complications of thoracoscopy. Ann Thorac Surg 1993;56:796–8.[Abstract]
8. Yu CJ, Yang PC, Chang DB, et al. Evaluation of ultrasonically guided biopsies of mediastinal masses. Chest 1991;100: 399–405.[Abstract/Free Full Text]
9. Kern JA, Daniel TM, Tribble CG, et al. Thoracoscopic diagnosis and treatment of mediastinal masses. Ann Thorac Surg 1993;56:92–6.[Abstract]
10. Schlinkert RT, Whitaker MD, Argueta R. Resection of select mediastinal parathyroid adenomas through an anterior mediastinotomy. Mayo Clin Proc 1991;66:1110–3.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): W. Roy Smythe Joseph E. Bavaria R. Alan Hall Gary M. Kline Larry R. Kaiser Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Smythe, W. R. Articles by Kaiser, L. R. Search for Related Content PubMed PubMed Citation Articles by Smythe, W. R. Articles by Kaiser, L. R.