Cases reported "Parathyroid Neoplasms"

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1/229. Median sternotomy for parathyroid adenoma.

    Most mediastinal parathyroid tumours lie within the thymus gland and may be retrieved when cervical thymectomy is carried out in the course of neck exploration for primary hyperparathyroidism (HPT). We report 4 patients, each of whom required sternotomy for removal of a true mediastinal parathyroid adenoma. Subtraction isotope scintigraphy suggested the presence of a mediastinal tumour prior to cervical exploration in 2 individuals and prior to re-exploration in a third. When localisation before initial exploration for HPT suggests a parathyroid tumour within the chest, consideration should be given to proceeding to sternotomy, at first operation if a comprehensive neck exploration, including cervical thymectomy, fails to uncover the adenoma. Uniquely, one of our patients underwent sternotomy for HPT when 23 weeks pregnant.
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2/229. Nonrecurrent laryngeal nerves: anatomic considerations during thyroid and parathyroid surgery.

    PURPOSE: In head and neck surgery, damage to the recurrent laryngeal nerve (RLN) during thyroid surgery is the most common iatrogenic cause of vocal cord paralysis. Identification of the RLNs and meticulous surgical technique can significantly decrease the incidence of this complication. Nonrecurrent RLNs (NRRLNs) are exceedingly rare. Surgeons need to be aware of their position to avoid damage to them. MATERIALS AND methods: A retrospective review of 513 RLN exposures over a 7-year period was performed. RESULTS: Two NRRLNs were encountered, for an incidence of 0.39%. CONCLUSION: NRRLNs are rare. awareness of their existence will prevent the surgeon from accidentally severing one if it is encountered during routine thyroid or parathyroid surgery.
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3/229. color-Doppler in the imaging work-up of primary hyperparathyroidism.

    Primary hyperparathyroidism (PHP) is a rare disease that must be suspected in all the cases of recurrent calcium nephrolithiasis, and that may be totally corrected by surgery. The imaging techniques permit to locate the hyperplastic gland or adenoma before intervention, but their usefulness in patients without a history of previous neck surgery is still debated. Several imaging techniques have been proposed with the aim of locating parathyroid hyperfunctioning glands, including high resolution sonography (US) with color-Doppler (CD), scintigraphy, computed tomography (CT) and magnetic resonance imaging (MRI). We report here a case of recurrent calcium oxalate nephrolithiasis sustained by PHP, which demonstrates how US coupled with CD and echocontrast enhancement is useful in the preoperative location of parathyroid glands. US is the first choice technique in the evaluation of PHP because it is less expensive and useful in detailing lesions of the neck when carried out by a skilled operator. CD should be regarded as a useful complement of US enhancing its sensitivity (80 vs 90%) especially in the cases of associated thyroid gland diseases. Tc-99m SESTAMIBI scintigraphy coupled with MRI is mandatory in high risk surgical patients, namely in those undergoing repeated neck surgery. In conclusion, considering that surgeon must explore all the four parathyroid glands (because of the possibility of multiple adenomas or hyperplasia) a well definite location of the adenomatous lesion may reduce the risks and the time of intervention, and allow the use of alternative procedures, such as videoscopic surgery. On this view and in terms of economy, only US and CD coupled with Tc-99 SESTAMIBI scintigraphy should be considered before surgery.
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4/229. Parathyroid incidentaloma discovered during thyroid ultrasound imaging.

    We report two patients with incidentally discovered enlarged parathyroid glands while performing neck ultrasonography (US) for thyroid nodules. The parathyroid masses were seen as hypoechoic, homogeneous, oval nodules, separated from the thyroid gland. Both patients were completely asymptomatic, although subclinical evidence of hyperparathyroidism (serum PTH and calcium levels in the upper limit of the normal range, increased ionized serum calcium, osteocalcin, urinary calcium and hydroxyproline) was subsequently found in one patient. An enhanced uptake on sesta-MIBI scinti scan was concordant with the US finding in the two cases. PTH levels in the wash-out from the US-guided fine needle aspiration biopsy, confirmed the parathyroid origin of the lesions. Cytology and immunocytochemistry were, in our cases, unreliable diagnostic procedures. The extensive use of US imaging in thyroid pathology may increase the finding of US incidentally discovered parathyroid adenomas. The early detection of silent parathyroid pathologic findings may extend the natural history of these masses to a preclinical stage. Further investigations are necessary to evaluate the evolution of parathyroid incidentalomas and therefore their clinical significance.
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5/229. Complementary nature of radiotracer parathyroid imaging and intraoperative parathyroid hormone assays in the surgical management of primary hyperparathyroid disease: case report and review.

    PURPOSE: This article illustrates the complementary nature of preoperative radionuclide parathyroid imaging and intraoperative rapid parathyroid hormone (PTH) assays in primary hyperparathyroid disease. The authors review the literature on these procedures and compare this protocol and its cost-effectiveness with those of the classic four-gland exploration. MATERIALS AND methods: Preoperative parathyroid imaging with Tc-99m MIBI and intraoperative rapid PTH assays were performed at the time of neck exploration. RESULTS: One of two parathyroid adenomas seen on radionuclide images would have been missed if the authors had relied solely on the initial decrease in PTH assay value to a normal level. CONCLUSIONS: Tc-99m MIBI imaging and intraoperative rapid PTH assays are complementary; when used together, they lessen the likelihood that abnormal parathyroid glands will be overlooked. This experience and that of others suggest these combined procedures are cost-effective.
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6/229. Hyperfunctioning parathyroid carcinoma.

    Primary hyperparathyroidism is rarely caused by carcinoma. We report a patient who manifested many of the clinical and radiographic features of the disease. When encountering symptomatic hypercalcemia with or without a palpable neck mass, carcinoma should be considered in the differential diagnosis. Patient survival depends on an aggressive surgical approach to the primary lesion and recurrent disease.
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7/229. Cutaneous spreading of parathyroid carcinoma after fine needle aspiration cytology.

    BACKGROUND: Ultrasound-guided fine needle aspiration cytology (FNAC) of suspect parathyroid adenomas is sometimes used for the diagnosis of primary hyperparathyroidism (PHPT). FNAC complications are rare or mild. We describe the first case in literature of cutaneous spread of parathyroid carcinoma after FNAC. CASE: A woman underwent a neck ultrasound which revealed a solid hypoechogenic nodule of 1.5 cm at the level of the inferior pole of the right thyroid. In the same time a FNAC of the nodule was performed. Cytology showed no atypical cells. Successively PHPT was diagnosed and a few weeks later the patient had a subcutaneous lump in the same area of FNAC. The patient underwent surgery and histology of the specimen showed a differentiated parathyroid carcinoma. The postoperative course was regular and calcium and parathormone resulted normal. CONCLUSION: The use of FNAC should be carefully assessed in the presence of suspect parathyroid carcinoma, because this could cause a possible diffusion of a parathyroid carcinoma along the needle tract.
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8/229. Parathyroid carcinoma in a dialysis patient.

    A 75-year-old woman who had been receiving dialysis for 3 years and had a long history of chronic renal failure attributable to reflux nephropathy was investigated for progressive hypercalcemia in the context of very high intact parathormone (iPTH) levels. Imaging showed two functional parathyroid glands in the neck. At parathyroidectomy, four variously enlarged parathyroid glands were found and completely resected, without autotransplantation. The histology of one of the glands showed invasive parathyroid carcinoma. Parathyroid carcinoma is a very rare condition, with only 16 previous cases involving dialysis patients described in the literature. We review the literature to draw together presentational and therapeutic information on the management of this problem in the setting of renal replacement therapy.
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9/229. Endoscopic surgery for a parathyroid functioning adenoma resection with the neck region-lifting method.

    Recently, endoscopic surgery has been applied to cervical exploration. We have developed new techniques for endoscopic neck surgery. We reported on a 53-year-old Japanese man with functioning parathyroid adenoma resected by endoscopic surgery with a neck region-lifting method. A 10-mm midline trocar for the endoscope and two 5-mm lateral trocars were inserted from the anterior chest wall to avoid neck scars. There were no intraoperative complications. The incisions were completely covered by the patient's undergarments.
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10/229. Papillary thyroid carcinoma associated with parathyroid adenoma detected by pertechnetate-MIBI subtraction scintigraphy.

    Two cases of papillary thyroid carcinoma coexisting with a parathyroid adenoma are reported. A double-tracer pertechnetate-MIBI subtraction scan combined with neck ultrasound correctly visualized the site of the parathyroid adenoma despite the presence of thyroid nodule(s) located in the opposite thyroid lobe in one case and in both thyroid lobes in the other case. In both patients, the papillary thyroid carcinoma was cold with Tc-99m pertechnetate and hot with MIBI. Total thyroidectomy and parathyroidectomy of a solitary parathyroid adenoma were performed in both patients. Pertechnetate-MIBI subtraction scanning associated with neck ultrasound appears to be a useful imaging technique to detect parathyroid adenoma before operation in patients with concomitant thyroid nodular disease. A MIBI-hot and Tc-99m pertechnetate-cold thyroid nodule can indicate the possible presence of a malignant lesion.
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