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Mediastinal parathyroid exploration: A clinical and pathologic study of 47 cases

  • International Association of Endocrine Surgeons—Manuscripts Presented at the 31st Congress of the International Society of Surgery
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Abstract

Of the 1,200 patients with hyperparathyroidism surgically treated at the Massachusetts General Hospital (MGH) from 1926 to 1984, there were 47 who underwent mediastinal exploration. Of these, 30 patients (64%) had hyperfunctioning parathyroid glands successfully excised by median sternotomy. Twelve of these underwent their initial neck operation at the MGH, and 18 were referred to us having undergone 1 or more previous unsuccessful neck explorations. There were 17 females and 13 males. The ages of these patients ranged from 17 to 75 years. Twenty-four patients had nephrolithiasis or nephrocalcinosis; 15, osteitis fibrosa cystica; 14, renal and bone disease; 6, peptic ulcer disease; 2, hypertension; and 1, gouty arthritis. Two patients were asymptomatic with hypercalcemia detected by routine simultaneous multichannel analyzer. The serum calcium level ranged from 11.4 to 18.4 mg/100 ml with a mean of 13.8 mg/100 ml, and phosphorus from 1.4 to 3.3 mg/100 ml with a mean of 2.0 mg/100 ml. Of the 11 patients who had plasma parathyroid hormone determinations, the values ranged from 1 to 11 times normal. In 24 patients, the mediastinal tumor was intrathymic in location and the remaining 6 were parathymic, either adjacent to the great vessels or the pleura. The tumors varied greatly in size, ranging from 0.7 to 5.0 cm in greatest dimension, weighing 0.3 to 18.0 g. Five of these patients had hyperfunctioning supernumerary glands. Pathologic evaluation revealed 26 parathyroid adenomas and 4 primary hyperplastic glands. In 17 patients (36%) mediastinal exploration was unsuccessful. Four of the patients successfully explored developed permanent hypocalcemia. The complications included 1 recurrent laryngeal nerve injury, 1 phrenic nerve injury, 1 pneumothorax, and 1 spontaneously resolving postoperative pleural effusion. There were no deaths or other significant complications. We believe hyperfunctioning mediastinal tumors are rare and mediastinal exploration should be undertaken only when careful selective criteria are met.

Résumé

De 1926 à 1984, 1200 malades avec hyperparathyroïdisme ont été traités au Massachusetts General Hospital (MGH); 47 de ces cas ont nécessité une exploration médiastinale et 30 (64%) d'entre eux présentaient des parathyroïdes hyperfonctionnelles qui ont été extirpées avec succès par sternotomie médiane. Douze des malades avaient été opérés au Massachusetts et 18 avaient subi ailleurs sans succès une ou plusieurs réinterventions cervicales. Le groupe de ces patients comprenait 17 femmes et 13 hommes âgés de 17 à 75 ans. Vingt-quatre d'entre eux présentaient une lithiase rénale ou une néphrocalcinose; 15, ostéites fibreuses cystiques; 14 maladies rénales ou osseuses; 6 maladies ulcéreuses; 2, hypertensions; et 1 cas de goutte articulaire. Deux malades ne présentaient pas de troubles mais une hypercalcémie décelée par les examens biologiques multiples de routine. Le taux du calcium sérique allait de 11.4 à 18.4 mg/100 ml (moyenne 13.8 mg/100 ml) et celui du phosphore de 1.4 à 3.3 mg/100 ml (moyenne 2.0 mg/100 ml). Chez 11 sujets dont le taux de parathormone avait été déterminé ce dernier était de 1 à 11 fois celui du taux normal. Chez 26 sujets la tumeur médiastinale siègeait au sein du thymus, chez 4 hors du thymus soit au niveau des gros vaisseaux ou de la plèvre. La taille de la tumeur était très variable: de 0.7 à 5.0 cm ainsi que le poids: de 0.3 à 18 g. Cinq fois il s'agissait de glandes surnuméraires hyperfonctionnelles. A l'examen anatomo-pathologique les lésions répondaient à 26 adénomes et à 4 hyperplasies. Chez 17 sujets (36%) l'exploration médiastinale ne fut pas suivie de succès, chez 4 des malades explorés avec succès se développa une hypocalcémie permanente. Les complications consistèrent en une blessure d'un récurrent, d'un nerf phrénique, en un pneumothorax, en un épanchement pleural qui se résorba spontanément. Il n'y eut aucun décès. En conclusion les auteurs pensent que les tumeurs parathyroïdiennes sont rares et que l'exploration médiastinale ne doit être pratiquée qu'après la mise en oeuvre de critères séléctifs bien choisis.

Resumen

Entre 1,200 pacientes con hiperparatiroidismo tratados quirúrgicamente en el Hospital General de Massachusetts (MGH) entre 1926 y 1984, hubo 47 casos que fueron sometidos a exploración mediastinal. En 30 (64%) de éstos había glándulas paratiroideas hiperfuncionantes que lograron ser exitosamente removidas por mediastinotomía mediana. Doce de éstos tuvieron su exploración cervical inicial en el MGH, y 18 fueron referidos a nosotros después de haber sido sometidos a 1 o más exploraciones cervical infructuosas. Hubo 17 mujeres y 13 nombres, con edades entre 17 y 75 años. Veinte y cuatro presentaron nefrolitiasis o nefrocalcinosis; 15 osteitis fibrosa quística; 14, enfermedad renal y osea; 6, enfermedad péptica ulcerosa; 2, hipertensión; y 1, artritis gotosa. Dos pacientes aparecieron asintómaticos con hipercalcemia detectada mediante el analizador simultáneo de múltiples canales. El calcio sérico osciló entre 11.4 y 18.4 mg/100 ml con un promedio de 13.8 mg/100 ml, y el fósforo sérico entre 1.4 y 3.3 mg/100 ml con un promedio de 2.0 mg/100 ml. En los 11 pacientes en que se hizo determinación de la hormona paratiroidea en plasma, los valores tuvieron un rango de 1 a 11 veces el valor normal. En 26 pacientes, el tumor mediastinal apareció intratímico en su ubicación y en los otros 4 apareció en localización paratímica, adyacente a los grandes vasos o a la pleura. Los tumores presentaron una gran variación en tamaño entre 0.7 y 5.0 cm en su diámetro mayor, con pesos entre 0.3 y 18.0 gramos. Cinco de estos casos representaban glándulas supernumerarias hiperfuncionantes. El estudio histopatológico reveló 26 adenomas paratiroideos y 4 glándulas con hiperplasia primaria. En 17 pacientes (36%) la exploración mediastinal resultó infructuosa. Cuatro de los pacientes explorados exitosamente desarrollaron hipocalcemia permanente. Las complicaciones incluyeron una lesión del nervio recurrente laríngeo, una lesión del nervio frénico, un neumotórax, y una efusión pleural que tuvo resolución espontánea. No se presentaron muertes ni otras complicaciones de significación. Creemos que los tumores mediastinales hiperfuncionantes son raros y que la exploración mediastinal debe ser emprendida sólo cuando se hayan cumplido rigurosos criterios de selección.

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  1. Surgical Services of the Massachusetts General Hospital and the Harvard Medical School, Boston, Massachusetts, USA

    Chiu-an Wang M.D., Randall D. Gaz M.D. & Ashby C. Moncure M.D.

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  1. Chiu-an Wang M.D.
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  2. Randall D. Gaz M.D.
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Wang, Ca., Gaz, R.D. & Moncure, A.C. Mediastinal parathyroid exploration: A clinical and pathologic study of 47 cases. World J. Surg. 10, 687–694 (1986). https://doi.org/10.1007/BF01655558

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