Thoracoscopic Removal of Mediastinal Parathyroid Lesions: Selection of Surgical Approach and Pitfalls of Preoperative and Intraoperative Localization

Abstract

Thoracoscopic surgery is safe and feasible for resection of deep mediastinal parathyroid lesions. Such lesions localized preoperatively at the aortic arch or upper region can be treated via a cervical approach. Preoperative sestamibi scan can sometimes give a false-positive result in cases of concurrent thymoma.

Mediastinal parathyroid adenomas and their surgical implications

“…The use of a gamma probe intraoperatively could help identify the parathyroid gland, and has been suggested by some to reduce unnecessary dissection and decrease operating time. 19 On the other hand, others have suggested that the use of a gamma probe in the mediastinum is limited owing to accumulation of radioisotopes in the myocardium. 20 Conversely, intraoperative parathyroid hormone monitoring has been found to be useful as it may help reduce the failure rate of surgery and prevent unnecessary re-exploration.…”

“…Iihara et al attempted to answer this question in their retrospective analysis of 14 patients. 19 They suggested the level of the aortic arch on the horizontal chest CT should be used as a landmark for guiding a suitable surgical approach. Those adenomas found above the aortic arch in the superior mediastinum can be treated successfully by a transcervical approach while those found in the middle or posterior mediastinum below the level of the aortic arch should be approached transthoracically.…”

Aortopulmonary window parathyroid gland causing primary hyperparathyroidism in men type 1 syndrome

“…In our case the intraoperative palpation of the region was extremely useful to correctly localize the gland and to freed it by the surrounding structures. In our opinion, to have at least two concordant preoperative localization studies is recommended to guide the surgeon, especially when the patient is approached with thoracoscopic or robotic surgery [16,20,21]. The type of surgery for MEN1-HPT remains controversial.…”

“…However uptake of 99mTc-MIBI is not specific and selective for parathyroid tissue as mitochondria are able to take up the tracer with high radioactivity being found also over the heart. This aspect contraindicates the use of radio guided surgery [15] and for the same reason a false positive result is also possible in presence of a mediastinal thymoma, as it is usually rich in mitochondrial content [16]. CT scan and MRI are usually associated with scintigraphy for confirming the mediastinal lesion(s) and overall to visualize the relations with the surrounding structures to guide the surgeon [17][18][19].…”

Surgery for Ectopic Parathyroid Adenoma in Lower Part of Superior Mediastinum through a Transcervical Incision

“…Iihara et al . [2] regarded the level of the aortic arch, on the preoperative chest CT images, as a useful landmark for guiding a suitable surgical approach. Specifically, the authors recommended a traditional transcervical approach for the successful removal of those masses found above the aortic arch in the superior mediastinum, and a thoracoscopic approach for those found below the level of the aortic arch.…”