Ectopic Parathyroid Adenoma
Ectopic Parathyroid Adenoma
Ectopic Parathyroid Adenoma
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<strong>Ectopic</strong> <strong>Parathyroid</strong><br />
<strong>Adenoma</strong><br />
Kiyanda Baldwin<br />
SUNY Downstate Grand Rounds<br />
Long Island College Hospital<br />
April 28, 2011
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Patient Presentation<br />
• 76 y/o woman referred for elevated PTH<br />
(180) & Ca (10.7)<br />
• PMH: HTN, hyperlipidemia, osteoarthritis<br />
• PSH: total thyroidectomy (3/09) due to<br />
suspicious nodules B/L; path: thyroiditis<br />
w/ pseudopapillary hyperplasia,<br />
orthopedic surgery
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Physical Exam<br />
• HEENT: normocephalic, atraumatic, no<br />
lymphadenopathy, no palpable masses,<br />
well healed neck scar<br />
• CVS S1S2 RRR<br />
• Chest CTA B/L<br />
• Abd soft NT ND +BS<br />
• Ext FROM X4 2 +pulses x4
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Work Up<br />
• PTH 180, Ca 10.7<br />
• Sestamibi scan<br />
possible parathyroid adenoma in the right<br />
lower paratracheal area
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Excision of parathyroid<br />
adenoma<br />
• Incision through thyroidectomy scar<br />
• Nodule found in right lower paratracheal<br />
area<br />
• Path consistent with lymph node<br />
• Nodule found in mediastinum behind<br />
sternum<br />
• Path consistent w/ parathyroid adenoma<br />
• PTH at 10 minutes: 18
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Postoperatively<br />
• No complaints<br />
• Tolerated advance in diet<br />
• POD #1 Ca 8.2<br />
• Discharged POD #1
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<strong>Ectopic</strong><br />
<strong>Parathyroid</strong><br />
<strong>Adenoma</strong>
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Preop Localization<br />
• 99m Technetium labeled Sestamibi<br />
◦ Most used, >80% sensitivity<br />
• Neck Ultrasound<br />
◦ >75% sensitive, intrathyroidal parathyroids<br />
• Single-photon emission CT<br />
◦ Superior to other nuclear medicine imaging,<br />
good for mediastinal parathyroids<br />
• CT & MRI<br />
◦ Less sensitive than sestamibi, good for<br />
paraesophageal and mediastinal<br />
Shwartz, Sabiston
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Invasive Preoperative Localization<br />
• Selective arteriography w/ venous PTH<br />
sampling<br />
Sabiston
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Invasive Preop Localization<br />
Ultrasound localization guided FNA of a<br />
suspicious parathyroid lesion<br />
Sabiston
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Intraoperative<br />
Localization<br />
• Intraoperative PTH assay<br />
◦ Operative failure rates 6%1.5%<br />
• Radioguided parathyroidectomy<br />
◦ 99m Tc-sestamibi injected IV 2-4hrs before<br />
surgery, adenoma localized w/ gamma counter<br />
◦ Excised adenoma emits radioactivity 20-50% in<br />
excess of postexcision background<br />
Sabiston
Perioperative Adjuncts During<br />
Minimally Invasive<br />
<strong>Parathyroid</strong>ectomy<br />
• Prospective trial<br />
• 254 patients w/ PHPT<br />
• Single surgeon/single institution<br />
• sestamibi scans, radioguided, and ioPTH<br />
testing<br />
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• Results: ioPTH has highest sensitivity,<br />
PPV, and accuracy<br />
Chen et al. Ann Surg 2005: 242:375-383
Anatomy<br />
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• Superior<br />
glands:<br />
Posteromedial<br />
aspect of the<br />
thyroid near<br />
tracheoesophag<br />
eal groove<br />
• Inferior<br />
glands:<br />
Widely<br />
distributed<br />
below the<br />
inferior thyroid<br />
A<br />
Sabiston
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<strong>Ectopic</strong> Locations<br />
• Thymus 15%<br />
• Intrathyroidal<br />
1%<br />
• Sup thyroid<br />
poles<br />
• Carotid Sheath<br />
• Ant/Post<br />
mediastinum<br />
• Ant to carotid<br />
bulb<br />
• Retroesophageal<br />
Sabiston
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Where to explore?<br />
• Retropharyngeal & esophageal spaces<br />
• Trace RLN into chest<br />
• Open carotid sheath<br />
• Thymectomy<br />
• Consider ipsilateral thyroid lobectomy<br />
• DO NOT PERFORM MEDIAN<br />
STERNOTOMY<br />
Sabiston
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References<br />
• Schwartz’s Principles of Surgery, 9 th Ed<br />
• Sabiston Textbook of Surgery, 18 th Ed<br />
• Chen et al. Ann Surg 2005: 242:375-383
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