Primary hyperparathyroidism sustained by a giant adenoma of the parathyroid gland

A case of primary hyperparathyroidism sustained by an unusually large parathyroid adenoma is presented. The tumor affected a 45-year-old woman with a 15-year history of nephrolithiasis and presented as a palpable neck mass. On the basis of clinical findings and ultrasound examination, it was initially misdiagnosed as a thyroid nodule. CT scan and transesophageal endosonography gave a correct definition of the tumor, which was located behind the left thyroid lobe and expanded posterior to the pharynx and the esophagus in the prevertebral space. At surgery a parathyroid tumor measuring 8 x 7 x 3 cm and weighing 90 g was successfully removed. No signs of malignancy were observed by both morphological and cell kinetic analyses.     

Mediastinal parathyroid adenoma detected by 99mTc-methoxyisobutylisonitrile: report of a case

In a randomized controlled clinical trial, 14 patients requiring resection of tumors were divided in two groups: one group was anesthetized with nitrous oxide [67% N2O-33% O2 (vol/vol)] and the other with propofol. Two other groups of subjects were studied: a group of patients that was undergoing orthopedic procedures and was anesthetized with nitrous oxide [67% N2O-33% O2 (vol/vol)] and a control group (fasted for 10 hrs and no anesthesia). In patients requiring resection of tumors, the blood L-methionine concentration was significantly lower and the blood amino acid pattern was significantly affected after the administration of nitrous oxide (120-310 mins) compared with values after the induction of anesthesia and before surgery. The administration of propofol (120-240 mins) did not produce any of these changes. No patients required blood transfusion during surgery, and the patients had not previously been treated with cancer chemotherapeutic agents. The administration of nitrous oxide (60-150 mins) to patients undergoing orthopedic procedures did not affect blood L-methionine. It is concluded that the administration of nitrous oxide to cancer-bearing patients, but not to those undergoing orthopedic surgery, produced major changes in amino acid metabolism; therefore, consideration should be given to the avoidance of exposure of cancer patients to nitrous oxide.     

Cure of hyperparathyroidism in pregnancy by sternotomy and removal of a mediastinal parathyroid adenoma

Primary hyperparathyroidism is rarely reported during pregnancy but can cause significant maternal and neonatal morbidity. We report a case of hyperparathyroidism during pregnancy requiring a median sternotomy for resection of a mediastinal parathyroid adenoma. Surgery resulted in normalisation of serum calcium, resolution of symptoms, and prevented neonatal hypocalcaemia.     

Excision of a parathyroid adenoma of the aorto-pulmonary window under thoracoscopy

OBJECTIVES: Neck exploration is usually required in all cases of primary hyperparathyroidism. Without a precise localization preoperatively cervicotomy may be unsuccessful, especially in case of an ectopic adenoma. CASE REPORT: A patient with primary hyperparathyroidism due to a solitary adenoma localized in the middle mediastinum was identified on preoperative computed tomography and technetium-99m-sestamibi radionuclide scan. The tumor was successfully removed at thoracoscopy without neck exploration. DISCUSSION: Preoperative localization of primary hyperparathyroid tumors is not indicated in all patients. In some selected cases (acute hypercalcemia, reoperation, serious illness) prior neck exploration would be useful in guiding the surgeon.     

Positive 131cesium scanning in parathyroid adenoma

In a case of primary hyperparathyroidism, a palpable nodule, at the base of the right lobe of the thyroid, proved 'cool' during 99mTc scanning, but 'hot' when scanned with radiocesium. The uptake of this tracer was higher than the uptake of 75Seselenomethionine after suppression with T3. The authors discuss the possibility of cases of 'false-positive' radiocesium uptake in extrathyroid nodules, and in particular, the use of this tracer for the detection of parathyroid adenoma by scanning.     

Hyperparathyroidism due to a cystic parathyroid adenoma after irradiation of the neck

A 48-year-old female with hypercalcaemia diagnosed 3 years prior to admission is described. The patient underwent x-ray therapy of the neck for keloid scars 35 years prior to the diagnosis of hypercalcaemia. The hypercalcaemia was found to be the result of primary hyperparathyroidism. A cystic parathyroid adenoma was identified during surgery and was, on microscopic examination, composed of oxyphil cells rich in mitochondria. The cystic fluid contained 360 times higher C-terminal PTH than peripheral serum and almost 4000 times higher PTH as intact 1-84 amino acid residue species. We concluded that previous X-ray irradiation was related to the pathogenesis of the patient's parathyroid adenoma. The mild nature of the patient's hyperparathyroidism was possibly related to the composition of the tumour of oxyphil cells, known to be a poorly functioning variant of the parathyroid cell. Since parathyroid 'cysts' are obviously necrotic parathyroid adenomas, aspiration of the cysts alone cannot be expected to be curative and, therefore, it is recommended to treat cystic parathyroid adenomas by surgical extirpation.     

Distribution of the solitary adenoma over the parathyroid glands

One hundred and ten patients with primary hyperparathyroidism were studied, in which a normal parathyroid gland was found on the same side as an adenoma (both confirmed by histological examination), and the upper or lower location could clearly be defined during surgery. The distribution of the adenomas over the upper and lower glands was unequal: 61.8 per cent in the superior versus 38.2 per cent in the inferior position. Statistical analysis revealed that this is not a random distribution (p = 0.013). The explanation of this relative predilection is unknown. The finding should not influence the surgical procedure for primary hyperparathyroidism.     

An ectopic parathyroid adenoma revealed by L-thyroxine side effect on bone. Case report

Yersinia was isolated from imported raw meat and fowl products by HeLa cell treatment and conventional KOH-treatment, to obtain information on the origin of pathogenic Yersinia in Japan. Forty-one strains of Yersinia enterocolitica and one strain of Yersinia pseudotuberculosis, serotype 4b were isolated from 38 (3.0%) of 1278 samples of pork, two (0.3%) of 612 samples of beef and two (0.3%) of 615 samples of chicken. Y. enterocolitica isolates belonged to B:4/O:3 (biotype/serotype, 15 strains), B:3/O:3 (two strains) and B:3 variant/O:3 (17 strains) and B:3/O:5.27 (seven strains). The B:4/O:3 which is globally prevalent among humans and animals was isolated from pork samples from Denmark and the US and from beef samples from Australia, the B:3/O:3 from pork samples from Canada, the B:3 variant/O:3 from pork samples from Taiwan and from chicken samples from Thailand, the B:3/O:5.27 from pork samples from the US and Taiwan and Y. pseudotuberculosis, serotype 4b from pork samples from Canada. These findings suggest that pathogenic Y. enterocolitica strains can be introduced into Japan by the import of pork from pig producing countries. The HeLa cell treatment was found to be superior to the conventional method.     

Autonomous thyroid adenoma, papillary thyroid carcinoma, and ectopic parathyroid adenoma in a patient with primary hyperparathyroidism and a nontoxic multinodular goiter

OBJECTIVE: To discuss the method for nipple-areola preserved mastectomy with one-stage breast reconstruction in cancer surgery. METHODS: Because of the merits of sufficient blood supply and plasticity of rectus abdominis musculocutaneous flap, we used one-stage breast reconstruction after modified radical mastectomy. The incision line was covered and the nipple-areola was preserved. The reconstructed breast was naturally in contour. RESULTS: 21 cases were treated from 1990 to 1995, and 18 of them received horizontal-rhombus shaped rectus abdominis musculocutaneous flaps and 3 longitudinal-rhombus flaps for breast reconstruction. Nipple-areola was preserved in 16 cases. Objective evaluation after operation showed that the excellent and satisfied rate reached to 90.5%; and subjective evaluation showed that the excellent and satisfied rate reached to 95.2%. Thirteen cases have been followed up for 3 years, and 9 for 5 years. Three-year survival rate was 100% (13/13), and 5-year 88.9% (8/9). CONCLUSION: The method is recommendable for the treatment of stage I-II breast cancer.     

Hypothyroidism and hypercalcemia: report of a case with a parathyroid adenoma and review of the literature

A woman with hyperthyroidism, hypercalcemia, and a parathyroid adenoma is described. Various studies indicate that in hypothyroid subjects given an acute dose of calcium, the serum calcium levels remain elevated for longer periods than in control subjects. In part, this may be due to diminished bone uptake. Despite these studies which would tend to support the contention that hypothyroid patients "have a propensity to hypercalcemia" (Lowe et al), overt and significant hypercalcemia is unusual. Hypothyroidism is listed as a possible cause of hypercalcemia. This does not seem to be warranted by a review of the literature. The reference most often cited is that of Lowe et al. In their particular case, the hypercalcemia improved with thyroid replacement therapy. This also happened in our case. However, the measurement of IPTH levels led to the correct diagnosis. IPTH levels were not available at the time of Lowe's report and hyperparathyroidism was not completely excluded. Therefore, at this time, the reported association of hypercalcemia with adult hypothyroidism needs further examination to determine if this association is real.     

The role of ultrasonography in the diagnosis of enlarged parathyroid glands

The ultrasonographic diagnosis of parathyroid glands was introduced by the Japanese in 1975. Only after more perfect machines have been introduced, first of all by advancement of "real-time" technique, this method started being used as a routine. The paper shows results of ultrasonographic investigation in 200 patients separated into two groups. In the first group 100 patients were examined with a clinical suspect of primary hyperparathyroidism from which in 30 the existence of parathyroid gland adenoma was diagnosed. Scintigraphy of parathyroid glands was performed in the smaller group of patients; the comparison of these two methods was done, and in 77.7% cases coincidence was found. In the group of 10 operated patients comparison of the two mentioned methods was carried out, with surgical or pathohistologic findings and the coincidence was complete. In the second group 100 patients were examined belonging to the chronical program of hemodialysis, from which in 24 cases existence of swollen parathyroid glands was found. Comparison of ultrasonographic and scintigraphic findings was also done and the coincidence was 68.75%. At the end, the importance of ultrasonography in the first diagnostic stage of swollen parathyroid glands was pointed out.     

Transrectal ultrasonography and operative selection for early carcinoma of the rectum

BACKGROUND: Transrectal ultrasonography (TRUS) supplements clinical evaluation of early carcinoma of the rectum in selecting patients for local operative therapy, such as transanal excision (TAE). STUDY DESIGN: This study was done to evaluate the accuracy of ultrasonographic staging of tumor depth (T stage) in patients with suspected early carcinoma of the rectum, to compare ultrasonographic with clinical T-staging accuracies within this patient group, to determine if any specific tumor characteristics (configuration, size, location) predispose toward ultrasonographic T-staging inaccuracy, and to examine the role of TRUS in operative selection for patients with early carcinoma of the rectum. RESULTS: Between April 1990 and December 1992, 62 patients with primary carcinoma of the rectum underwent ultrasonographic staging (uT), whereby three uT4, 27 uT3, 24 uT2 and eight uT1 carcinomas were identified. Of the 32 patients with suspected intramural (uT1 or uT2) disease, 27 underwent prompt operative excision or resection at our institution, allowing comparative histopathologic staging. In this highly selected patient subset, uT1 staging was correct in all instances; uT2 staging was incorrect in 45 percent of instances, with 30 percent having unpredicted transmural penetration. Ultrasonographic and clinical staging accuracies were quantitatively similar, and no tumor characteristics were consistently associated with ultrasonographic imprecision. CONCLUSIONS: Among patients with clinically suspected early carcinoma of the rectum, the decision to perform TAE is supported by ultrasonographic T1 staging. By contrast, the decision to perform TAE cannot be based solely on ultrasonographic T2 staging, because of the possibility for transmural penetration of tumor.     

Ectopic parathyroid adenoma. Two cases treated with video-assisted thoracoscopic surgery

In recurrent or persistent hyperparathyroidism, accurate location of the abnormal gland is essential before further surgery, but the variety of available imaging techniques suggests that no one procedure is universally reliable. We report two cases in which clear preoperative visualization of adenoma with double-phase 99mTc-MIBI scintigraphy and exact high-resolution CT location permitted successful minimally invasive surgery.     

Comparitive study of three images examination in preoperative localization of parathyroid adenoma

The ability to localize parathyroid adenoma with B ultrasound, CT scan and thal-lium-technetium scanning (TTS) was eraluated in 41 randomly selected patients with parathyroid adenoma proved pathologically from May, 1985 to May, 1993. The results indicated that the sensitivity was 92.86%, 73.91% and 33.3%; the specificity, 95.65%, 94.2% and 100%; and the accuracy, 95%, 89.1%, 83.3% in above three images examinations. Therefore, the predictable positive rates were 86.6%, 80.95 and 100%; the predictable nagative rates were 97.78%, 91.55%, 0%. There was no significant difference between B ultrasound and CT scan (P > 0.05) in the detection of the location of adenomas. We suggest that B ultrasound could be the first choice in the detection of the location of parathyroid adenoma before surgery, and the CT scan be applied for the unascertained patents who had B ultrasound exam, or surgical exploration, and those with suspected mediastinal adenoma.