Disorders of the Mediastinum: Student/Resident Case Report Poster - Disorders of the Mediastinum |

Hypercalcemia and Mediastinanal Mass: Role of Minimal Invasive Chest Surgery FREE TO VIEW

Alisan Fathalizadeh, MD; Simran Randhawa, MD; Nimisha Parikh; Thaer Obaid, MD; Doraid Jarrar, MD
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Einstein Healthcare Network, Philadelphia, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):552A. doi:10.1016/j.chest.2016.08.640
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Mediastinum

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Ectopic mediastinal parathyroid adenomas are rare and removal in the past has been through sternotomy or thoracotomy. Localization studies in addition to thyroid ultrasound and sestamibi scan include computed tomography that can help in precise localization and surgical planning for a minimal invasive approach through either video-assisted thorascopic surgery (VATS) or robotic surgery.

CASE PRESENTATION: An 80 year-old African American female with no past medical or surgical history presented with 4 days of lower abdominal pain and urinary frequency. She was afebrile with vitals within normal limits, however did have a hypercalcemia of 18.5 mg/dL and creatinine of 1.8 on admission. Her magnesium, phosphorus, and potassium were 1.2 mg/dL, 3.9 mg/dL, and 3.5 mEq/L. Intact PTH level was found to be elevated at 1,213 pg/mL. Admission EKG demonstrated some QT shortening and thus the patient was admitted to the medical service under telemetry. She was provided with IV fluid resuscitation and electrolyte repletion with subsequent improvement of her renal function. Thyroid ultrasound demonstrated multinodular goiter and a questionably enlarged right parathyroid gland. A follow up nuclear medicine parathyroid scan demonstrated activity in the right superior mediastinum representing ectopic parathyroid gland. Subsequent CT scan of the chest demonstrated 3 cm posterior mediastinal soft tissue mass. Patient had uneventful VATS excision of the posterior mediastinal mass through three 5 mm ports. Intraoperative PTH level was 3,993 at the beginning of surgery and dropped to 343 15 minutes after removal of the mass. Chesttube was removed the next day and patient was discharged several days later.

DISCUSSION: Ectopic hyperfunctioning parathyroid tissues have been localized in the mediastinum in 11-25% of patients with hyperparathyroidism, presenting an additional diagnostic challenge secondary to the anatomic variation. Surgical resection is indicated in symptomatic ectopic parathyroid adenomas or asymptomatic patients with concerning features including a serum calcium more than 1.0 mg/dL above the upper limit of normal, marked hypercalciuria or renal stones, reduced creatinine clearance, decreased bone density, and age <50.

CONCLUSIONS: Minimal invasive surgical techniques such as VATS and robotic -assisted resection provide good access to the mediastinal space with excellent visualization. Morbidity is minimized and this approach seems to compare favorable to an open approach.

Reference #1: Benjamin Wei, William Inabnet, James Lee, Joshua Sonett: Optimizing the Minimally Invasive Approach to Mediastinal Parathyroid Adenomas. Ann Thorac Surg 2011; 92:1012-7.

DISCLOSURE: The following authors have nothing to disclose: Alisan Fathalizadeh, Simran Randhawa, Nimisha Parikh, Thaer Obaid, Doraid Jarrar

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