RADIOGUIDED PARATHYROIDECTOMY VIA VATS
1369
adenoma relative to other chest structures (Fig. 2). This
revealed a mass in the left anterior mediastinum, consistent
with a parathyroid adenoma.
The patient was taken to the operating room after injec-
tion with 10 mCi Tc-99m sestamibi for intraoperative lo-
calization. A thoracoscopic exploration using three ports
(11, 11, and 5 mm) was performed after establishing one-
lung ventilation with a double-lumen endotracheal tube. A
gamma probe (NeoProbe; Ethicon Endo-Surgery, Inc., Cin-
cinnati, OH, USA), was used to assist the exploration and
localize increased counts to the preaortic area anterior to the
left phrenic nerve. The mediastinal pleura was excised at
this location, and the mediastinal fat pad incised anterome-
dial to the ascending aorta using a harmonic scalpel. Once
incised, the fat pad was explored, and the adenoma identi-
fied and resected. The gamma probe was used to confirm
that the resected specimen had very elevated counts consis-
tent with parathyroid tissue. This was sent to pathology and
confirmed to be a 425-mg hypercellular parathyroid. No
further elevations in gamma counts were noted on inspec-
tion of the mediastinum with the NeoProbe. The patient’s
PTH level at the time of incision was 195 pg/ml. The level
decreased to 25 and 21 pg/ml when measured at 5 and 10
minutes, respectively, after excision of the adenoma, con-
FIG. 1. Tc-99m sestamibi-SPECT scan showing a mediastinal para-
thyroid adenoma. Top, (left) early images with anterior view and (right)
posterior view; bottom, delayed images.
In this article, we report on a patient who presented with firming that no other hyperfunctioning parathyroid glands
primary hyperparathyroidism for the first time and had a were present. Because the intraoperative PTH levels con-
Tc-99m sestamibi scan localizing a single lesion retroster- firmed surgical cure, the operation was terminated and a
nally in the left anterior mediastinum, below the level of the chest tube was placed through one of the 11-mm port sites.
suprasternal notch. We subsequently performed a radiogu- The chest tube was removed the following morning, and the
ided parathyroidectomy via video-assisted thoracoscopic patient was discharged home on postoperative day 1, less
surgery (VATS) to resect this parathyroid adenoma and than 24 h after surgery. In follow-up, the patient’s serum
used intraoperative PTH testing to confirm cure and avoid calcium levels normalized and have remained stable at
neck exploration. To our knowledge, this represents the first 9.1–9.4 mg/dl at 1 month after surgery. Her intact PTH
case report of a patient with a single, mediastinal parathy- levels have remained less than 55 pg/ml. Within 1 week, the
roid adenoma cured with radioguided parathyroidectomy patient was functioning at full capacity, which included
via VATS without a neck exploration.
participating in her weekly bowling league.
CASE REPORT
DISCUSSION
The patient was a 43-year-old woman with a history of
recurrent calcium oxylate renal stones. Her past medical
Minimally invasive parathyroidectomy may be the pro-
history was significant for gastroesophageal reflux disease, cedure of choice for primary hyperparathyroidism. Approx-
hiatal hernia, nephrolithiasis, and mild mental retardation. imately 70% of patients with primary hyperparathyroidism
Her surgical history was significant for bilateral breast re- can be localized with preoperative imaging and are there-
duction, cesarean section, percutaneous nephrostomy tube, fore candidates for the minimally invasive approach.(3) This
and lithotripsy for her renal calculi. During investigation of has led to an increase in the use of preoperative parathyroid
her recurrent renal calculi, her calcium was found to be imaging. Before the development of minimally invasive
elevated to 11.9 mg/dl (normal range, 8.5–10.2 mg/dl), and parathyroidectomy, most surgeons proceeded directly to
her parathyroid hormone level was elevated to 304 pg/ml bilateral neck exploration for patients with the biochemical
(normal range, 15–65 pg/ml). Her alkaline phosphatase was diagnosis of primary hyperparathyroidism, without per-
132 mg/dl, and 24-h urinary calcium was 319 mg. Bone forming preoperative localization scans. In experienced
densitometry studies were significant for decreased lumbar hands, bilateral exploration is associated with a Ͼ95% cure
and femoral neck scores. A planar Tc-99m sestamibi local- rate and minimal morbidity.(1,2) However, up to one-half of
ization scan was performed, which demonstrated increased the failures in these cases are caused by mediastinal para-
uptake in the mediastinum consistent with amediastinal thyroid adenomas.(4) With the increasing use of preopera-
parathyroid adenoma (Fig. 1). A subsequent repeat study tive parathyroid imaging, many of these mediastinal adeno-
using a combined nuclear medicine SPECT and computed mas can now be detected before neck exploration.
tomography (CT) scanner (GE VG/Hawkeye; General Elec- Therefore, what should be the approach in a patient with
tric, Waukesha, WI, USA) was performed to localize the primary hyperparathyroidism who has a localizing scan to
Kuester
