Undescended Parathyroid Adenomas: A Leading Cause of Persistent Primary Hyperparathyroidism

Roy, Ankita; Khan, Mozammel H. A.; Frazzetta, Joseph; Kabaker, Adam S.; Jong, Steven de

doi:10.5005/jp-journals-10002-1306

Cited by 2 publications

(3 citation statements)

References 14 publications

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“…Though carotid sheath involvement is rare (11,12), identification and resection of parathyroid adenomas within the sheath has been demonstrated to be especially difficult. Groups have previously described cases in which failed primary surgery for hyperparathyroidism has been attributed to adenomas later localized to the carotid sheath (13)(14)(15)17).…”

Section: Discussionmentioning

confidence: 99%

“…One anatomical variant that presents a unique challenge in both diagnosis and surgical resection is a parathyroid adenoma within the carotid sheath. In two large reports, which together examined nearly 1,200 parathyroid surgeries performed for primary hyperparathyroidism, only two cases had adenomas involving the carotid sheath (11,12). Despite its rare presentation, there have been multiple cases in which failed primary parathyroid resection has been attributed to ectopic tissue later localized to the carotid sheath (13,14).…”

Section: Introductionmentioning

confidence: 99%

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Indocyanine green fluorescence guided resection of parathyroid adenoma of the carotid sheath: a case report and review of the literature

Rupp¹,

Barba²,

Goldhaber³

et al. 2023

Gland Surg

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Background: Ectopic parathyroid tissue can pose difficulties in diagnosis, management, and resection of adenomas in patients with hyperparathyroidism. The use of multimodal pre-operative imaging is recommended due to the diverse anatomic presentation of parathyroid adenomas and the potential presence of multiple adenomas. Resection failure still can occur, however, indocyanine green (ICG) fluorescence imaging is an intraoperative tool that has potential to help address this challenge. In the case which follows we demonstrate the use of ICG fluorescence imaging to assist in successful resection of a parathyroid adenoma located within the carotid sheath.Case Description: We present the case of a 75-year-old woman with primary hyperparathyroidism due to a parathyroid adenoma localized to the left carotid sheath, posterior to the carotid artery. Careful resection was aided by ICG fluorescence guidance allowing for complete resection and immediate postoperative restoration of normal Parathyroid Hormone and calcium levels. The patient had no peri-operative complications and had an unremarkable post-operative course. Conclusions:The anatomical heterogeneity of parathyroid gland adenomas within and around the carotid sheath presents a unique diagnostic and surgical scenario; however, the use of intra-operative ICG, as presented in this case, has important implications for endocrine surgeons and surgical trainees alike. This tool provides improved intra-operative identification of the parathyroid tissue allowing for safe resection, especially in cases involving critical anatomical structures.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Indocyanine green fluorescence guided resection of parathyroid adenoma of the carotid sheath: a case report and review of the literature

Rupp¹,

Barba²,

Goldhaber³

et al. 2023

Gland Surg

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“…2 Although the rate of UPGs at initial operation has been reported at 0.08%-2%, this increases to 6.2%-8% in modern reoperative case series, as these ectopic locations are more likely to be missed at first operation. [3][4][5] Ectopic glands are of particular relevance in renal hyperparathyroidism as all glands are considered hyperplastic and require identification. 6 The incidence of bilateral UPGs is unknown but rare.…”

mentioning

confidence: 99%

Peculiar parathyroids: bilateral undescended ‘inferior’ parathyroids, located at the level of the submandibular glands

Finlayson

Biggar

2023

ANZ Journal of Surgery

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Peculiar parathyroids: bilateral undescended 'inferior' parathyroids, located at the level of the submandibular glands A 40-year-old male with hyperparathyroidism secondary to haemodialysis-dependent diabetic renal failure was referred for parathyroidectomy. He underwent bilateral neck exploration, however only the two superior glands were identified and removed. The thymus could similarly not be identified. Despite extensive neck exploration including high along the carotid sheaths towards the bifurcation, incorporating the use of intraoperative ultrasound, no additional parathyroid tissue was found. Post-operatively, serum PTH levels were persistently elevated, thus further imaging was obtained to locate the missing inferior glands.99mTc-sestamibi SPECT/CT imaging identified foci consistent with enlarged parathyroid glands at the level of the angle of the mandible (Fig. 1). Ultrasound was able to correlate these findings and was used preoperatively to identify the undescended parathyroid glands and mark the overlying skin.The patient underwent re-exploration and both glands were identified. The glands were positioned medial to the carotid artery, immediately deep and superior to the origin of the superior thyroid artery and adjacent to the submandibular glands. Thymic tissue (confirmed histologically) was identified and excised along with the gland on each side. The PTH level dropped post-operatively (Fig. 2).Undescended parathyroid glands (UPGs) are a rare but important cause of recurrent or persistent hyperparathyroidism. 1,2 In a landmark paper by Wang in 1977 describing the locations of glands in 112 reoperative cases, only one was located at the angle of the jaw, highlighting the rarity of this location. 2 Although the rate of UPGs at initial operation has been reported at 0.08%-2%, this increases to 6.2%-8% in modern reoperative case series, as these ectopic locations are more likely to be missed at first operation. [3][4][5] Ectopic glands are of particular relevance in renal hyperparathyroidism as all glands are considered hyperplastic and require identification. 6 The incidence of bilateral UPGs is unknown but rare. Case series

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Undescended Parathyroid Adenomas: A Leading Cause of Persistent Primary Hyperparathyroidism

Cited by 2 publications

References 14 publications

Indocyanine green fluorescence guided resection of parathyroid adenoma of the carotid sheath: a case report and review of the literature

Indocyanine green fluorescence guided resection of parathyroid adenoma of the carotid sheath: a case report and review of the literature

Peculiar parathyroids: bilateral undescended ‘inferior’ parathyroids, located at the level of the submandibular glands

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