scholarly journals SAT-367 A Case Series: Discovery of Parathyroid Carcinoma During Parathyroidectomy for Primary Hyperparathyroidism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Chellse Gazda ◽  
Jessica Abramowitz ◽  
Marconi Abreu
Keyword(s):  
Vitamin D ◽  
Bone Density ◽  
Recurrent Laryngeal Nerve ◽  
Parathyroid Carcinoma ◽  
Laryngeal Nerve ◽  
Normal Range ◽  
Thyroid Lobe ◽  
Urine Calcium ◽  
Neck Ultrasound ◽  
The Right

Abstract Introduction: Parathyroid carcinoma is rare and represents <1% of patients diagnosed with hyperparathyroidism (1). Clinical Cases: We present two cases of incidentally diagnosed parathyroid carcinoma during parathyroidectomy for primary hyperparathyroidism. A 69-year-old female was referred for hypercalcemia of 10.7 mg/dL (normal range 8.4-10.2). She had bone pain, fatigue, and mild depression. She was taking triamterene-hydrochlorothiazide, vitamin D 2000 international units daily, and 1 caltrate daily. Her thiazide diuretic was discontinued, and a repeat calcium was 9.5 mg/dL with a PTH of 79 pg/mL (normal range 14-64). Vitamin D and renal function were normal. A 24 hour urine calcium was elevated at 706 mg/24 hours (normal range 100-321). A bone density revealed osteopenia. Based on the high urine calcium, a thyroid ultrasound was completed and showed an enlarged right parathyroid gland. Intraoperatively, the surgeon found a superior parathyroid gland adherent to the local soft tissues with recurrent laryngeal nerve entrapment. The right superior parathyroid and right thyroid lobe were resected. Pathology demonstrated an infiltrating parathyroid carcinoma. Postoperative monitoring has included: calcium, creatinine, PTH and neck ultrasound every six months without evidence of recurrence. A 79-year-old man was referred for an approximate 18-month history of hypercalcemia. He had a prior kidney stone and constipation. He was not on calcium supplementations or thiazides. On lab testing calcium was 11.0 mg/dl with prior levels of 11.7 mg/dl. PTH was 246 pg/ml and vitamin D was 20.1 ng/ml (normal range 30-80). Imaging was obtained for parathyroid localization. A neck ultrasound and nuclear medicine study showed a right inferior parathyroid adenoma. A bone density revealed osteoporosis. Intraoperatively, the surgeon found a bilobed parathyroid extending intrathyroidal and adherent to the recurrent laryngeal nerve. The right inferior parathyroid, right thyroid lobe, and isthmus were resected. Pathology was consistent with parathyroid carcinoma. The patient had recurrent laryngeal nerve damage with persistent hoarseness postoperatively. Clinical Lessons: Patients with parathyroid carcinoma typically present with symptomatic hypercalcemia with mean levels of 13.5-14 mg/dL and mean PTH values 8.7 times the upper limit of normal (1). Given the rarity of the condition, there are no guidelines for surveillance (1). These cases highlight atypical, mild, and early presentations of an unusual and typically aggressive disease and serve as an example of how to monitor for recurrence. Reference: 1- Stack BC, Bodenner DL. Medical and Surgical Treatment of Parathyroid Diseases An Evidence-Based Approach. Switzerland: Springer, Cham; 2017.http://link.springer.com/chapter/10.10 07/978-3-319-26794-4_31#enumeration. Accessed November 3, 2019.

scholarly journals SAT-379 Giant Parathyroid Adenoma

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Sima Saberi ◽  
Matthew J Wasco ◽  
Ramin Behjatnia ◽  
Beth Kimball
Keyword(s):  
Vitamin D ◽  
Parathyroid Adenoma ◽  
Serum Calcium ◽  
Parathyroid Carcinoma ◽  
Width Ratio ◽  
Normal Range ◽  
Urine Calcium ◽  
Spot Urine ◽  
Parathyroid Adenomas ◽  
25 Oh Vitamin D

Abstract Giant parathyroid adenoma Background: Primary hyperparathyroidism is the most common cause of hypercalcemia. On ultrasound PTH adenomas are typically homogenous, hypoechoic, oval or bean-shaped with peripheral vascularity. Clinical Case: A 60 year old woman with a history of calcium oxalate nephrolithiasis presented with fatigue, worsening depression, body aches of 3 months duration. Labs showed a serum calcium 11.1 mg/dl (normal range 8.5–10.1 mg/dl), PTH 114.3 pg/ml (normal range 12–88 pg/ml), 25 OH Vitamin D 11 ng/ml (normal range above 29 ng/ml), alkaline phosphatase 137IU/L (normal range 27–120 IU/L), spot urine calcium 34.8 mg/dl, spot urine creatinine 92.1 mg/dl (estimated 24 hour urine calcium 415 mg/dl). She was started on Vitamin D 1000 IU daily. A PTH scan with SPECT/CT showed a right parathyroid adenoma and possible thyroid nodules. A neck ultrasound demonstrated a left 1.5 cm thyroid nodule and a right 3cm lesion. She underwent FNA of the left thyroid nodule and pathology was suggestive of a benign follicular nodule. She underwent parathyroid gland exploration with resection of the right lesion which was a 3.5 x 2.5 x 1.4 cm right superior 5.68 gm PTH adenoma. Postoperatively her serum calcium normalized to 10.1 mg/dl, PTH was 8.4 pg/ml, 25 OH vitamin D was 15 ng/ml. Her Vitamin D dose was increased. Clinical Lessons: A normal parathyroid gland typically weighs 30–60 mg and is 3–4 mm in size. The differential diagnosis for large parathyroid lesions is parathyroid carcinoma vs giant parathyroid adenoma. Although there is not a definitive size cutoff to define giant parathyroid adenomas, a size greater than 3.5 gm has been used (1). On ultrasound giant parathyroid adenomas are homogenous with smooth borders whereas parathyroid carcinomas are large lobulated heterogeneous hypoechoic lesions (2). A depth/width ratio on ultrasound may be the ultrasound parameter with greatest discriminatory capacity as a depth/width ratio greater than or equal to 1 had 94% sensitivity and 95% specificity for parathyroid carcinoma (2). Whether vitamin D deficiency is a risk factor for the development of large parathyroid glands is controversial as there has been conflicting data on this (1,3). Because there is no serum calcium level that distinguishes parathyroid carcinoma from a parathyroid adenoma neck ultrasound may be a helpful tool in evaluating these patients. References: 1. Spanhemier PM, Stoltze AJ, Howe JR, et al. Do giant PTH adenomas represent a distinct clinical entity? Surgery. 2013 Oct; 154(4):714–719. 2. Hara H, Igarashi A, Yano Y, et al. Ultrasonagraphic features of PTH carcinoma. Endocr J. 2001 April 48(2):213–217. 3. Rao DS, Honasoge M, Divine GW, et al. Effect of vitamin D nutrition on PTH adenoma weight: pathogenetic and clinical implications. J Clin Endocrinol Metab. 2000 Mar 85(3): 1054–1058.

scholarly journals Functional Parathyroid Cyst: A Rare Cause of Malignant Hypercalcemia with Primary Hyperparathyroidism—A Case Report and Review of the Literature

2012 ◽  
Vol 2012 ◽  
pp. 1-5 ◽  
Author(s):  
Areej Khan ◽  
Yusra Khan ◽  
Shahzad Raza ◽  
Ghulam Akbar ◽  
Monis Khan ◽  
...  
Keyword(s):  
Primary Hyperparathyroidism ◽  
Recurrent Laryngeal Nerve ◽  
Parathyroid Carcinoma ◽  
Anterior Mediastinum ◽  
Laryngeal Nerve ◽  
Rare Presentation ◽  
Parathyroid Cyst ◽  
Severe Hypercalcemia ◽  
Parathyroid Cysts ◽  
The Right

Parathyroid cysts are rare lesions found in the neck and anterior mediastinum. They are often nonfunctional (>90%) and rarely in the functional form. This paper discusses a case of severe hypercalcemia (23 mg/dL) secondary to a rare functional parathyroid cyst. The patient was later found to have a hemorrhagic cyst with compression of the right recurrent laryngeal nerve. Preoperative diagnosis of the lesion was parathyroid carcinoma. However, reexploration of the parathyroid mass along with microscopic study confirmed the diagnosis of a parathyroid cyst. Following cystectomy, the patient restored her baseline functional status with preservation of the right recurrent laryngeal nerve. Postoperative followup three years later showed no evidence of cyst recurrence. This paper illustrates the rare presentation of parathyroid functional cysts with severe hypercalcemia and primary hyperparathyroidism. Physicians should be aware of the presence of hemorrhage, inflammation, and compressive symptoms in these cysts which mimic parathyroid carcinoma. These patients should be managed with aggressive medical and surgical intervention.

Anatomical and developmental aspects of iatrogenic injury to the right recurrent laryngeal nerve in surgical resections of substernal goiter

2021 ◽  
Author(s):  
Rossano Kepler Alvim Fiorelli ◽  
Alfredo Jorge Vasconcelos Duarte ◽  
Aline de Quadros Teixeira ◽  
Thiago Scharth Montenegro ◽  
Pedro Eder Portari Filho ◽  
...  
Keyword(s):  
Recurrent Laryngeal Nerve ◽  
Laryngeal Nerve ◽  
Iatrogenic Injury ◽  
Substernal Goiter ◽  
The Right

Neonatal Vocal Cord Paralysis Following Extracorporeal Membrane Oxygenation

PEDIATRICS ◽  
1989 ◽  
Vol 84 (5) ◽  
pp. 793-796 ◽  
Author(s):  
Robert E. Schumacher ◽  
Irvin J. Weinfeld ◽  
Robert H. Bartlett
Keyword(s):  
Respiratory Failure ◽  
Extracorporeal Membrane Oxygenation ◽  
Recurrent Laryngeal Nerve ◽  
Vocal Cord ◽  
Vocal Cord Paralysis ◽  
Vocal Cord Palsy ◽  
Laryngeal Nerve ◽  
Membrane Oxygenation ◽  
The Right ◽  
Unilateral Vocal Cord Paralysis

Five cases of unilateral vocal cord paralysis/ paresis were diagnosed following extracorporeal membrane oxygenation for newborn respiratory failure. All were right sided and transient in nature. None of the five patients had other findings commonly associated with vocal cord palsy. The extracorporeal membrane oxygenation procedure requires surgical dissection in the carotid sheath on the right side of the neck, an area immediately adjacent to both the vagus and recurrent laryngeal nerve. It is speculated that vocal cord paralysis in these infants was acquired as a result of the extracorporeal membrane oxygenation cannulation. Although the vocal cord paralysis resolved in all cases, two patients had difficult courses after extracorporeal membrane oxygenation. Therefore, laryngoscopic examination should be considered for patients after extracorporeal membrane oxygenation.

scholarly journals Intrathyroidal Parathyroid Carcinoma: Report of an Unusual Case and Review of the Literature

2013 ◽  
Vol 2013 ◽  
pp. 1-5 ◽  
Author(s):  
Lizette Vila Duckworth ◽  
William E. Winter ◽  
Mikhail Vaysberg ◽  
César A. Moran ◽  
Samer Z. Al-Quran
Keyword(s):  
Thyroid Gland ◽  
Parathyroid Carcinoma ◽  
Unusual Case ◽  
Thyroid Tissue ◽  
Parathyroid Tissue ◽  
African American Female ◽  
Thyroid Lobe ◽  
Local Infiltration ◽  
Sestamibi Scan ◽  
The Right

Intrathyroidal parathyroid carcinoma is an exceedingly rare cause of primary hyperparathyroidism. A 51-year-old African American female presented with goiter, hyperparathyroidism, and symptomatic hypercalcemia. Sestamibi scan revealed diffuse activity within an enlarged thyroid gland with uptake in the right thyroid lobe suggestive of hyperfunctioning parathyroid tissue. The patient underwent thyroidectomy and parathyroidectomy. At exploration, a 2.0 cm nodule in the usual location of the right inferior parathyroid was sent for intraoperative frozen consultation, which revealed only ectopic thyroid tissue. No parathyroid glands were identified grossly on the external aspect of the thyroid. Interestingly, postoperative parathyroid hormone levels normalized after removal of the thyroid gland. Examination of the thyroidectomy specimen revealed a 1.4 cm parathyroid nodule located within the parenchyma of the right superior thyroid, with capsular and vascular invasion and local infiltration into surrounding thyroid tissue. We present only the eighth reported case of intrathyroidal parathyroid carcinoma and review the literature.

scholarly journals Anatomical Variations of the Recurrent Laryngeal Nerve and Implications for Injury Prevention during Surgical Procedures of the Neck

Diagnostics ◽  
2020 ◽  
Vol 10 (9) ◽  
pp. 670
Author(s):  
Alison M. Thomas ◽  
Daniel K. Fahim ◽  
Jickssa M. Gemechu
Keyword(s):  
Recurrent Laryngeal Nerve ◽  
Surgical Procedures ◽  
Anatomical Variations ◽  
Laryngeal Nerve ◽  
Inferior Thyroid Artery ◽  
Branching Pattern ◽  
The Right ◽  
Relationship Of ◽  
Intrinsic Laryngeal Muscles ◽  
Formalin Fixed

Accurate knowledge of anatomical variations of the recurrent laryngeal nerve (RLN) provides information to prevent inadvertent intraoperative injury and ultimately guide best clinical and surgical practices. The present study aims to assess the potential anatomical variability of RLN pertaining to its course, branching pattern, and relationship to the inferior thyroid artery, which makes it vulnerable during surgical procedures of the neck. Fifty-five formalin-fixed cadavers were carefully dissected and examined, with the course of the RLN carefully evaluated and documented bilaterally. Our findings indicate that extra-laryngeal branches coming off the RLN on both the right and left side innervate the esophagus, trachea, and mainly intrinsic laryngeal muscles. On the right side, 89.1% of the cadavers demonstrated 2–5 extra-laryngeal branches. On the left, 74.6% of the cadavers demonstrated 2–3 extra-laryngeal branches. In relation to the inferior thyroid artery (ITA), 67.9% of right RLNs were located anteriorly, while 32.1% were located posteriorly. On the other hand, 32.1% of left RLNs were anterior to the ITA, while 67.9% were related posteriorly. On both sides, 3–5% of RLN crossed in between the branches of the ITA. Anatomical consideration of the variations in the course, branching pattern, and relationship of the RLNs is essential to minimize complications associated with surgical procedures of the neck, especially thyroidectomy and anterior cervical discectomy and fusion (ACDF) surgery. The information gained in this study emphasizes the need to preferentially utilize left-sided approaches for ACDF surgery whenever possible.

scholarly journals Non-recurrent inferior laryngeal nerve: a case report

2020 ◽  
Vol 7 (10) ◽  
pp. 3469
Author(s):  
Shah Urvin Manish ◽  
Boopathi Subbarayan ◽  
Saravanakumar Subbaraj ◽  
Tirou Aroul Tirougnanassambandamourty ◽  
S. Robinson Smile
Keyword(s):  
Recurrent Laryngeal Nerve ◽  
Nodular Goiter ◽  
Anatomical Variations ◽  
Laryngeal Nerve ◽  
Anatomical Landmarks ◽  
Inferior Laryngeal Nerve ◽  
Nonrecurrent Inferior Laryngeal Nerve ◽  
Aged Woman ◽  
Middle Aged Woman ◽  
The Right

The incidence of Non-recurrent laryngeal nerve (NRLN) is reported to be 0.6%-0.8% on the right side and in 0.004% on the left side. Damage to this nerve during thyroidectomy may lead to vocal cord complications and should therefore be prevented. A middle-aged woman with a nodular goiter who underwent subtotal thyroidectomy for multinodular colloid goiter. We encountered a non-recurrent laryngeal nerve on the right side in a patient during surgery. We were not able to find the inferior laryngeal nerve in its usual position using the customary anatomical landmarks. Instead, it was emerging directly from the right vagus nerve at a right angle and entering the larynx as a unique non-bifurcating nerve. Nonrecurrent inferior laryngeal nerve incidence is very rare, but when present, increases the risk of damage during thyroidectomy. Hence, it is very important to be aware of the anatomical variations of the inguinal lymph node (ILN) and the use of safe meticulous dissection while looking for the nerve during thyroidectomy. The use of Intra-operative neuro-monitoring (IONM) if available in thyroid surgery allows the surgeon to recognize and differentiate branches of the inferior laryngeal nerve (ILN) from sympathetic anastomoses, as well as NRLN during surgery.

270 LYMPHADENECTOMY ALONG BILATERAL RECURRENT LARYNGEAL NERVE UNDER SINGLE-PORT INFLATABLE MEDIASTINOSCOPY THROUGH LEFT NECK APPROACH

2021 ◽  
Vol 34 (Supplement_1) ◽  
Author(s):  
X Wu ◽  
X Gan ◽  
Q Cao
Keyword(s):  
Minimally Invasive ◽  
Recurrent Laryngeal Nerve ◽  
Minimally Invasive Esophagectomy ◽  
Cell Cancer ◽  
Laryngeal Nerve ◽  
Lower Edge ◽  
Invasive Esophagectomy ◽  
Surgical Methods ◽  
Left Neck ◽  
The Right

Abstract   Mediastinal lymphadenectomy is a crucial part of minimally invasive esophagectomy, and requires transthoracic operation, which is a crucial independent risk factor for the incidence of pulmonary complications. Conventionally, non-transthoracic esophagectomy was often achieved by mediastinoscope-assisted laparoscopic transhiatal surgery. Because of the small space, the lymphadenectomy could be only performed partially under mediastinoscope in upper mediastinal. We propose a new approach of lymphadenectomy along bilateral recurrent laryngeal nerve under mediastinoscopy through one left-neck incision. Methods A 3-cm incision paralleling the clavicle was made at 2-cm from the supraclavicular region in the left neck. After established pneumomediastinum (10-12 mmHg carbon dioxide), esophagectomy begins to perform over the aortic arch to the level of lower edge of the left main bronchus, and the lymphadenectomy along the left RLN has also accomplished during this process. At the level of lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, the instruments could get accessed to the right RLN. The lymphadenectomy could get accomplished up to 2-cm at the upper edge of the RSA. Results The mean age of 56 esophageal squamous cell cancer patients was 67.4 years, 46 males and 10 females. Tumor location: middle thoracic, 31 patients, lower thoracic, 23 patients. Preoperative TNM staging: T1b was 10 cases, T2 was 35 cases, and T3 was 11 cases. The median number of mediastinal LNs removed was 17 (9 to 23); 6 (2 to 9) along the left RLN; 3 (1 to 6) along the right RLN. 7 patients (12.5%) developed RLN palsy. Postoperative laryngoscopy showed that all of the 7 RLN palsy were left side, none of them appeared at 3 months postoperation. Conclusion This approach enables the lymphadenectomy along bilateral RLN through one left neck incision. During the operation, the upper mediastinal LNs along the bilateral RLN were clearly revealed and en bloc excised. Meanwhile, the bilateral RLN were fully exposed and protected during the procedure. Compared with the previous surgical methods,this procedure is less invasive, and the bilateral RLN could be exposed much clearer. It would provide a novel approach for the minimally invasive esophagectomy, especially lymphadenectomy.

Dissociation of the right recurrent laryngeal nerve

ASVIDE ◽  
2020 ◽  
Vol 7 ◽  
pp. 208-208
Author(s):  
Xiangfeng Gan ◽  
Hongcheng Zhong ◽  
Xiaojian Li ◽  
Xiaojin Wang ◽  
Wenwen Huo ◽  
...  
Keyword(s):  
Recurrent Laryngeal Nerve ◽  
Laryngeal Nerve ◽  
The Right

Stimulation of vagal C-fibers alters timing and distribution of respiratory motor output in cats

1989 ◽  
Vol 67 (6) ◽  
pp. 2249-2256 ◽  
Author(s):  
H. R. Holmes ◽  
J. E. Remmers
Keyword(s):  
Vagus Nerve ◽  
Recurrent Laryngeal Nerve ◽  
Breathing Pattern ◽  
Laryngeal Nerve ◽  
C Fibers ◽  
Vascular Congestion ◽  
Vagal Afferent ◽  
Posterior Cricoarytenoid ◽  
The Right ◽  
Decerebrate Cats

Pulmonary vascular congestion or pulmonary embolism in humans produces shallow tachypnea, and indirect experimental evidence suggests that this characteristic breathing pattern may result from activation of vagal unmyelinated afferents from the lung. We have investigated, in decerebrate cats, reflex changes in breathing pattern and in the activation of the diaphragm, posterior cricoarytenoid, and thyroarytenoid muscles caused by activating C-fiber afferents in the vagus nerve. The right vagus nerve was sectioned distal to the origin of the recurrent laryngeal nerve, eliminating vagal afferent traffic although preserving motor innervation of the larynx on that side. The left cervical vagus was stimulated electrically, and efferent activation of the laryngeal muscles was avoided by cutting the left recurrent laryngeal nerve. Transmission to the brain of vagal afferent traffic resulting from this stimulation was controlled by graded cold block of the nerve cranial to the site of application of the stimulus. Activation of C-fibers, when A-fibers were blocked, significantly decreased respiratory period and amplitude of diaphragm inspiratory burst. In addition, this selective activation of vagal C-fibers augmented postinspiratory activity of the diaphragm and recruited phasic expiratory bursts in the thyroarytenoid. We conclude that, in unanesthetized decerebrate cats, afferent traffic of vagal C-fibers initiates a pontomedullary reflex that increases respiratory frequency, decreases tidal volume, and augments braking of expiratory airflow.

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