Surgical treatment of persistent tertiary hyperparathyroidism induced by parathyroid adenomas in the aortopulmonary window

Background. Aortopulmonary window is a rare localization of ectopic parathyroid glands. This localization is the difficulty in diagnosis and surgical treatment, especially in conditions of the heavy somatic pathology that develops with prolonged of kidney replacement therapy. Persistence of tertiary hyperparathyroidism after cervical revision does not give in medical treatment, accompanied by the progression of bone and systemic symptoms of the disease, including death.Materials and Methods. Illustrates a case successful diagnosis and surgical treatment this rare disease. We discuss the treatment and diagnostic tactics. Female patient (age 66) had the experience of peritoneal dialysis for 6 years. She underwent cervical parathyroidectomy. Ectopic mediastinal paratiroma detected by gamma scintigraphy (from 99mTc-MIBI). Determination of the exact tumor location proved to be impossible before the surgery due to bad mental condition of the patient. Localization of adenomas was defined on the surgery after a sternotomy. Results. Operation efficiency proved decrease parathyroid hormone from 2095 pg / ml (before operation) to 10 pg / ml (1.5 months after surgery). After surgery, there was a mediastinal hematoma. The patient was discharged 21 days after surgery healed by.Conclusions. The use a sternotomy leads to the removal of the tumor. This access may be used when an unknown location. This access is a forced for tertiary hyperparathyroidism.

renal hyperparathyroidism, aorto-pulmonary window, ectopic parathyroid gland, sternotomy, parathyroidectomy

1. Бикбов Б.Т., Томилина Н.А. Заместительная терапия больных с хронической почечной недостаточностью в Российской Федерации в 1998-2011 гг. (отчет по данным Рос- сийского регистра заместительной почечной терапии. Часть первая). // Нефрология и диализ. - 2014. - Т. 16. -№1 - С. 11-127.

2. Akaberi S., Clyne N., Sterner G., Rippe B., Reihnér E., Wagner P., et al. Temporal trends and risk factors for parathyroidectomy in the Swedish dialysis and transplant population - a nation-wide, population-based study 1991 - 2009. // BMC Nephrology. 2014;15(1):75. doi: 10.1186/1471-2369-15-75

3. Lafrance J-P., Cardinal H., Leblanc M., Madore F., Pichette V., Roy L., et al. Effect of cinacalcet availability and formulary listing on parathyroidectomy rate trends. // BMC Nephrology. 2013;14(1):100. doi: 10.1186/1471-2369-14-100

4. Locatelli F., Messa P., Bellasi A., Cozzolino M., Di Luca M., Garibotto G., et al. What can we learn from a statistically inconclusive trial? Consensus conference on the EVOLVE study results. // G Ital Nefrol. 2013;30(5).

5. Ермоленко В.М., Волгина Г.В., Добронравов В.А., Рожинская Л.Я., Смирнов А.В., Томилина Н.А., и др. Национальные рекомендации по минеральным и костным нарушениям при хронической болезни почек Российское диализное общество (Май 2010 г.) // Нефрология и диализ.- 2011. - Т. 13. - №1 - С. 33-51.

6. Мохов Е.М., Сутягин А.А. Персистирующий тяжелый третичный гиперпаратиреоз после тотальной паратиреоидэктомии, резистентный к медикаментозному лечению. // Вестник экспериментальной и клинической хирургии. - 2013. - Т. VI. - №2 - С. 260-263.

7. Arnault V., Beaulieu A., Lifante J-C., Sitges Serra A., Sebag F., Mathonnet M., et al. Multicenter Study of 19 Aortopulmonary Window Parathyroid Tumors: The Challenge of Embryologic Origin. // World Journal of Surgery. 2010;34(9):2211-2216. doi: 10.1007/s00268-010-0622-1

8. Zerizer I., Parsai A., Win Z., Al-Nahhas A. Anatomical and functional localization of ectopic parathyroid adenomas. // Nuclear Medicine Communications. 2011;32(6):496-502. doi: 10.1097/MNM.0b013e32834557a3

9. Doppman J.L., Skarulis M.C., Chen C.C., Chang R., Pass H.I., Fraker D.L., et al. Parathyroid adenomas in the aortopulmonary window. // Radiology. 1996;201(2):456-462. doi: 10.1148/ radiology.201.2.8888240

10. Meyer M., Timmerman G.L., VanderWoude J.C., Lovrien F.C. Hyperparathyroidism: a rare mediastinal presentation of an ectopic adenoma. // South Dakota Medicine. 2014;67(3): 101-103, 105, 107.

11. Said S.M., Cassivi S.D., Allen M.S., Deschamps C., Nichols F.C., Shen K.R., et al. Minimally Invasive Resection for Mediastinal Ectopic Parathyroid Glands. // The Annals of Thoracic Surgery. 2013;96(4):1229-1233.doi: 10.1016/j.athoracsur.2013.05.084

12. Long K.L., Lee C.Y., Ramaiah C., Sloan D.A. Intrapericardial parathyroid adenoma. // Journal of Surgical Case Reports. 2013;2013(8):rjt064-rjt064. doi: 10.1093/jscr/rjt064

13. Kim W.K., Kim D.K., Choi S.H., Kim H.R., Kim Y.H., Park S-I. Intrathoracic Parathyroid Adenomatosis: A Case Report. // The Korean Journal of Thoracic and Cardiovascular Surgery. 2013;46(4):302-304. doi: 10.5090/kjtcs.2013.46.4.302

14. Kao C.L., Chou F.F., Chang J.P. Minimal invasive surgery for resection of parathyroid tumor in the aortopulmonary window. // Journal of Cardiovascular Surgery. 2003;44(1):139-140.

15. Ali M., Kumpe D.A. Embolization of Bronchial Artery-supplied Ectopic Parathyroid Adenomas Located in the Aortopulmonary Window. // Journal of Vascular and Interventional Radiology. 2014;25(1):138-143. doi: 10.1016/j.jvir.2013.10.008

16. Geissler B., Gröber S., Zügel N., Lindemann F. Radio-guided Parathyreoidektomie: Erfolgreiche intraoperative Lokalisationsdiagnostik bei primarem und rezidivierendem Hyperparathyreoidismus mit 99 mTc-MIBI. // Der Chirurg. 2001;72(10):1179-1185. doi: 10.1007/s001040170057

17. Schwarzlmüller T., Brauckhoff K., Løvås K., Biermann M., Brauckhoff M. High cardiac background activity limits 99mTc-MIBI radioguided surgery in aortopulmonary window parathyroid adenomas. // BMC Surgery. 2014;14(1):22. doi: 10.1186/1471-2482-14-22

18. Conzo G., Perna A., Avenia N., De Santo R.M., Della Pietra C., Palazzo A., et al. Evaluation of the ‘putative’ role of intraoperative intact parathyroid hormone assay during parathyroidectomy for secondary hyperparathyroidism. A retrospective study on 35 consecutive patients. // Endocrine. 2012;42(3): 606-611. doi: 10.1007/s12020-012-9648-5

19. Ильичева Е.А., Аюшеева А.В., Рожанская Е.В., Папешина С.А., Апханова Н.Г. Клинико-морфологические параллели почечного гиперпаратиреоза. Материалы 22(24) Российского симпозиума с международным участием “Эндокринная хирургия 2003-2014 гг.”; 11-13 сентября; 2014;СПб: 2014. с. 166.

20. Iacobone M., Mondi I., Viel G., Citton M., Tropea S., Frego M., et al. The results of surgery for mediastinal parathyroid tumors: a comparative study of 63 patients. // Langenbeck's Archives of Surgery. 2010;395(7):947-953.