Analysis of the successful clinical treatment of 140 patients with parathyroid adenoma: A retrospective study.

BACKGROUND: Parathyroid adenoma (PA) sometimes recurs after surgery, how to improve the surgical success rate of PA is the key to the treatment of this disease. AIM: To investigate the clinical features, diagnosis, and surgical treatment of patients with PA. METHODS: Patients who were pathologically confirmed with PA and had undergone surgery for the first time between January 2010 and December 2017 at the Beijing Shijitan Hospital affiliated to Capital Medical University were included in the study. The clinical features, localization diagnosis, and surgical treatment of these patients were analyzed. RESULTS: Of the 140 patients, 32 were male and 108 were female; 132 cases had one adenoma, and 8 had two adenomas. In addition, 114 cases had clinical symptoms, among which 51, 28, 23, 8, and 4 had urinary system, skeletal system, digestive system, neuromuscular system, and neuropsychiatric symptoms, respectively, while 26 cases had no obvious symptoms. The median level of preoperative parathyroid hormone (PTH) was 201.0 pg/mL. The positive detection rate of technetium-99m sestamibi (Tc-99m MIBI) single-photon emission computed tomography/computed tomography (SPECT/CT), ultrasound examination, and the combined use of Tc-99m MIBI SPECT/CT and ultrasound examination was 92.9%, 85.5%, and 96.4%, respectively. Open surgery was performed in all patients, and PTH was monitored during surgery. The success rate of surgery was 98.6%. After surgery, 21 cases developed hypocalcemia, 1 case developed temporary hoarseness, and 19 cases had transient hypoparathyroidism but there was no permanent hypoparathyroidism, postoperative hemorrhage, or hematoma in the surgical area. CONCLUSION: For patients with clinically unexplained skeletal system, urinary system, and neuropsychiatric symptoms, the possibility of PA should be considered. Imaging examinations such as ultrasound and Tc-99m MIBI SPECT/CT could be integrated before surgery to obtain accurate localization diagnosis. Precise preoperative localization, intraoperative PTH monitoring, and delicate surgery to protect the integrity of the PA capsule ensure a minimally invasive and successful surgery.

The characteristics of clinical changes in primary hyperparathyroidism in Chinese patients.

In Western countries, the presentation of primary hyperparathyroidism (PHPT) changed from a symptomatic to an asymptomatic disease after the 1970s, whereas in China, only one study has evaluated the changing clinical characteristics and biochemical profiles of PHPT patients. The aim of this study was to explore changes in the clinical characteristics of PHPT in Chinese patients. Overall, 140 consecutive patients with PHPT were studied between January 1, 2010 and June 30, 2016. The patients were divided into two groups: 32 consecutive patients from January 1, 2010 to March 31, 2013 were included in group 1, and 108 consecutive patients from April 1, 2013 to June 30, 2016 were included in group 2. The most frequent complaints were ostealgia (46.02%), urolithiasis (41.59%), constipation (25.66%), fatigue (18.58%), polydipsia and polyuria (15.93%) and fracture history (15.04%). The number of cases in group 2 was 3.38-fold greater than that of group 1. The parathyroid hormone (PTH) and fasting blood glucose (FPG) levels were higher in group 1 than those in group 2 (p = 0.039, p < 0.001). In 62.14% of patients with PHPT, the proportion of the first diagnosis due to hypercalcemia found using a multichannel autoanalyzer in group 1 was lower than that found in group 2 (p = 0.039), and the proportion of the first diagnosis due to parathyroid lesions captured using routine neck ultrasonography in group 1 was higher than in group 2 (p = 0.003). The proportion of parathyroid carcinoma cases was higher in group 1 than group 2 (p = 0.036). Cases of PHPT increased with time, but the proportion of parathyroid carcinoma cases was lower in group 1 than that in group 2. Over time, the first diagnosis switched from parathyroid lesions captured by routine neck ultrasound to hypercalcemia found by a multichannel autoanalyser. At our centre, PHPT in Chinese patients still demonstrates classic characteristics.

[Management of thyroid carcinoma with metastases in the upper mediastinum and axillary area].

OBJECTIVE: To investigate the clinical characteristics and management of thyroid carcinoma with the upper mediastinal and axillary metastasis. METHODS: Six cases of thyroid carcinomas with metastases to mediastinum and axillary, in addition to the neck, undergoing surgeries from 2006 to 2011 were reviewed. Five cases was papillary carcinoma and one was follicular carcinoma. Of six patients, five underwent surgical treatment at least one time previously and one of them received a radiotherapy with total dose of 60 Gy. (131)I treatment and thyroxine were used postoperatively in all cases. RESULTS: The numbers of metastatic nodes in the axillary were 2/7, 3/12, 2/6, 1/5, 3/7 and 3/10 respectively, while the numbers in the upper mediastinum ranged from 2 to 6, with a 4.3 average, a metastatic lymph node in the retropharyngeal space was also found in one patient. Horner's sign occurred in three cases, temporary hypocalcemia in two cases and chylous fistula in one case. No injury to the recurrent laryngeal nerve or to important vessels. Neck or lower mediastinum recurrence and new lung metastasis occurred in three cases separately. No recurrence in the upper mediastinum or axillary area was found with the follow-up of 23-77 months. One died of heart disease 4 years after operation. CONCLUSION: The surgical treatment of node metastases in the upper mediastinum and axillary from the well-differentiated thyroid cancer is safe and has a promising outcome.

[Surgical treatment of hyperparathyroidism due to parathyroid tumors].

OBJECTIVE: To study the clinical features of hyperparathyroidism due to parathyroid tumors, and evaluate the efficiency of surgical management. METHODS: Twenty-two patients with hyperparathyroidism resulted from parathyroid tumors were reviewed. The age ranged from 32 to 79 years, 9 males and 13 females. Recurrent laryngeal nerve was routinely exposed, and procedures were performed in normal tissue in initial surgery. Additional selective neck dissection of levels II, III, IV, and VI was taken in the cases with recurrent cancer. Local flaps were used to repair the esophageal defects after resecting tumors. The recurrent laryngeal nerves of 4 cases had to be sacrificed because they were embedded in the tumor tissues despite the nerves had normal function before operation. Prophylactic tracheostomy was performed in 5 cases. RESULTS: Eight cases were identified pathologically as parathyroid carcinoma, of them four with neck metastasis, and 14 cases as parathyroid adenoma after surgery. Their PTH dropped to normal level within two hours after surgery and hypercalcemia disappeared in two days postoperatively. The PTH and serum calcium were in normal range during the follow-up of 12 to 40 months. Recurrence occurred again in two cases in 6 and 8 months after the removal of the recurrent tumor tissues respectively. Esophageal fistula, chylous fistula and dehiscence of sternotomy developed in three cases separately. The tracheostomy was removed in four cases two weeks after operation and in one case six weeks after operation. One patient with parathyroid adenoma died of hypocalcemia about two weeks after operation and another one with recurrent parathyroid carcinoma also died of hypercalcemia 52 months after revised surgery. CONCLUSION: Extended resection of tumor and intraoperative PTH assay were strongly suggested for the managements of both benign and malignant parathyroid tumors.

[Surgical treatment of recurrent parathyroid carcinoma with invasion of the upper aerodigestive tract].

OBJECTIVE: To evaluate the factors contributed to the recurrence of parathyroid carcinoma with the invasion of the upper aerodigestive tract and the outcomes of reoperation. METHODS: Six cases reviewed, in which the age ranged from 32 to 79 years old. The initial diagnoses and surgical procedures, the sites and surgical treatment of the recurrent disease, and the chemical markers, such as parathyroid hormone (PTH) and serum calcium, were retrospectively studied. The preoperative PTH levels ranged from 860 to 2830 ng/L. In 4 patients the recurrence diseases were founded in the tracheoesophageal groove, of them one with invasion of the larynx only and one with invasion of the larynx and pharynx in addition to the trachea and esophagus involvement. Selective neck dissection for level II, III, IV and VI was taken in all cases in addition to the removal of the local recurrent diseases. Recurrent laryngeal nerves were so badly embedded in tumor tissue that they were intentionally resected in 4 patients although they were functionally normal before operation. Prophylactic tracheostomy was carried out in 5 cases. RESULTS: PTH level dropped more than 70% of that prior the operation at 10 min after the removal of the tumor-bearing tissues and to normal range within the first 2 hours postoperatively, and hypocalcemia disappeared in 2 days postoperatively. All cases experienced significant improvement in symptoms and signs in the first three days postoperatively. PTH and serum calcium levels were within normal range in 4 cases during the follow-up of 11 to 40 months, while hyperparathyroidism was encountered 8 and 11 months postoperatively in other 2 cases, respectively. Esophageal fistula, chylous fistula and dehiscence of sternotomy developed in 3 cases separately. Of 5 patients with tracheostomy, the tracheostomy tubes were removed two weeks in 4 cases and six weeks in the other one after operation. CONCLUSIONS: Recurrent parathyroid carcinoma even with invasion of the upper aerodigestive tract still has promising surgical outcomes. Both the precise localization of the recurrent diseases and the intraoperative PTH assay are importance to the successful treatment of these diseases.

[Surgical management of tumor in the conjunctive area among neck, thorax and axilla].

OBJECTIVE: To study the surgical management of tumors in the conjunctive area among the neck, thorax and axilla and its efficacy. METHODS: From Oct. 1999 to March 2006, eleven cases with benign tumors in the area between the neck, thorax and axilla were collected and analysed. Among them, five neurilemmoma, three neurofibroma, two chondroma and one meningioma, respectively. CT scans showed that the neck, thorax and axilla were affected simultaneously more or less. In this group, direct invasion to the vertebra was found in 4 cases, and spinal compression in one patient. After the disarticulation and displacement of the clavicle, the tumor was removed with the structures of importance in the neck, thorax and axilla under direct views. A bypass was constructed between the axillary vein and the medial end of the subclavian vein. RESULTS: All these tumors were completely removed, injury of vertebral artery was encounter in two cases, and immediate repair was successfully carried out. No other serious complications were found in this group. During the follow-up period from 3 months to 3 years and 5 months, local recurrence was found in no patient. CONCLUSIONS: Benign tumors in the area between neck, thorax and axilla could be successfully dissected and removed with displacement of the medial portion of the clavicle.

[Diagnosis and treatment of Madelung's disease].

OBJECTIVE: To review the characteristics of Madelung's disease which is rare and unfamiliar to clinicians and to find the method of diagnosis and treatment. METHODS: Detailed clinical data of 7 patients with Madelung's disease were reviewed and analyzed. And related literatures were discussed together. RESULTS: All of 7 patients have excessive subcutaneous fat deposit predominantly around neck. One patients had the complication of central and peripheral neuropathy, One patients had the complication of glucose intolerance, One patients had the complication of chronic hepatopathy and hyperuricaemia. These 3 patients were associated with sleep apnea syndrome simultaneously. Another one patient was accompanied by autonomic nervous system disease only. Total neck lipectomy and abstinence from alcohol were performed on 5 patients. No recurrence was seen during a follow-up of 6 months to 5 years. One patient received partial lipectomy twice and relapsed again. All pathological results were nonencapsulated fat. One patient refused treatment. Six men patients were alcohol abusers. CONCLUSIONS: Madelung's disease is characterized by massive accumulation of nonencapsulated subcutaneous fat mainly located symmetrically in the neck. Chronic alcoholism may be a major risk factor. It may be associated with some internal diseases. Total neck lipectomy to improve figuration and relieve pressure and abstinence from alcohol may be the main effective therapy.

[Cochlear implantation in patients with otitis media-related diseases].

OBJECTIVE: To evaluate the indications, surgical techniques and complications of cochlear implantation in patients with otitis media-related diseases. METHODS: Retrospective study of the data collected from patients receiving cochlear implantation. Totally 866 cases of cochlear implantation were performed in Peking Union Medical College Hospital from May 1995 to February 2006. Among which, 41 patients with otitis media-related diseases were grouped into 5 types: chronic secretory otitis media (13 cases), silent (subclinical) otitis media (18 cases), dry eardrum perforation (1 case), bilateral cholesteatoma of middle ear (2 cases) and middle ear granuloma (7 cases). Seven cases were accompanied with deformities of middle ear and (or) inner ear. Pedicled aponeurosis of occipitofrontalis muscle was transplanted to cover and protect the inserted electrodes and facial nerve in a patient with bilateral cholesteatoma after radical mastoidectomy. RESULTS: All the 41 patients with otitis media-related diseases were successfully implanted in one stage or staged operations and followed up uneventfully for 5 months to 6 years and 11 months. All implant devices had worked normally and all patients had performed well. CONCLUSIONS: Patients with chronic secretory otitis media, silent (subclinical) otitis media, middle ear granuloma or dry ear-drum perforation could be operated in one stage or staged procedures safely and effectively. Patients with bilateral cholesteatoma could be implanted after radical removal of related lesions. Pedicled aponeurosis of occipitofrontalis muscle could be transplanted in cases of mastoid bowl to cover and protect the inserted electrodes and the exposed facial nerve and with easy access to observe the mastoid cavity. Active suppurative otitis media was contraindicated for cochlear implantation. Long-term following-up was essential for better evaluation of the outcomes of cochlear implantation in patients with otitis media-related diseases.

[Forty-three tracheal stricture with Ni-Ti shape memory alloy stent].

OBJECTIVE: To evaluate the application of Ni-Ti shape memory alloy stent for treating tracheal stricture, including its indications and complications. METHODS: Forty-three patients clinical data were analyzed, among them, 15 suffered from tumor; 7 trauma; 4 granulation; 1 Wegener's granuloma, 2 rhinoscleroma, 1 without clear diagnosis; 7 were relapsing polychondritis; 1 were respiratory amyloidosis; 4 were tracheobronchial tuberculosis, 5 were tracheobronchomalacia. The stricture degree: Level I: 15 patients, Level II:24 patients, Level III:4 patients. The location of stricture in 5 patients extended to the subglottis area. All patients had tracheal stricture and accepted the treatment with Ni-Ti shape memory alloy stent. RESULTS: Forty-two patients breathed freely after the operation, 1 patient died after surgery. The tracheostoma in 18 patients was closed 34 days after operation. Among the remaining 8 patients with tracheostoma:3 patients left hospital with tracheal cannula; 1 patient died,2 patients were found stent shifted and no evident breath improving; 2 patients were found granulation and had secondary operation with laser. CONCLUSION: Ni-Ti shape memory alloy stent can expand the tracheal stricture quickly and thus improve the breath effectively, which is minimally invasive and simple. It can be used as a method in the treatment of tracheal stricture.

[Complications of tracheoesophageal puncture for Blom-Singer voice restoration after total laryngectomy].

OBJECTIVE: To investigate causes and treatment of complications of tracheoesophageal puncture for Blom-Singer voice restoration after total laryngectomy. METHODS: From 1986 to 2004, one hundred and fifty one cases with Blom-Singer technique after total laryngectomy for voice restoration were retrospectively analyzed. RESULTS: All cases were followed up from 6 months to 15 years. Among 151 cases, 138 cases got successful phonation and the total success rate of voice restoration was 91.4%. Of the 151 cases, 15 cases occurred complications. The rate of complications was 9.9%. The common complications included fistula granulations, infection, and leakage. Twelve cases got successful treatment accordingly, and the other 3 cases failed in phonation. CONCLUSIONS: The procedure of tracheoesophageal puncture for voice restoration is relatively simple and has low complications. this method had high phonation success and good phonation quality, which is one of the best way to make laryngectomee to speak.

[Surgical management of metastatic disease in the conjunctive area between neck and thorax].

OBJECTIVE: To study the surgical management of metastatic disease in the conjunctive area between the neck and thorax and its efficacy. METHODS: Fourteen cases with metastatic node disease in the area between neck and thorax were collected and analysed. Eleven tumors were from the thyroid cancer, and the other three were from the hypopharyngeal cancer, esophagual cancer and malignant pheochromocytoma, respectively. The clavicle was displaced or resected, and the upper half of the manubrium might also be resected when necessary. The recurrent laryngeal nerve and phrenic nerve were exposed and protected. The metastatic disease was completely removed with the internal jugular and/or the brachiocephalic vein resected or spared, depending on the disease condition. RESULTS: In 10 cases with metastases from the thyroid, no local recurrence was found within the follow-up period from 2 to 5 years. In contrast, no patient with metastatic disease from hypopharyngeal or esophageal cancer survived more than 11 months. No serious complications were found in this group. CONCLUSIONS: The surgical treatment of node metastases in the conjunctive area between neck and thorax from the well-developed thyroid cancer has promising effect and is comparatively safe.