[Lipo-adenomatous hyperplasia of the parathyroid glands. An unusual case of primary hyperparathyroidism].
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Biomedical subjects
Publications and source records attributed to E Sarfati.
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A technetium-thallium (99mTcO4-201Tl) subtraction scan was performed in a patient with clinical and biological evidence of hyperparathyroidism. The 201Tl image indicated a normal thyroid gland. The 99mTcO4 image revealed a left inferior thyroidal extension with an intense and transient focus corresponding to an ultrasonographic nodule. The transient character of the focus was not explicable in terms of vascular kinetics. A supplementary scintigram using 123I confirmed the presence of an inferior extension of the thyroid, but no increased uptake was found. A nodule weighing 250 mg containing a parathyroid adenoma surrounded by normal thyroidal tissue was excised at the focus site. Biological serum levels returned to normal after the operation. It is concluded that the analysis of 99mTcO4 dynamic data could improve the accuracy of parathyroid subtraction scintigraphy.
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The authors report 17 cases of superficial carcinomas collected amongst a series of 100 gastric carcinomas. Three principal points are analysed: clinical picture, diagnostic and treatment. Clinical problems indicate the multiplicity of classifications used and their sometimes incomplete nature. This led the authors in 1970 to develop a classification with 4 parameters, derived from the T N M classification and from that of Gutmann. The diagnostic problems raises yet again for these superficial carcinomas the need for routine screening which is the only way to increase early diagnoses, and hence the effectiveness of treatment. The therapeutic problem is concerned with the discussion of the limitations of wide excision as a matter of principle.
On the basis of four cases of cancer of the stomach occurring after surgery for benign gastroduodenal lesions, the authors analyse 1690 cases published in the literature. The development of these cancers, which occur much more frequently than in the normal population, is favoured by all of the local pathophysiological consequences of the initial operation, although no one factor is predominant. These cancers have a very poor prognosis, with a mean 5 year survival of 6.9%. These very disappointing results can only be improved by early detection as a result of systematic endoscopic follow-up.
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A case of parathyroid adenoma is reported which was of interest in two respects: the very atypical localization in the middle mediastinum and the clearly visible lesion on a straight thoracic film.
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Many surgical procedures have been put forward to treat perforations of the thoracic oesophagus seen late. The authors propose a simple stapling technique which can be applied in the cervical segment or below the lesion if required, and report the results obtained in 4 cases. The spontaneously reversible temporary derivation obtained ensures better healing of the lesion and avoids the need for subsequent reconstructive surgery.
The case of a 54-year-old man with a retroperitoneal seminoma and normal testes is reported. Diagnosis was established late, when the tumor had become large and inoperable and produced symptoms of subocclusion. Onset of gynecomastia, an uncommon occurrence, had been recorded two years earlier and should have given rise to suspicion. The tumor was a histologically unmixed seminoma with very significant beta-HCG secretion. A chemotherapy-radiotherapy combination produced dramatic improvement. From data from a review of the literature, pathogenesis, diagnosis and management of this uncommon type of seminoma are discussed.
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Persistent or recurrent hyperparathyroidism after total parathyroidectomy with forearm implant may be caused by hyperplastic grafted tissue, residual parathyroid tissue left in the neck or the presence of a supernumerary gland not found during surgery. A correct assessment of graft function is needed to localize the source of hormone excess and to avoid an unnecessary neck reoperation in cases of graft dependent hyperparathyroidism. In 12 patients with relapsing hyperparathyroidism after total parathyroidectomy with forearm implant, total ischemic blockade of the arm bearing the parathyroid graft produced a "transitory implantectomy" with a significant reduction of serum levels of intact PTH in those with graft hyperfunction. In 6 patients with proved supernumerary glands, total ischemia of the graft was not followed by significant changes in intact PTH. Hyperparathyroidism was reversed after surgical resection of the parathyroid implants in the 6 patients with positive responses to the ischemic maneuver. A repeat neck reoperation removing cervical or mediastinal supernumerary glands was followed by control of recurrent hyperparathyroidism in the 6 patients with a negative response to the ischemic blockade. Total ischemic blockade of the arm bearing the parathyroid graft is a valuable method for a correct assessment of graft function after total parathyroidectomy with forearm autotransplantation.
In order to reduce the respiratory morbidity of thoracotomy in esophageal surgery, several methods have been used, such as blunt dissection and endoscopic dissection through mediastinoscopy. It seems that the latter reduces drastically the morbidity but does not allow full visualization of the esophageal wall, a disadvantage in some circumstances. We describe a thoracoscopic dissection of the esophagus which gives a large and magnified view of the pleural cavity, of the mediastinum, and of the esophagus.
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Four-unit fixed partial dentures were fabricated as a one-piece casting or as two-piece castings joined by soldering prior to the addition of porcelain. The accuracy of the two techniques was compared and evaluated using an anatomic cast-metal master model. All procedures, including SEM measurements, were performed directly on the master model. The cast one-piece units had smaller vertical marginal openings than did the soldered units. The rigid nature of the abutments evokes the problems occurring with osseointegrated implants.
The difficult and disappointing cases encountered in patients who were operated upon for hyperparathyroidism between 1960 and 1987 have been studied. Ninety two patients underwent negative cervicotomy. Among the 12 patients who underwent a second operation, 4 were found to have cervical adenomas and in 6 others mediastinal adenomas were discovered by sternotomy. Most of the other cases were diagnostic errors. The present frequency of negative surgical operations is very low: 2 to 3 per cent of the cases; errors of diagnosis are exceptional, and the unusual sites of adenomas are better known. Seventeen patients were reoperated upon for persistent or recurrent hypercalcaemia despite excision of a 1st parathyroid lesion; 3 cancers which had been mistaken for adenomas at the 1st operation; 6 had a 2nd adenoma which had passed unnoticed during an exploration that was probably too limited and as hypercalcaemia persisted all 6 were reoperated upon with success at different intervals; finally, 8 patients had undiagnosed primary hyperplasia (as part of polyadenomatosis in 5 cases). Recurrences were observed, often after a long period, up to 3 to 5 years. Hypercalcaemia was corrected by the 2nd operation in only 5 out of 8 cases. In retrospect, it was found that the pathological examination could not always determine if the lesion was malignant or distinguish between adenoma and glandular hyperplasia.