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Improved catheterization technique and new laboratory methods have increased the value of venography in the diagnosis of tumors, especially of hormone-producing tumors. A review of catheterization techniques for the diagnosis of tumors of the adrenal glands, pancreas, parathyroid glands and orbit is presented with examples of findings.
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We report herein the rare case of a posterior mediastinal parathyroid adenoma 8 mm in diameter, that was identified by both 99m-technetium-methoxyisobutylisonitrile scintigraphy (Tc-MIBI) and high-resolution chest computed tomography (HRCT). Thoracoscopy clearly showed a mediastinal parathyroid adenoma which was successfully removed.
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Primary hyperparathyroidism occurs in about 1 in every 700 individuals. We analyzed our experience with 81 patients with persistent or recurrent hyperparathyroidism who were treated at the University of California, San Francisco, and the Veterans Administration Medical Center, San Francisco, from January 1979 through September 1988. In the 89 reoperations performed, the following six reasons or combination of reasons were responsible for the failed initial operation: (1) in 50 patients, there were multiple abnormal glands (30 hyperplastic and 20 second adenoma); (2) in 40 patients, the tumor was located in an ectopic position (22 mediastinal, 9 deep-seated cervical, 7 intrathyroidal, and 2 undescended); (3) in 17 patients, there were supernumerary parathyroid glands; (4) in 12 patients, the abnormal parathyroid glands were found in normal locations and the tumors were missed because of surgeon inexperience; (5) in 4 patients, failure was due to metastatic parathyroid cancer; and (6) in 4 patients, failure was due to errors on frozen section examinations. Preoperative localization studies usually identified the abnormal parathyroid tumor(s) prior to reoperations and were helpful in these patients. Knowledge of the reasons for failed parathyroid operations and the usual and unusual sites where parathyroid tumors are situated as well as a complete exploration should decrease the frequency of failed parathyroid operations. Localization studies are helpful for identifying these often elusive tumors.
A 62 year old female died of a chromophobe pituitary adenoma of the sphenoid bone. A normal pituitary gland was present within the sella turcica. She also had a chief cell parathyroid adenoma, a papillary thyroid carcinoma, and an ovarian thecoma (multiple endocrine neoplasia syndrome).
A 41-year-old woman was operated on for severe hyperparathyroid syndrome. At surgery a parathyroid tumor with the histopathologic pattern of carcinoma was found. After surgery serum calcium settled within normal limits (10.5 mg/dl, N.V. 8.5-10.8), whereas parathormone and calcitonin reached progressively high levels, respectively 400 ng/dl (N.V. up to 250) and 500 pg/ml (N.V. up to 100 ng/ml). Serum ultrafiltration analysis for parathormone and calcitonin showed many peaks of immunoreactivity with high molecular weight of both hormones. One year after surgery, metastases developed in the lymph nodes of the neck and the mediastinal, pleural and pancreatic regions. After death for tumor wasting, immunohistochemical study of the tumoral tissue with the peroxidase-antiperoxidase technique showed a relatively high density of calcitonin-containing cells. The findings in this case suggest that: several cells in this parathyroid cancer could secrete both parathormone and calcitonin; the hormonal secretion was impaired as suggested by the high molecular weight of both hormones found at gel-filtration analysis; the macromolecular profile of parathormone could explain the apparent function of the parathyroid cancer.