Angiography

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CHARLES

of Mediastinal

J.

TEGTMEYER,1

Parathyroid

E. MEREDITH

ALRICH,2

demmed,

The operative

The problem ing

the

Until

[parathyroid]

of parathyroid

close

disease

cooperation

recently,

the

parathyroid

of not

first was

localization

angiographic reported by

difficult thyroid

pnoblem. adenomas

sented

here

parathynoid previous neck

The localization is especially

illustrate

in the localization two patients with

the

value

the

localizaSeldinger

of difficult.

mediastinal The cases

of preoperative

a

panapre-

angiognaphy adenomas sungeny.

and

Reports

a 4.0

x 2.0 cm vascular

1C). The intense vascular blush in the tumor persisted (fig. 1B). The patient was explored through a median and

an

adenoma

was

Postoperatively,

readily Case

removed

from

hypoparathyroidism

controlled

with

medical

of the

cnicoid

The

inferior

pair

the

the

mass

(fig.

appeared sternotomy anterior

developed;

blood from

incision,

however,

by

the

artery

it was

therapy.

of

underwent

a neck

exploration

and

The

1 2

patient

artery

Department Department

Am J Roentgenol

was

reexplored.

was

identified

of of

Radiology, Surgery.

The

and University University

127: 243-246.

abnormal

traced

branch

of the

1976

the

derive only

from a

is posterior

at the

derive

from

level

short to

of the

the

lower

the

third

bnanchial

distance to reach the usual laryngeal nerve somewhat poles of the thyroid gland. migrate

in intimate

nela-

gland, and this to the relative

initial wide inconsistency

range

be

located

anywhere

is usually

However,

in the the

of

from

neck

and

the not

mediastinum

is

in the

1 % to 1 0% of cases

in from of

vascular

parathynoid

supply

our

also

often

mammary

from

patients

of

the

mediastinal

angiographic

are

finding sufficiently

has

previously

of the

ipsilateral

thyroid

Virginia 22901. Virginia 22901.

Address

reprint

13].

a

In both

inferior

thyroid

adenomas. in cervical displacement

inferior artery,

thyroid and

artery,

a vascular

[2, 1 3, 14]. Displacement of of the inferior thyroid artery “The single most important

demonstration from

from

Mediastinal supplied

by an anomalous [12,

vessels,

branches

the

supply

reported

abnormal

of the

been

1 or

of the

of the

fan removed

blood

parathyroid

findings

adenomas

The

glands is usually Intnathonacic pana-

artery

branch

adenoma.

[4, 10]. occasionally

[1 0, 1 1

innominate

adenomas

the

their

artery are

artery

the

an enlarged

supplied

size

derive

thyroid however,

blush or stain of the adenoma the cranial and caudal loops has also been described [13].

243

glands

migrate

which

adenomas

the

internal

arising

increased

of Virginia Medical Cente Tharlottesville, of Virginia Medical Center. Ctldrlottesville,

of

development.

gland

demonstration

on stretching

inferior

localization

of

panathynoids

the inferior adenomas,

panathyroid

to a 4.0 x 2.5 x 1 .5 cm

frus-

cartilage.

[5].

adenomas

branch of panathyroid

mediastinum.

the

supply of the cervical parathynoid the inferior thyroid arteries [8, 9].

thynoid

and

removal of the left lobe of her thyroid for hyperparathyroidism. Her hypercalcemia persisted (11.3-1 3.2 mg/100 ml). Parathyroid angiography demonstrated an enlarged branch of the right inferior thyroid artery descending into the upper mediastinum (fig. 2A and 2C). It curved around the medial border of a densely stained mass which is supplied (fig. 2B). thyroid

position, thyroid

infenion

upon

The female,

They

the thymus contributes

Angiognaphic

1A and

early

and

operations

7].

depends

2 a 75-year-old

pain

pouch.

They tnavense a greaten overlying the necunnent and inferior to the lower

of parathynoid

[6,

in

of glands

mediastinum

site

especially

seven

embryologic

superior

adult of the

bonder

artery

D. M.,

the

the

tumor,

be a difficult

It required

from

their location. They may larynx to the penicardium. An overlooked adenoma

male, was readmitted

supplied

to poles

tionship with of migration

to the hospital following a neck exploration for hyperparathyroidism. A bilateral subtotal thyroidectomy was performed, and two parathyroid glands were removed. One parathyroid was normal and the other was hyperplastic. His hypercalcemia persisted (10.7-17.6 mg/100 ml). Parathyroid angiography showed an enlarged left inferior thyroid artery. A prominent branch of this artery descended into the mediastinum

the

superior

However,

in

1

A. C., a 55-year-old

stem

bnanchial

distance

pouch. position lateral

[3, 4].

encountered

glands

fourth

can

locate and remove the first parathyroid in this country because it lay in the

Embryologically,

the

in patients presents

of mediastinal parathyroid previous unsuccessful neck Case

Case

adenomas explorations

exercise

to treated

parathynoid

[2]

of

years

of a parathyroid

mediastinum,

mediastinum [3]. The difficulties of

of

6

adenoma

of medicine.

in the diagnosis

the

E. KEATS1

discovery

in the

surgical

and

[1]

one involv-

disciplines

to

adenoma. Despite the fact, the tion of a panathyroid adenoma in 1954. The localization who have undergone

Pimpernel?

contributed

but

located

tnating

has become

many

radiologist

disease

one

he in hell?

elusive

THEODORE

Discussion

We seek him here, we seek him there, Those Frenchies seek him everywhere.

Is he in heaven?-ls

AND

parathyroid adenoma. The mediastinal adenoma was located behind the trachea, anterior to the esophagus. Postoperatively, the serum calcium returned to normal.

Two cases with mediastinal parathyroid adenomas are presented. Both patients had undergone previous unsuccessful neck explorations. Angiography correctly localized the parathyroid adenomas in each case, substantiating the value of parathyroid angiography in mediastinal tumors.

That

Adenomas

the requests

of thyroid to

a capillary gland

stain

as outlined

C. J. Tegtmeyer.

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244

TEGTMEYER

ET

AL.

Fig. 1 .-Case 1. A and B. Early and late arterial left subclavian arteriogram showing large branch artery descending into mediastinum to supply Diagrammatic representation.

phase subtraction films of (arrow) of inferior thyroid parathyroid adenoma. C,

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MEDIASTINAL

PARATHYROID

ADENOMAS

Fig. 2.-Case right subclavian

(arrows) entering C. Diagrammatic

0

2. A and

245

B. Early

arteriogram mediastinum representation.

and showing

late arterial phase subtraction films of branch of right inferior thyroid artery

to supply retrotracheal

parathyroid

adenoma.

TEGTMEYER

246

on

the

scan

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cervical

pnetation

separated

of the

an anomalous

artery

supplied

was

confirmed

thyroid

The

gland of the

the

The

intense

of the

present

cases.

were undertaken correctly localized

studies

were

prion

[1 0, 1 1 , 1 6-1

8]

other

the in

cases

10

were

spect

been

Arteriography

parathyroid

Selective

adenomas

Selective for

Doppman

of

PTH

locating

et al. [10] selectively a source

found

that

sampled of excess

thyroid

frequently roborates

veins

anastomose the surgical

adenomas

panathynoid

onstrates the Reexploration is

Angiognaphy

elevated

correctly

the

thyroid that

by a vascular

difficult

veins

ization

for

the

surgeon.

of mediastinal

This

greatly

of

pedicle

from

however,

because the

the

directly

14.

1 5. 1 6. 1

7.

neck. dem1 8.

panathynoid of

scar

adenomas

simplifies

which

veins. This cormost mediastinal

ade-

surgical

1 9.

tissue.

in both

our cases, and similar favorable results have been Tracing the course of the arterial supply provides map

study

of 84 cases.

of

reported. a road local-

20. 21.

adenomas. REFERENCES

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proposed

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usually

for

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medi-

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correct

two

6.

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and

JL,

Heath

previous

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these

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.

of

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the

arteriography

diagnosed [1 0, 1 3] . However, the adenoma was appreciated

nomas

tumors

thyroid

of

fan removed

mediastinal

localization

5.

diagnosis

staining

that

Two

pa-

thyroid

scan to permit easy the thyroid blush.

during surgery the adenomas.

performed

angiographic

14

inter-

of our

inferior

capillary

reveals

locate

studies studies

the

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ade-

and

angiographic

are sufficiently

literature

to

gland, In both

branch

as outlined on the adenoma blush from

of the

the

astinal

thyroid

tissue”

mediastinal

thyroid

is simplified.

adenomas

performed

cluding

the

adenoma.

by

adenoma.

A review

adenomas,

enlarged

the

the thyroid separation

cases

considered

from

angiograms

tients

tive

be

parathyroid

are well

been

it cannot

AnnSurgl7l

[15]. Unlike nomas

that

ET AL.

NEnglJ

22.

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1 966

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