Intrapericardial parathyroid adenoma
A 32-year-old male was referred to the endocrine surgery team with hypercalcemia and a history of several years of kidney stones. He had first been diagnosed with elevated serum calcium ∼6months prior to his visit in the endocrine surgery clinic but had experienced recurrent problems with nephrolithiasis for several years prior to this. He underwent three lithotripsy procedures and multiple urologic stent placements during this time. Additional symptoms included severe fatigue, weakness and joint pain. Aside from his nephrolithiasis and subsequent renal failure, the patient was otherwise healthy, with no medication use, no allergies, and no history of tobacco or alcohol use.\nSix months prior to our evaluation, at another hospital, the patient underwent failed neck exploration for primary hyperparathyroidism. Pre-operative imaging suggested a right inferior parathyroid adenoma, but bilateral neck exploration including a right thyroid lobectomy was unsuccessful. The initial operation was complicated by transient bilateral vocal cord palsies. The patient was evaluated by an otolaryngologist, and his weak voice and vocal cord palsies resolved without any further intervention.\nHis hypercalcemia persisted and the patient continued to suffer from nephrolithiasis. Despite his multiple urologic interventions, he developed renal failure with a creatinine peaking at 13.5 and requiring temporary dialysis. Parathyroid imaging, including sestamibi/SPECT scan as well as MRI/MRA of the neck and chest suggested an ectopic parathyroid adenoma in the aortopulmonary window (Fig. ). Following consultation with cardiothoracic surgery, the patient underwent a minimally invasive thoracic approach to the mediastinum, followed by conversion to a left posterolateral thoracotomy. Neither approach located the suspected mediastinal adenoma. A median sternotomy was then performed. The entire thymus and all mediastinal fatty tissues were removed without evidence of any abnormality. Finally, the pericardium was opened and a 0.610 g starfish-shaped parathyroid adenoma removed without complication (Figs and ). The patient's intraoperative PTH levels dropped precipitously from 400 to 53 pg/ml. The patient recovered uneventfully and was discharged home on calcium supplementation. At 6-month follow-up, no further evidence of renal stone disease was noted on imaging.