Letter to the Editor
Giant Functioning Mediastinal Parathyroid Cyst: An Unusual Cause of Exertional Dyspnea and Mild Dysphagia
Quiste paratiroideo funcionante gigante de localización mediastínica: una causa insólita de disnea de esfuerzo y disfagia de carácter leve
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(B) Histopathological examination revealed a pseudocystic wall, which contained hypercellular parathyroid tissue (hematoxylin–eosin staining, original magnification 400×).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In 2008, a 78-year-old man was referred to us for observation, after detecting a mediastinal mass with size progression located in the right hemithorax. The patient reported a 2-year history of mild dysphagia, associated with exertional dyspnea for the previous 6 months. His medical history included hypertension and inguinal hernia repair ten years earlier.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The physical examination was unremarkable; neck palpation in particular did not reveal cervical masses and the tracheal axis occupied the midline of the neck. Laboratory test results were normal, except for the serum calcium concentration, which was 14.2<span class="elsevierStyleHsp" style=""></span>mg/dl (normal 8.0–10.5<span class="elsevierStyleHsp" style=""></span>mg/dl) and phosphorus concentration, which was 1.9<span class="elsevierStyleHsp" style=""></span>mg/dl (normal 2.5–4.45<span class="elsevierStyleHsp" style=""></span>mg/dl). The serum parathormone (PTH) concentration was six times higher than the upper limit of normal. The spirometry was indicative of possible upper airway obstruction.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The chest radiograph showed the presence of a right mediastinal mass, displacing the trachea in an anterolateral direction. Contrast esophagography revealed right lateral displacement of the cervical esophagus and superior mediastinum. Chest computed tomography (CT) was performed with contrast media, which showed the presence of a large mediastinal mass (12<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm) with no contrast enhancement, located in the posterior visceral compartment, causing anterior displacement of the large vessels and trachea, and right anterolateral displacement of the esophagus (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A possible clinical diagnosis of parathyroid cyst was established. Surgical resection was scheduled using a thoracotomic approach without preoperative fine needle aspiration of the cyst, in order to minimize the risk of mediastinitis and/or uncontrolled bleeding in the pleural space. The surgical strategy excluded video assisted thoracic surgery (VATS) due to the size of the cyst. We chose a classical posterolateral thoracotomy with muscle preservation, which allowed complete resection of the cyst with respect to the other mediastinal structures. Histopathological examination revealed a pseudocystic wall that included hypercellular parathyroid tissue (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).</p><p id="par0025" class="elsevierStylePara elsevierViewall">The postoperative period was uneventful and the serum calcium concentration fell to 8.2<span class="elsevierStyleHsp" style=""></span>mg/dl. The patient was discharged 5 days postoperatively.</p><p id="par0030" class="elsevierStylePara elsevierViewall">On the contrast esophagography, carried out 3 months later, there was no displacement of the cervical and thoracic esophagus or stenosis. During the following 12 months, the serum calcium level remained within normal limits, so a cervical examination was not performed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Mediastinal parathyroid cysts are relatively rare. These unusual lesions can present with locoregional clinical manifestations and, when they are active from a biochemical point of view, can also be associated with systemic symptoms. In 1925, de Quervain published the first case of satisfactory surgical resection of a parathyroid cyst in the mediastinal compartment,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> although to date fewer than 150 cases have been described among published studies.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The non-specific symptoms are related with the appearance of a space-occupying lesion, such as the one described in this report. The cysts can cause dyspnea as a result of marked tracheal deviation or stenosis, or dysphagia due to esophageal compression or deviation.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The differential diagnosis is usually established by radiological examinations combined with laboratory tests, which show an increase in the serum calcium and/or PTH concentration.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In the context of a state of hyperparathyroidism, a functioning mediastinal cyst must be considered, so its resection should be performed with simultaneous cervical examination, which is easy to perform for cervical cysts infiltrating or located in the anterior mediastinum. For parathyroid cysts in the posterior mediastinal compartment that require thoracotomy, simultaneous cervicotomy appears to be overtreatment, and should only be considered after demonstrating persistent hyperparathyroidism after surgery.</p><p id="par0055" class="elsevierStylePara elsevierViewall">No deaths have been documented among published studies, although the resection of giant cysts can rarely be associated with postoperative complications.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> VATS has been described for the successful management of these cystic lesions, although all cases refer to small cysts located in the prevascular and anterior mediastinum.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The exceptional nature of this report resides in the large size of the parathyroid cyst, which ruled out a VATS approach. However, it was successfully resolved using a thoracotomic approach without any postoperative morbidity, which resulted in complete clinical resolution of the presenting symptoms.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">This study was carried out as part of research grant “Dottorato di Ricerca – XXVI ciclo – Scienze Chirurgiche – Alma Mater Studiorum Università degli Studi di Bologna”.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Davoli F, et al. Quiste paratiroideo funcionante gigante de localización mediastínica: una causa insólita de disnea de esfuerzo y disfagia de carácter leve. Arch Bronconeumol. 2013;49:408–9.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 597 "Ancho" => 1601 "Tamanyo" => 242261 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) The chest computed tomography with contrast medium shows a large mediastinal mass (12<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>cm) without contrast enhancement causing anterior displacement of the large vessels and trachea, and anterolateral displacement of the esophagus. (B) Histopathological examination revealed a pseudocystic wall, which contained hypercellular parathyroid tissue (hematoxylin–eosin staining, original magnification 400×).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Epithe-Korperchen-Cysti" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "F. 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Mizuno" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Jpn J Chest Surg" "fecha" => "1998" "volumen" => "12" "paginaInicial" => "676" "paginaFinal" => "680" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mediastinal parathyroid cyst: treatment with thoracoscopic surgery. A case report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T. Oyama" 1 => "H. Imoto" 2 => "K. Yasumoto" 3 => "S. Toyoshima" 4 => "A. Nagashima" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J UOEH" "fecha" => "1999" "volumen" => "21" "paginaInicial" => "317" "paginaFinal" => "23210" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10629902" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Thoracoscopic removal of mediastinal hyperfunctioning parathyroid glands: personal experience and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P.F. Alesina" 1 => "D. Moka" 2 => "J. Mahlstedt" 3 => "M.K. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 2 | 8 |
| 2024 October | 37 | 25 | 62 |
| 2024 September | 45 | 21 | 66 |
| 2024 August | 54 | 39 | 93 |
| 2024 July | 50 | 20 | 70 |
| 2024 June | 61 | 30 | 91 |
| 2024 May | 65 | 36 | 101 |
| 2024 April | 36 | 26 | 62 |
| 2024 March | 35 | 21 | 56 |
| 2024 February | 34 | 27 | 61 |
| 2023 March | 6 | 9 | 15 |
| 2023 February | 33 | 21 | 54 |
| 2023 January | 28 | 31 | 59 |
| 2022 December | 36 | 35 | 71 |
| 2022 November | 27 | 36 | 63 |
| 2022 October | 49 | 35 | 84 |
| 2022 September | 18 | 27 | 45 |
| 2022 August | 35 | 44 | 79 |
| 2022 July | 34 | 38 | 72 |
| 2022 June | 30 | 38 | 68 |
| 2022 May | 34 | 45 | 79 |
| 2022 April | 32 | 45 | 77 |
| 2022 March | 36 | 52 | 88 |
| 2022 February | 43 | 44 | 87 |
| 2022 January | 45 | 32 | 77 |
| 2021 December | 30 | 39 | 69 |
| 2021 November | 43 | 53 | 96 |
| 2021 October | 44 | 48 | 92 |
| 2021 September | 33 | 53 | 86 |
| 2021 August | 25 | 28 | 53 |
| 2021 July | 30 | 33 | 63 |
| 2021 June | 31 | 35 | 66 |
| 2021 May | 33 | 29 | 62 |
| 2021 April | 51 | 54 | 105 |
| 2021 March | 42 | 26 | 68 |
| 2021 February | 24 | 19 | 43 |
| 2021 January | 23 | 20 | 43 |
| 2020 December | 22 | 15 | 37 |
| 2020 November | 24 | 15 | 39 |
| 2020 October | 22 | 17 | 39 |
| 2020 September | 27 | 12 | 39 |
| 2020 August | 29 | 16 | 45 |
| 2020 July | 32 | 30 | 62 |
| 2020 June | 30 | 6 | 36 |
| 2020 May | 33 | 19 | 52 |
| 2020 April | 25 | 25 | 50 |
| 2020 March | 42 | 14 | 56 |
| 2020 February | 56 | 20 | 76 |
| 2020 January | 49 | 19 | 68 |
| 2019 December | 43 | 11 | 54 |
| 2019 November | 44 | 17 | 61 |
| 2019 October | 30 | 7 | 37 |
| 2019 September | 41 | 8 | 49 |
| 2019 August | 32 | 9 | 41 |
| 2019 July | 40 | 12 | 52 |
| 2019 June | 34 | 13 | 47 |
| 2019 May | 61 | 15 | 76 |
| 2019 April | 45 | 27 | 72 |
| 2019 March | 60 | 25 | 85 |
| 2019 February | 55 | 19 | 74 |
| 2019 January | 65 | 23 | 88 |
| 2018 December | 60 | 19 | 79 |
| 2018 November | 91 | 31 | 122 |
| 2018 October | 113 | 24 | 137 |
| 2018 September | 44 | 14 | 58 |
| 2018 May | 21 | 0 | 21 |
| 2018 April | 23 | 7 | 30 |
| 2018 March | 63 | 6 | 69 |
| 2018 February | 46 | 19 | 65 |
| 2018 January | 136 | 9 | 145 |
| 2017 December | 146 | 8 | 154 |
| 2017 November | 33 | 8 | 41 |
| 2017 October | 21 | 6 | 27 |
| 2017 September | 31 | 5 | 36 |
| 2017 August | 48 | 13 | 61 |
| 2017 July | 51 | 6 | 57 |
| 2017 June | 42 | 8 | 50 |
| 2017 May | 45 | 8 | 53 |
| 2017 April | 32 | 7 | 39 |
| 2017 March | 31 | 15 | 46 |
| 2017 February | 29 | 2 | 31 |
| 2017 January | 20 | 14 | 34 |
| 2016 December | 45 | 5 | 50 |
| 2016 November | 37 | 11 | 48 |
| 2016 October | 39 | 19 | 58 |
| 2016 September | 41 | 11 | 52 |
| 2016 August | 61 | 16 | 77 |
| 2016 July | 30 | 12 | 42 |
| 2016 March | 3 | 0 | 3 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 3 | 0 | 3 |
| 2015 October | 43 | 2 | 45 |
| 2015 September | 43 | 10 | 53 |
| 2015 August | 43 | 20 | 63 |
| 2015 July | 53 | 9 | 62 |
| 2015 June | 65 | 7 | 72 |
| 2015 May | 43 | 21 | 64 |
| 2015 April | 43 | 8 | 51 |
| 2015 March | 47 | 9 | 56 |
| 2015 February | 38 | 6 | 44 |
| 2015 January | 41 | 6 | 47 |
| 2014 December | 22 | 7 | 29 |
| 2014 November | 27 | 9 | 36 |
| 2014 October | 41 | 12 | 53 |
| 2014 September | 36 | 10 | 46 |
| 2014 August | 48 | 9 | 57 |
| 2014 July | 29 | 8 | 37 |
| 2014 June | 42 | 15 | 57 |
| 2014 May | 52 | 15 | 67 |
| 2014 April | 41 | 7 | 48 |
| 2014 March | 66 | 13 | 79 |
| 2014 February | 46 | 18 | 64 |
| 2014 January | 33 | 13 | 46 |
| 2013 December | 33 | 10 | 43 |
| 2013 October | 0 | 1 | 1 |
| 2013 September | 1 | 1 | 2 |
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